case report of peritoneal hydatidosis diagnosed as ovarian cyst narinder kaur,a,c buddhi kumar shrestha,a,c subha shrestha,a,c nabin pokharelb,d —–————————————————————————————————————————————— abstract: primary peritoneal hydatidosis is a rare condition and it was mistiaken for ovarian cyst. hydatid disease is caused by dog tape worm, echinococcus granulosus, and is the commonest one having worldwide distribution. human hydatid disease results from infection with larval form of echinococcus granulosus. the disseminated intra-peritoneal hydatid disease is a rare finding. a case of disseminated intra-abdominal hydatid disease is presented along with a review of literature and various therapeutic modalities. keywords: disseminated • hydatid cyst • peritoneal hydatidosis ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer b assistant professor c department of gynecology and obstetrics lumbini medical college teaching hospital, palpa, nepal d department of surgery lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. narinder kaur e-mail: nkaur@jlmc.edu.np how to cite this article: kaur n, shrestha bk, shrestha s, pokharel n. case report of peritoneal hydatidosis diagnosed as ovarian cyst. journal of lumbini medical college. 2013;1(2):118-9. doi:10.22502/jlmc.v1i2.34. ___________________________________________________________________________________ j. lumbini. med. coll. vol 1, no 2, july-dec 2013 case report jlmc.edu.np https://doi.org/10.22502/jlmc.v1i2.34 introduction: peritoneal hydatidosis is an uncommon finding. secondary peritoneal hydatidosis is more common than primary. secondary cases are commonly associated with hepatic hydatid cysts. only a few cases of primary peritoneal hydatidosis have been reported in the literature till date. in this report, we review seven cases of peritoneal hydatidosis of which one is a case of primary disseminated peritoneal hydatidosis while the rest are secondary to hepatic and / or splenic lesions. case report: mrs. xyz, 28 years old women admitted with complains of progressive enlargement of abdomen associated with pain. her main complain was pain in abdomen of one month duration. she was average built sick looking woman. her general parameters were within normal limits. on abdominal examination, abdomen was soft. there was a cystic mass about 15 cm x 15 cm in right iliac region. it was mobile and tender. there was no evidence of free fluid in peritoneal cavity. on local examination, cervix and vaginal were normal and healthy. uterus was of normal size. left fornix was free. in right fronix, same mass was felt which was tender with restricted mobility. clinical features were suggestive of twisted with imminent rupture of ovarian cyst. her blood pressure, urine analysis, hepatic and renal function test were normal. ecg was within normal limit. chest x-ray was normal. ultrasonography showed a mass of mixed echogenicity and right ovary was not visualized. laparotomoy was done. the operative findings were: uterus, tubes and ovaries on both sides were normal. there was no free fluid in peritoneal cavity. there was a cystic mass having adhesion with small intestine and rectum. the adhesions were separated and cyst was removed completely. there was no communication with any organ. peritoneal cavity lavage was done with 118 j. lumbini. med. coll. vol 1, no 2, july-dec 2013 jlmc.edu.np kaur n. et al. case report of peritoneal hydatidosis diagnosed as ovarian cyst hypertonic saline. there ware no daughter cysts and abdomen was closed in layers. oral albendazole 400 mg daily started from the second post operative day. recovery was uneventful. patient was discharged on 7th postoperative day with advice to take albendazole 400 mg daily for four to six months. on follow up, she reported once in opd. she is fine and fit and continuing albendazole treatment. discussion: hydatid disease is endemic in many parts of the world, where there is a close association of humans with dogs, the definitive host. liver (5575%) and lungs (18-35%) are the most commonly affected sites. studies have shown that peritoneal hydatidoisis is rare. it is usually secondary to heptic, splenic and mesenteric cyst or having concomitant to liver and retroperitoneal hydatidosis.1,2 the infection is usually acquired in childhood and remains asymptomatic until the adulthood. symptoms of cyst depend on its localization, pressure effect on the surrounding structures and rupture of cyst. abdominal pain is the most common complain. followed by pressure effect like nausea, weight loss and breathlessnss on exertion and orthopnea.2,3 in our case, woman came with lump in abdomen associated with pain. ultrasonography is the investigation of choice in the case; the clinical findings were suggestive of ovarian cyst of mixed echogenicity. ovary on the right side could not be visualized. the treatment of choice is surgical and complete removal. unroofing and drainage of cyst is safe alternative if the pericyst is adherent to surrounding structure.1-4 conclusion: primary pertoneal hydatidosis is a rare entity but always to be kept as differential diagnosis in case of lump in abdomen in endemic areas. ultrasonography is helpful in diagnosis and follow up of the case. definitive treatment is surgery. albendazole prevents the recurrence and should be given as a long term treatment. 1. blumgart lh. surgery of the liver, biliary tract and pancreas. vol 2, 4th ed, wb saunders, philadelphia, 2007. 2. chowdhury g, singh n. huge peritoneal hydatidosis mimicking ovarian cyst of india. j obstet gynecol india. 2012;62(2):194-4. 3. mosca f, portable tr, persi a. uncommon abdominal sites of hydatid disease, our experience with surgical treatment of fifteen cases. chir ital. 2006;56:333-44. 4. nadeem n, khan h, fatimi s. giant multiple intraabdominal hydatid cyst. j ayub med coll abbotabad. 2006;18:70-1. references: 119 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 12 may, 2020 accepted: 24 may, 2020 published: 26 may, 2020 a lecturer, department of community medicine, b assistant professor, department of obstetrics and gynaecology, c lumbini medical college teaching hospital, palpa, nepal. corresponding author: samata nepal e-mail: samata.kool@gmail.com orcid: https://orcid.org/0000-0001-9189-4510 how to cite this article: nepal s, aryal s. covid-19 and nepal: a gender perspective. journal of lumbini medical college. 2020;8(1):2 pages.doi: 8(1):2 pages.doi: https:// doi.org/10.22502/jlmc.v8i1.337 epub: 2020 may epub: 2020 may 26._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.337 samata nepal,a,c shreyashi aryal b,c covid-19 and nepal: a gender perspective the ongoing corona virus disease 19 (covid-19) pandemic is in its height, the measures taken to control the spread of this pandemic is acute and harsh. with the increasing new cases every hour it has caused a panic among every individual. economy of the countries are equally affected. however, the direct and indirect impact of this pandemic on gender related needs are least prioritized and discussed. evidences so far reveal the mortality being proportionately higher in males.[1,2] this fact may not remain the same in nepalese context because women are more vulnerable in this low-income country where limited resources are allotted to women’s health. majority of the workforce at frontline health care are women in the form of nurses, midwives and female community health volunteers (fchv). government of nepal has decided to mobilize fchvs for covid-19 response in the community and these fchvs who provide services at ground levels are at occupational risk of acquiring the infection. other service staffs like cleaners and laundry workers, more of whom are women, are also at greater risk of exposure. globally 70% of health work force comprises of women[3] and without proper training and appropriate protective equipment, they are likely to suffer and the containment of this pandemic will be of great challenge. the shortage of standard personal protective equipment (ppe); the temporary ppes made from plastic, raincoats and other materials; and ill-fitting sizes are likely to result in yet another catastrophe. women share the major hemisphere of informal or part time job as house maids, care takers, laborers and daily wage workers. they are likely to be underpaid and displaced from work during covid-19 pandemic. the situation would worsen when women are bread winners for the family. with frail financial condition the needs of the family especially nutritional requirement of children and the health care expenses for the family member with chronic diseases will be compromised. in the domestic front, nepalese women are more susceptible to covid-19 infection. many migrant workers have returned home from foreign countries. some of them have bypassed facilitybased quarantine and have not followed strict home quarantine measures. the potential risk of infecting their family, especially their wives seems inevitable. meanwhile, return of the male spouse has increased the demand of contraceptives. with every resource diverted to control the pandemic, availability and access to modern contraceptive method is a matter of concern. the averted health care system leads to increased morbidity and mortality related to maternal health, sexually transmitted infections, unwanted pregnancies and abortions. it is estimated that 61% of maternal deaths worldwide occur in fragile states, many of which are affected by conflict and recurring natural disasters.[4] during this pandemic, health care facilities have suspended non-emergency services. contraception and abortion have been kept under essential services however, access to these facilities are difficult during the lockdown and travel ban. women have not been able to exercise their reproductive rights fully. to add to these problems, domestic violence and other forms of genderbased violence (gbv) are on the rise [5] as people nepal s, et al. covid-19 and nepal: a gender perspective. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 across the country are under lockdown during the coronavirus outbreak. mental distress does not show immediate impacts but in the long run has severe consequences. the gender and health inequalities are driven to its height during pandemics. a gendered human right analysis during ebola and zika outbreak revealed “an effective global response to public health emergencies must engage with the rights and needs of affected women”.[6] in the present context of covid-19 pandemic, continued access to safe reproductive health services, expansion of mitigation measures to contain gbv and safety of frontline health care workers should be taken into consideration in nepalese scenario. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. gausman j, langer a. sex and gender disparities in the covid-19 pandemic. j womens health (larchmt). 2020;29(4):465-6. pmid: 32320331 doi: https://doi.org/10.1089/jwh.2020.8472 2. the lancet. the gendered dimensions of covid-19. lancet. 2020;395(10231):1168. pmid: 32278370 pmcid: pmc7146664 doi: https://doi.org/10.1016/s0140-6736(20)30823-0 3. boniol m, mcisaac m, xu l, wuliji t, diallo k, campbell j. gender equity in the health workforce: analysis of 104 countries. world health organization; 2019. https://apps.who.int/ iris/handle/10665/311314 4. center for reproductive rights. briefing paper: ensuring sexual and reproductive health and rights of women and girls affected by conflict. 2017. https://www.reproductiverights.org/sites/ crr.civicactions.net/files/documents/ga_bp_ conflictncrisis_2017_07_25.pdf 5. allen-ebrahimian b. china’s domestic violence epidemic. axios. 7 mar 2020. https:// www.axios.com/china-domestic-violencecoronavirus-quarantine-7b00c3ba-35bc-4d16afdd-b76ecfb28882.html 6. davies se, bennett b. a gendered human rights analysis of ebola and zika: locating gender in global health emergencies. international affairs. 2016;92(5):1041-60. doi: https://doi. org/10.1111/1468-2346.12704 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 10 may, 2020 accepted: 22 may, 2020 published: 10 june, 2020 aassistant professor, department of pharmacology, blumbini medical college teaching hospital, nepal. corresponding author: naresh karki e-mail: karki007naresh@gmail.com orcid: https://orcid.org/0000-0002-8788-6443 how to cite this article: karki n. “solidarity trial”: a feeling of trust towards covid-19 treatments. journal of lumbini medical college. 2020;8(1):2 pages. doi: https://doi.org/10.22502/jlmc.v8i1.335 epub: 2020 june 10. _______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.335 naresh karki a,b “solidarity trial”: a feeling of trust towards covid-19 treatments corona virus disease (covid-19) drugs are not being developed at the pace in which the disease is spreading throughout the world. who and its partners have announced the worldwide clinical trial on 18th march 2020, known as “solidarity trial” for greater co-ordination of developments of drugs. [1]“solidarity trialis an international clinical trial to help find an effective treatment for covid-19”.[1, 2] the trial is randomized, open-label and adaptive. this trial will analyze four treatment options against standard of care, after recruiting patients from various countries, and then will approach to their relative effectiveness against the disease. the aim of this trial is to rapidly explore if any of the administered drugs will slow progression of disease or improve survival.[2] the rationale of conducting “solidarity trial” is to reduce time taken by the trials. randomized clinical trials generally take years to conduct, while, “solidarity trial” will reduce the duration by 80%.[2] by enrolling patients from around the world, this trial might be able to provide result more rapidly than multiple small trials. moreover, those small multiple trials will not be able to gather solid evidence required to determine the relative effectiveness of given unproven drugs. [2] besides this, with involvement of multiple countries, the cost of trial will also reduce. already, 100 countries including norway, canada, spain, argentina, thailand, south africa, india, indonesia, switzerland and others have committed to join this trial. norway is the first country to contribute its first patient for this important trial.[2] this trial will provide simplified procedure to enable hospitals to participate without any paperwork. the countries with least infrastructure can follow a main protocol, while those with better facility will launch “daughter trials” that will gather added data.[2,3] four treatment options are selected for this trial on the basis of evidence gathered from animal studies, clinical studies and laboratory results. they are remdesivir, lopinavir with ritonavir, lopinavir with ritonavir + interferon beta-1a and chloroquine or hydroxychloroquine.[2,3] remdesivir, acts by inhibiting rna-dependent rna polymerase and stops viral replication, has provided encouraging outcome in middle east respiratory syndrome (mers) and severe acute respiratory syndrome (sars).[2,3] lopinavir /ritonavir, approved for treatment of hiv, are protease inhibitors. they block the aspartic protease enzyme that breaks down proteins into small pieces needed for viral replication. [3] these drugs were tried in china for treatment of covid-19.[4] but, there was no significant clinical improvement and reduction in mortality among patients. however, there was reduction in median time to clinical improvement by one day comparing to standard-care group.[4] interferon beta-1a is a class of protein called cytokines that are produced by host cells in response to virus. then, they signal other cells around them to enhance anti-virus defense mechanism.[3] it has shown some effective results against covid-19 in combination with lopinavir/ritonavir.[2,3] furthermore, chloroquine or hydroxychloroquine are believed to interfere with fusion of virus with host cell by increasing ph of viral endosome or to allow zinc influx to viral cell that inhibits rna-dependent rna polymerase.[3] they have shown possible beneficial effect against pneumonia caused by covid-19 in small studies conducted in china and france.[2,3] karki n. “solidarity trial”: a feeling of trust towards covid-19 treatments. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 eligible patients for this trial are adults (age ≥ 18years) with confirmed diagnosis of covid-19 recently or already admitted to participant hospital. [2] patients with any contraindication to the study treatments will be excluded from trial. the patients are asked to sign written consent which explains that they understand all the possible risks and beneficial effects of this trial. .[2] there will be a medical team for each patient responsible to monitor if any of the study treatment would be definitely unsuitable to the patient. the severity of disease is assessed by recording clinical presentations like difficulty in breathing, patient on oxygen, patient on ventilator, and radiography of chest showing bilateral lung abnormalities. the underlying medical conditions are also recorded like chronic lung disease, chronic heart disease, chronic liver disease, chronic renal disease, tuberculosis and hiv.[2] then, the patients are randomly allocated to treatment options. this may include local standard of treatment only or local standard of treatment plus one of remdesivir, chloroquine or hydroxychloroquine, lopinavir with ritonavir, lopinavir with ritonavir plus interferon beta-1a.[2.3] this random allocation of treatment options is done by computer, not any medical staff. the critical information of trial is only collected at randomization stage and at the time patient is discharged or dead. this information includes which drugs were given, duration of therapy, date of discharges, date of death and cause of death.[2] this entire trial is monitored by global data and safety monitoring committee, an independent group of experts.[2] this clinical trial has brought the world to one stage for common goal related to health issue. the world may believe that this trial will soon bring good and positive result of treatment options for covid-19 with the support of multiple countries under umbrella of who. additionally, this trial will also create important basis for conducting new trials collaboratively if any new pandemics will occur unfortunately in the future. references: 1. mullard a. flooded by the torrent: the covid-19 drug pipeline. lancet. 2020;395(10232):124546. pmid: 32305088. doi: https://doi. org/10.1016/s0140-6736(20)30894-1 2. world health organization. “solidarity” clinical trial for covid-19 treatments [internet]. who: geneva; 2020 march. [cited 2020 may 7]. available from: https://www.who.int/ emergencies/diseases/novel-coronavirus-2019/ global-research-on-novel-coronavirus-2019ncov/solidarity-clinical-trial-for-covid-19treatments 3. kupferschmidt k, cohen j. who launches global megatrial of the four most promising coronavirus treatments [internet].science; 2020 mar 22. [cited 2020 may 8]available from:https://www. sciencemag.org/news/2020/03/who-launchesg l o b a l m e g a t r i a l f o u r m o s t p r o m i s i n g coronavirus-treatments 4. wang bcy, wen d, liu w, wang j, fan g, ruan l, et al. a trial of lopinavir-ritonavir in adults hospitalized with severe covid-19. n engl j med. 2020;382(19):1787-99.available from: https://www.nejm.org/doi/full/10.1056/ nejmoa2001282 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 22 may, 2020 accepted: 24 may, 2020 published: 28 may, 2020 a assistant professor, department of obstetrics and gynaecology, b lumbini medical college teaching hospital, palpa, nepal. corresponding author: shreyashi aryal e-mail: shreyashiaryal@gmail.com orcid: https://orcid.org/0000-0002-6832-3530 how to cite this article: aryal s, shrestha d. motherhood in nepal during covid-19 pandemic: are we heading from safe to unsafe? journal of lumbini medical college.2020;8(1):2 pages. doi: https://doi. org/10.22502/jlmc.v8i1.351 epub: 2020 may 28._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.351 shreyashi aryal,a,b deepak shrestha a,b motherhood in nepal during covid-19 pandemic: are we heading from safe to unsafe? safe motherhood program (smp) has been one of the successful ongoing maternal health programs in nepal. it is the major reason for nepal being able to reduce its maternal mortality ratio (mmr) significantly falling from 539 to 281 deaths per 100000 live births over the decades.[1] smp has nine components out of which three components mainly deal with pregnancy and puerperium; birth preparedness plan, rural ultrasound program and the “aama and new born program”. the latter one is one of the key components of smp which includes incentives, free delivery services and free sick newborn care. financial incentives are provided for transport and completion of four antenatal visits, and for health care workers attending deliveries.[2] however, with the corona virus disease (covid-19) pandemic, this program might not be enough to ascertain a safe motherhood for nepalese women. this program aims to reduce the three delays leading to maternal morbidity and mortality namely, delay in reaching care, seeking care and receiving care. but with a nationwide lockdown, the chances of these delays have increased even more. pregnant women are being requested to delay regular antenatal checkups to minimize transmission through hospitals. this means missing prenatal vitamins, immunization and chances to diagnose high risk pregnancies. with 80% antenatal coverage and only 59% institutional deliveries, nepal still has high mmr compared to some other countries in southeast asia.[3,4] reduced antenatal visits may lead to missed chances of diagnosing pregnancy complications in time. there is a possibility of delay in seeking care when pregnant mothers are unsure when to visit the hospitals because of the uncertainty of availability of their services during the pandemic. for women hailing from remote areas, the travel ban during the lockdown causes a delay in reaching care. in the present scenario, halt in local transportation, scarce ambulance services, and geographical remoteness in the mountainous country nepal, leaves a pregnant woman with the only option of delivering at home. without aseptic measures, home delivery is not risk free. few fortunate ones who reach the health care center might already have developed complications. when they reach late to the hospital, free delivery services are futile in preventing complications. with inadequate personal protective equipment (ppe) and limited workforce, there is an expected delay in receiving care to some extent. rural ultrasound program which is a part of smp might also be affected because of inadequate ppe for health care workers in the rural locations. easy availability of blood transfusion services is another component of smp but during the lockdown, this access is also not easy. in the absence of blood products, obstetric emergencies are difficult to manage optimally. with all these delays enhanced due to the effects of the pandemic, mmr is predicted to increase, thereby threatening the most appraised outcome of the smp. maternal mental health is altogether an unaddressed issue in safe motherhood. with incidences of depression and domestic abuse aryal s, et al. motherhood in nepal during covid-19 pandemic: are we heading from safe to unsafe? jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 increasing during this time, safe pregnancy cannot be guaranteed. alternative methods for antenatal and postnatal care like awareness through social media, videoconferencing and telemedicine can be some effective options. teaching women to take their own fundal height through online classes is one of the methods to detect early growth restrictions,[5] but keeping in mind the unavailability of internet access and literacy level of women in rural areas, this might not be the feasible option either. mobilizing female community health volunteers, while maintaining the norms of physical distancing, should be continued for both antenatal and postnatal period to detect danger signs. continuing postpartum care including contraception is another important aspect to prevent morbidities. with recommendations for early discharge and difficulty in follow up, postpartum complications can be expected to rise. policies to increase access to institutional delivery addressing the barriers to the three delays need to be formulated and implemented. with increasing number of covid-19 positive cases, pregnant women are also likely to get infected. when medical resources are diverted for covid-19 cases, high risk pregnancies will definitely get suboptimal treatment but even healthy pregnancies might resort to becoming complicated. obstetric preparedness has to be a priority at this point. nepal witnessed its first covid-19 mortality and the deceased was a new mother in her first week of puerperium. preliminary reports suggest that a delay in reaching health care due to unavailability of transportation was the reason of untimely demise of this 29-year-old new mother.[6] smp has to be tailored to fit this pandemic so that maternal mortality remains low. the government has risen up to the challenge to reduce mmr successfully in the past. at this point if we let the pandemic increase mmr, it will be a slip hard to recover from. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. bhandari a, gordon m, shakya g. reducing maternal mortality in nepal. 2011;118 suppl 2:26-30. pmid: 21951499 doi: https://doi. org/10.1111/j.1471-0528.2011.03109.x 2. safe motherhood program. government of nepal. ministry of health and population. available from: https://www.mohp.gov.np/eng/ program/reproductive-maternal-health/safemotherhood-programme 3. ministry of health moh/nepal, new era/ nepal, and icf. 2017. nepal demographic and health survey 2016. kathmandu, nepal: moh/ nepal, new era, and icf. available from: http://dhsprogram.com/pubs/pdf/fr336/fr336. pdf 4. bhandari tr. maternal and child health situation in southeast asia. n j obstet gynaecol. 2012;7:5–10. doi: https://doi.org/10.3126/njog. v7i1.8825 5. bergman e, axelsson o, kieler h, sonesson c, petzold m. relative growth estimated from selfadministered symphysis fundal measurements. acta obstet gynecol scand. 2011;90(2):179-85. pmid: 21241264 doi: https://doi.org/10.1111/ j.1600-0412.2010.01026.x 6. poudel a. nepal reports its first covid-19 death. the kathmandu post. 2020 may 16. available from: https://tkpo.st/2tey3lu licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 9 may, 2020 accepted: 22 may, 2020 published: 22 may, 2020 aresident, b-department of digestive surgery, breast and thyroid surgery, kagoshima university graduate school of medicine, kagoshima, japan. cgeneral surgeon, department of surgery, steel memorial muroran hospital, ddepartment of gastroenterological surgery ii, hokkaido university graduate school of medicine, sapporo, japan. e-mch gi surgery, maharajgunj medical campus, tribhuvan university teaching hospital, kathmandu, nepal. corresponding author: pramod nepal e-mail:npl.pmd@gmail.com orcid: https://orcid.org/0000-0002-3376-239x how to cite this article: nepal p, poudel s, maharjan n. covid-19 pandemic: a surgical perspective from japan. journal of lumbini medical college. 2020;8(1):2 pages. doi: 2020;8(1):2 pages. doi: https://doi.org/10.22502/jlmc.v8i1.326 epub: 2020 may 22. epub: 2020 may 22. _______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.326 pramod nepal,a,b saseem poudel,c,d narendra maharjan a,e covid-19 pandemic: a surgical perspective from japan japan reported its first covid-19 case after a returnee from wuhan, china tested positive for the virus on 16 january, 2020. on april 8, the japanese government declared emergency in tokyo and six other prefectures of the country; a nationwide emergency was declared on april 16. the total reported cases were 15,477 and total deaths 755 as of may 7, 2020. japan surgical society (jss)[1] and japanese society of gastroenterological surgery (jsgs)[2] have published recommendations for surgery and appropriate measures of safety. patients are triaged based on the severity of their disease and level of outbreak. the elective surgery acuity scale (esas) by american college of surgeons is recommended to triage the patients.[3] the guidelines consider the risk of infection during the interventions that generate aerosol such as tracheal intubation, extubation, tracheostomy, mask ventilation, bronchoscopy, chest drainage, gastrointestinal endoscopy etc. jss and jsgs recommend designated operating room (or) with adequate supply of necessary drugs, and restriction on the unnecessary movement of people to reduce the frequency of opening and closing the door. anesthesia should be provided by anesthetists (as per guidelines from japan society of anesthesiology); surgeons and medical personnel not involved in anesthetizing the patient should not be present in the or during the procedure and the or should preferably be in negative pressure. when performing the laparoscopic surgeries, jss has recommended sages guidelines on smoke and gas evacuation during open, laparoscopic and endoscopic procedures, and advocate on the use of high-precision filter and the exhaust gas to prevent possible virus spread through surgical smoke.[4] after surgery, the postoperative care of infected or suspected patients should be taken care by minimum number of personnel waiting outside the or. the personal protective equipment (ppe) of the people involved in the transportation of the patient to or should not be the same that was used at the time of surgery. the surgical gown should be donned and doffed inside the or. it is further suggested taking shower inside the or area post-surgery, and maintaining hand hygiene and social distancing inside or. in cases of emergency surgery, jss and jsgs recommend waiting for the test results in suspected cases until the time permits, to wear full ppe for emergency surgery in confirmed and suspected cases, and to select the surgical procedure from the viewpoint of shortening the operating time and ensuring maximum safety of patients and the medical staffs. emergency surgeries are asked to be postponed if possible when the number of staff is less, such as during night hours. the hospitals are asked to judge the need for surgery and stability of continued supply of medical equipment based upon the latest situation. jss follows center for disease control (cdc) recommendations on use of ppe. to deal with the exhaustion and mental fatigue caused by ppe, short procedures are nepal p et al. covid-19 pandemic: a surgical perspective from japan. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 to be opted for, and if possible and required during long procedures, surgeons should be replaced. the hospitals are expected to provide accommodation facilities for the medical staffs who finished surgery or treatment of confirmed or suspected cases and cannot return to their homes. jss and jsgs also endorse general etiquettes, for example; getting clothes off and washing immediately when reaching home, reducing physical contact between families, proper cleaning of phones, regular cleaning inside home with 60% alcohol, using hand sanitizers or disposable gloves while purchasing goods, at bank atms, vending machines, refueling at gas stations, etc. when arriving to hospital, the health workers are expected to take off the clothes they wore from home and put them into bags as not to get infected with the virus. while reflecting the on-field scenario, in addition to jss and jsgs guidelines, multiple measures are being carried out by each institution. individual hospitals have formulated working protocols and screen the patients before surgery. hospitals in least disease outbreak areas, for example kagoshima university hospital, gastrointestinal surgeries are carried out as usual, whereas elective surgeries in oral cavity and oropharynx are postponed. the hospitals in places with greater outbreak have postponed non-emergency benign cases. surgery for cancer is done regularly in most of the hospitals. in some hospitals, chest ct is performed before surgery and non-emergency surgeries in patients with pneumonia or fever are suspended. certain well-resourced hospitals perform polymerase chain reaction (pcr) to screen elective cases. there is the issue of lack of disposable gowns and masks; hospitals have started rationing and searching for alternative reusable options. full ppe and n95 respirators are not used routinely yet. concern over spread of virus via surgical smoke in laparoscopic surgery is rising, however, none of the hospitals have suspended laparoscopic procedures. inside hospitals, the doctors, staffs and patients are required to wear masks, and visitors are permitted during the counselling on patient’s conditions. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. japanese surgical society. proposal for surgery for new corona virus-positive and suspected patients (revised version)]. japanese. retrieved from https://www.jssoc.or.jp/ 2. the japanese society of gastroenterological surgery (jsgs). https://www.jsgs.or.jp/index. php 3. american college of surgeons (acs). https:// www.facs.org/ 4. resources for smoke and gas evacuation during open, laparoscopic, and endoscopic procedures. society of american gastrointestinal and endoscopic surgeons (sages). retrieved from https://www.sages.org/resources-smokegas-evacuation-during-open-laparoscopicendoscopic-procedures/ licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 26 may, 2020 accepted: 28 may, 2020 published: 30 may, 2020 amch resident (ctvs), bassociate professor, cmanmohan cardiothoracic vascular and transplant center. corresponding author: krishnaprasad bashyal email: drbashyal85@gmail.com orcid: https://orcid.org/0000-0002-8871-2779 how to cite this article: bashyal k, shrestha kr. vascular surgery in covid-19 period and beyond: acknowledging the new normal. journal of lumbini medical college.2020;8(1):2 pages. doi: https://doi. org/10.22502/jlmc.v8i1.358 epub: 2020 may 30._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.358 krishnaprasad bashyal,a,c kajan raj shrestha b,c vascular surgery in covid-19 period and beyond: acknowledging the new normal the first infected case of severe acute respiratory syndrome coronavirus 2 (sarscov-2) in nepal was diagnosed on 23 january, 2020 which was also the first recorded case in south asia, but after confirmation of subsequent cases on march 23 and 24, the entire nation was put under lock down.[1] between january and march, the government took preventive measures by upgrading health infrastructure, setting up health desks at important public spaces like airports, spreading public awareness through various means, sealing off of international borders.[2,3] initially our optimism stemmed from the slow rise in cases compared to our neighbors which delivered hope that things will be back on track soon. but with consistently escalating infection rates it was clear that we are as vulnerable to this as any other nation. for us, it reflected in thinning out of emergency and urgent cases. this, was sure to have a significant impact on patients’ lives. on one hand owing to confinement measures, to avail specialty services was becoming a challenge for them, especially those from remote, rural areas where transportation even if desired is accessible on select occasions. on the other, phobia of coronavirus led patients to defer going to distant tertiary hospital as far as possible. with all this, our patients might end up with higher stages of vascular diseases, higher degrees of unsalvageable limbs, and delayed presentation in acute emergencies. anticipating this situation our institute (manmohan cardiothoracic vascular and transplant center), resumed most patient services at the earliest possible time. provision for online consultations were made, either through social platforms or hospital's phone application. for those whom this was not an option, personal cell phone numbers of respective faculty and residents were provided for telephonic consultations. to test for coronavirus disease (covid-19), we use either an antibody based rapid diagnostic kit (rdt) or polymerase chain reaction (pcr) test. molecular pcr of respiratory tract samples is the recommended method for identification and laboratory confirmation of covid-19 cases[4] as studies suggest that majority develop antibody response only in second week after symptom onset. [5,6] considering the limited resources, but yet prioritizing safety of health workers our institution has a modified protocol. anyone with influenza like illness (ili), exposure / contact history, fever >100 0 f or clinician’s suspicion would directly take the rtpcr test. those scheduled for surgery, admission or observation, belonging to hot zones but not meeting above criteria would any way take the rdt, and if this comes out to be positive, would be immediately shifted to isolation ward and pcr test be done at earliest. strictly adhering to standard operating protocols (sops), we resumed performing surgeries, prioritizing patients as per urgency. we only use two operating rooms. one designated for suspected or positive cases and other for negative ones. similarly, the post-operative ward was also divided. even after resuming work, we saw a drastic fall in the number bashyal k, et al. vascular surgery in covid-19 period and beyond: acknowledging the new normal. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 of cases which can be inferred from that in the past sixty days of lock down, we have only performed 52 vascular surgeries as opposed to approximately 230 in this same period last year which is a more than seventy five percent reduction. this implies a decrease of almost 40% in hemodialysis access (hd) procedures, 17% of surgery for acute limb ischemia (ali) and vascular injuries, 5% of bypass/hybrid procedures for limb claudication vis-a-vis previous year. (fig. 1) fig. 1 comparison of vascular surgeries in the two years. we believe technology in such situations can be extensively utilized as a boon for both, the doctor and the patient. a telemedicine unit can be setup at district and/or zonal hospitals to make appointments with their physicians easier, as even a simple smart phone would suffice. internet in nepal is now available in almost every corner of the country, (places as high as the annapurna base camp boast of it).[7] this would provide crucial patient – doctor interface, keep the patient content while negating the need to travel long distances in crowded public transports for the same appointment. assuming 7-8 minutes be dedicated for each patient, an average 20-25 patients can be tele-examined in a three hours session every day. doctors, other health workers can be periodically updated through webinars to better their efficiency and broaden spectrum of diseases that can be managed at these centers. we have to develop a work culture assuming the coronavirus is here to stay, as sooner or later the lockdown has to be lifted to resume normal life and the only way, we can be prepared for it is by start preparing now. we must lead a dynamic change in our system, shifting paradigm of vascular surgery to primary health centers via trainings, webinars, workshops and continuing medical education (cme). conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. jha j. lockdown to combat coronavirus: a necessary measure nepal 2020 [updated 25 march 2020]. available from: http://english. lokaantar.com/articles/lockdown-combatcoronavirus-necessary-measure/. 2. adhikari d. nepal seals borders with china, india amid virus fears. anadolu agency. 2020 mar 22. available from: https://www.aa.com.tr/ en/asia-pacific/nepal-seals-borders-with-chinaindia-amid-virus-fears/1775205#. 3. karki b. nepal takes steps to prepare for covid-19. the diplomat. 2020 mar 9. available from: https://thediplomat.com/2020/03/nepaltakes-steps-to-prepare-for-covid-19/. 4. world health organization. advice on the use of point-of-care immunodiagnostic tests for covid-19 2020. available from: https:// w w w. w h o . i n t / n e w s r o o m / c o m m e n t a r i e s / detail/advice-on-the-use-of-point-of-careimmunodiagnostic-tests-for-covid-19. 5. okba nma, muller ma, li w, wang c, geurtsvankessel ch, corman vm, et al. severe acute respiratory syndrome coronavirus 2-specific antibody responses in coronavirus disease 2019 patients. emerg infect dis. 2020;26(7) [epub ahead of print]. pmid: 32267220 doi: https://doi.org/10.3201/ eid2607.200841 6. liu y, liu y, diao b, ren f, wang y, ding j, et al. diagnostic indexes of a rapid igg/igm combined antibody test for sars-cov-2. medrxiv. 2020;[preprint]. doi: https://doi. org/10.1101/2020.03.26.20044883 7. whitman m. internet access on everest base camp trek 2019. available from: https:// ebctrekguide.com/internet-access-everest-basecamp-trek. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 5 may, 2020 accepted: 25 may, 2020 published: 29 may, 2020 a lecturer, department of surgery, b lumbini medical college teaching hospital, palpa, nepal. corresponding author: suman baral e-mail:brylsuman.sur@gmail.com orcid: https://orcid.org/0000-0003-0906-138x how to cite this article: baral s. jugaad culture amidst covid-19: a time to step up for innovation in low-income countries. journal of lumbini medical college.2020;8(1):3 pages. doi: https://doi.org/10.22502/jlmc. v8i1.339 epub: 2020 may 29. _______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.339 suman baral a,b jugaad culture amidst covid-19: a time to step up for innovation in low-income countries more than four months have already elapsed after the world first encountered corona virus claimed to originate from wuhan, china. scientifically, termed sudden acute respiratory syndrome corona virus (sars-cov-2), that causes coronavirus disease of 2019 (covid-19), this deadly pathogen has already claimed about 2.83 lakhs casualties with four million infected and 1.5 million recovered as of 11 may 2020.[1] different preventive measures like hand washing, social distancing, nation-wide lock down from march 23 have been practised in nepal which has definitely dwindled the number of positive cases. they have helped flatten the curve and procure time for preparation for forthcoming disaster.[2] total documented positive cases have been 120 till date (11 may 2020) with zero mortality in nepal. [3] however, the scenario might be out of control in coming days where claims of inadequate testing due to lack of diagnostic kits have been a major issue. whatever be the outcome in upcoming days, for an economically poor country like nepal, preparation seems satisfactory despite challenges to outsourcing the necessary kits like personal protective equipment (ppe) and diagnostic polymerase chain reaction (pcr) machines etc. when the whole world is striving for necessary commodities to combat the unseen enemy due to overwhelming stipulation, it seems obvious that the low economy must foresee that they may not be prioritized for succor. ‘jugaad’ also known as frugal innovation; might be the only way out for indigenous clusters in developing nations. the concept of innovation is still primitive in countries like nepal where the importation surge and declining exportation have hugely created a trade deficit and financial gains from remittance and tourism have again seen the reroute of the capital for exotic goods. current scenario of worldwide pandemic of covid-19 has showered a limelight for producing necessary combat armors like ppe using locally available materials which included gowns made from rubberized taffeta fabric, rain coat, shoe covers, masks, head shields etc. the project led by national innovation center (nic) nepal under the leadership of ramon magsaysay award winner, dr mahavir pun has painted a silver lining in already compromised health care system of the country providing these artefacts to health care workers and ambulance drivers where there has been a deficit. locally made gowns and their reuse after adequate sterilization through autoclave, though have doubts of complete translucency against novel corona virus, they act as a boon during hardships and provide sense of reliability to health personnel, however false security could be dangerous. yet, this is better than to be none at all.[4] construction of corona booth for swab collection which has been xeroxed from south korea model where rows of plastic booths fitted with de-pressurizer, intercom, and attached gloves for doctors outside the booth to interact with and collect samples from the patient; has been an important asset reinforced by nic, nepal.[5] many hospitals in nepal are using such cubicles which have decreased the use of ppe already in deficit and helped to stockpile for the upcoming tragedy should it happen. ventilators availability is another salient issue in the country where the stakeholders claim baral s. jugaad culture amidst covid-19: a time to step up for innovation in low-income countries. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 the availability of 360 machines among which 260 are within the capital city kathmandu and 25% of these apparatus are broken which corresponds to one ventilator per 114,000 nepalese population. [6] to combat this issue, again nic nepal initiated the repair of 85 ventilators which were crippled and succeeded making 40 ventilators reusable. paaila technology, a robotics and artificial intelligence based company in nepal took the initiative of producing low-cost ventilators which have already been experimented in animals and on the verge of testing in humans once they get approval from the government, however human efficacy and safety is yet to be elucidated.[7] a nursing robot also has been developed by paaila which is designed to assist health personnel reducing interaction with corona infected patients. furthermore, it will facilitate communication between patients and medical staff using video technology. also, it helps in delivering food and medicine to patients without manual intervention. they also announced an ultraviolet (uv) disinfection robot which is capable of sterilizing hospitals, banks, airports, and public places that will help in controlling the disease thereby mitigating the risk of exposing people to contamination.[8] for compensation of the face mask shortage, nic-nepal prepared replaceable mask from fabrics of hepa filter, n99 filter for n95 to facilitate the fight against this contagion which has been tested for the efficacy and the results were satisfactory. development of the disinfection boxes using uvc (ultra-violet c) light and hydrogen peroxide in order to facilitate reuse of n95 mask also has been one of the bricolages in the journey of fight against coronavirus. to mitigate the scarcity and fulfill the demands of services to fight the pandemic, government of nepal established temporary covid hospitals with emergency beds and intensive care units along with quarantine and isolation units throughout the country. however, proper functioning of such units has always been a question among the public and health workers. covid-19 surveillance system and selfassessment of the suspected individual has been developed by the government that provides detailed evaluation to know the likelihood of corona infection to a person where the suspected individual entries the data regarding symptoms. based upon the symptoms of the suspected individual, the system suggests a person for self-quarantine and asks for updating their health status continuously for 14 days. the geographic information system(gis)-based mapping capacity of the system will help service providers track the person in quarantine, delivering service at door to the person and location-based strategic planning and making decisions to address the issues.[9] also, the government launched covid tracing and tracking application on 10th may, based on bluetooth technology which traces the suspected individual and real time status could be achieved. this draft encapsulates the glorified accomplishment of the country to combat the coronavirus led by the accountable natives which definitely has painted a silver lining for the upcoming generations. now, time has come to march into the real innovation, following footsteps of two techno giants india and china, providing the insights to the world that we are growing on to be independent financially, technically and operationally. conflict of interest: the author declares that no competing interest exists. funding: no funds were available for the study. references: 1. covid-19 coronavirus pandemic. available from: https://www.worldometers.info/ coronavirus/ ( accessed on 11 may 2020) 2. kshetry r. nepal’s community hand washing campaign pays off in times of covid 19 crises https://www.wsscc.org/2020/04/03/nepalscommunity-handwashing-campaign-pays-offin-times-of-covid-19-crisis/ ( accessed on 11 may 2020) 3. coronavirus disease (covid-19) outbreak updates & resource materials. available from: https://heoc.mohp.gov.np/update-on-novelcorona-virus-covid-19/ ( accessed on 11 may 2020) 4. livingston e, desai a, berkwits m. sourcing personal protective equipment during the covid-19 pandemic. jama. 2020;323(19):1912–1914. doi: 10.1001/ jama.2020.5317. 5. 5. kim si, lee jy. walk-through screening center for covid-19: an accessible and efficient screening system in a pandemic situation. j korean med sci. 2020;35(15):e154. pmid: 32301300 doi: 10.3346/jkms.2020.35. e154 6. neupane a. nepal has just 1 ventilator for 1,14,000 people https://myrepublica. nagariknetwork.com/news/nepal-has-just-oneventilator-for-114-000-people/ ( accessed on 11 may 2020) 7. gurung k. in nepal, a device to protect corona patients from risk has been developed. available from: https://swasthyakhabar.com/story/32138. (accessed on 11 may 2020) 8. robots on the rise amid covid-19 pandemic: how is paaila technology contributing. available from: https://ictframe.com/robots-on-therise-amid-covid-19-pandemic-how-is-paailatechnolgy-contributing/ (accessed on 11 may 2020) 9. nepal covid-19 surveillance system and selfassessment app. available from: https://www. n r e n . n e t . n p / n e p a l c o v i d 1 9 s u r v e i l l a n c e system-and-self-assessment-app/ (accessed on 11 may 2020) baral s. jugaad culture amidst covid-19: a time to step up for innovation in low-income countries. j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 jlmc.edu.np licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 10 june, 2020 accepted: 13 june, 2020 published: 22 june, 2020 a lecturer, department of obstretics and gynecology, bassistant professor, department of obstretics and gynecology, clumbini medical college teaching hospital, palpa, nepal. corresponding author: arati shrestha email: draratistha@gmail.com orcid: https://orcid.org/0000-0001-5214-3271 how to cite this article: shrestha a, aryal s, shrestha d. covid-19, pregnant women and their hard-wired worry. journal of lumbini medical college. 2020;8(1): 3 pages. doi: https://doi.org/10.22502/jlmc.v8i1.381 epub: 2020 june 22._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.381 arati shrestha,a,c shreyashi aryal,b,c deepak shrestha b,c covid-19, pregnant women and their hardwired worry in our day to day obstetric practice we face a number of concerns raised by the pregnant women regarding their health. some of the frequently asked queries include: if they would develop health problems like high blood pressure and/or diabetes; if they would have a normal delivery or would require an intervention in the form of cesarean section or instrumentation, if they would have the birth experience as they envision and if the stress is harmful during the ongoing pregnancy. every pregnant woman strives her best to give birth to a healthy child. as every pregnancy is a period of uncertainties and risks, pregnant women are anxious about their well-being and that of their baby. the list of concerns are endless with the addition of corona virus disease (covid-19). if we look back into the past, viral infections such as influenza, h1n1, and severe acute respiratory syndrome (sars) caused immense maternal and fetal complications during pregnancy. due to compromised, pregnant women are more vulnerable to being infected.[1] sars-cov-2 is a new strain of corona virus that is similar to middle east respiratory syndrome corona virus (mers-cov) and severe acute respiratory syndrome coronavirus (sars-cov). these viruses spread primarily by coughing and sneezing or direct contact. most patients infected with any one of these three strains of corona virus may remain asymptomatic or may develop relatively mild symptoms such as fever, cough and fatigue. however, some may develop severe forms of the disease leading to pneumonia and respiratory failure; requiring oxygen or other respiratory support. pregnant women infected with mers-cov or sars-cov were at high risk of developing severe pneumonia; heart failure and other complications which could be life threatening leading to death in many cases.[2] due to lack of meticulous evidences on the number of confirmed cases and further categorizing them based upon disease severity and other associated co-morbid conditions in nepal, we can only presume the effects of covid-19 as per the information gathered from other countries. nevertheless, information on covid-19 during pregnancy are promising; unlike the mers-cov or sars-cov infections.[3] however, there is a concern that pregnant women might be more prone to miscarriage, preterm birth and fetal growth restriction if they get infected with covid-19.[4] in nepal, it is feared that covid-19 peak is yet to be reached, as seen with other countries who were hit hard by the global pandemic. most of the information we have are based on the reports of the sick patients or those that were believed to be at high risk for having infection with covid-19 and many mild cases might still be undetected. in that setting, we might learn more about the worst outcomes before we learn about milder ones. the centers for disease control and prevention (cdc) has released interim clinical guidance for management of patients with confirmed covid-19, and guidance for evaluating and testing infected people. american college of obstetricians and gynecologists (acog) has developed covid-19 frequently asked questions (faqs) for obstetriciangynecologists to supplement this practice advisory and provide additional information for clinicians on shrestha a, et al. covid-19, pregnant women and their hard-wired worry. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 the frontline of the covid-19 pandemic.[4] it is still unclear if covid-19 has a potential of vertical transmission. it is reported that the sarscov-2 receptor shares the same receptor, angiotensin converting enzyme (ace2), with sars-cov.[5] based on the single cell rna-sequencing database, analysis of mrna expression over maternal-fetal interface was done. the result showed ace2 has very low expression in different cell types of maternal fetal interface except slightly high in decidual perivascular cell cluster.[5] this concludes that mother-to-fetus transmission will be significantly lower, which will help to avoid unnecessary panic among the general public. it is still unknown whether there are other receptors responsible for the sars-cov-2 infection, further studies are required in this matter. as the maternal secretions are likely to get in contact with the newborn during the process of delivery, vertical transmission cannot be totally denied. it has been very challenging for pregnant women to receive health services during this pandemic. visiting hospital for regular check-ups or other health issues and delivery during a pandemic can be petrifying. most hospitals have made protocols on protecting pregnant women during delivery; like rescheduling or canceling elective surgeries, moving many procedures and visits out of the hospital setting and into outpatient facilities, evaluating possible covid-19 patients in an isolated area, separating known or suspected covid-19 patients from other patients limiting their visitors; checking visitors for symptoms of possible covid-19 infection, and identifying dedicated staff to care for covid-19 patients. to avoid the risk of getting infected through health care workers, efforts have been made to limit the number of staffs who are exposed to these patients; nurses, doctors and hospital workers are checked for symptoms of possible covid-19 infection when they come to work and health workers need to stay at home if they are ill.[6] if any patient has to deliver a baby while suspected or known to be infected with covid-19, the cdc recommends isolation and separation from the baby until recovery, to avoid infecting the newborn. breast milk can be expressed and provided to the baby, as there is no evidence of the presence of the virus in breastmilk of infected mothers.[7] the best way to prevent infection with covid-19 during pregnancy is to decrease the chances of being exposed to the virus. the who recommends basic hygiene practices which include regularly washing of hands with soap and water, covering mouth with an elbow while sneezing or coughing, maintaining a “social distance” of at least 1.8 meters (six feet) from others; avoiding unnecessary and unprotected contact with suspected covid-19 patients, and washing hands thoroughly after any contact.[8] to help pregnant women avoid any contact with others, communications via telephone or video conference (telemedicine) should be encouraged. it is important for health care providers to stay up to date with new evidences on covid-19, as new information are released everyday. as a practicing obstetrician, although limited, less severity of disease and minimal complications are the information that can be shared with anxious pregnant patients to comfort them. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. shrestha a, et al. covid-19, pregnant women and their hard-wired worry. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 references: 1. world health organization (who). clinical management of severe acute respiratory infection when novel coronavirus (ncov) infection is suspected: interim guidance. available from: https://www.who.int/publicationsdetail/clinical-management-of-severe-acuterespiratory-infection-when-novel-coronavirus(ncov)-infection-is-suspected accessed 2020 mar 14. 2. lamouroux a, attie-bitach t, martinovic j, leruez-ville m, ville y. evidence for and against vertical transmission for sars-cov-2 (covid-19). am j obstet gynecol. 2020; [epub ahead of print]. doi: https://doi.org/10.1016/j. ajog.2020.04.039 3. schwartz da, graham al. potential maternal and infant outcomes from coronavirus 2019ncov (sars-cov2) infecting pregnant women: lessons from sars, mers, and other human coronavirus infections. viruses. 2020;12(2):194. doi: https://doi.org/10.3390/v12020194 4. american college of obstetricians and gynecologists practice advisory: novel coronavirus 2019 (covid-19). 2020 march 13. available from: https://www.acog.org/ clinical/clinical-guidance/practiceadvisory/ articles/2020/03/novel-coronavirus-2019 5. zheng ql, duan t, jin lp. singlecell rna expression profiling of ace2 and axl in the human maternal–fetal interface. reprod dev med. 2020;4:7-10. doi: https://doi. org/10.4103/2096-2924.278679 6. centers for disease control and prevention. interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings. available from: https:// www.cdc.gov/coronavirus/2019-ncov/infectionc o n t r o l / c o n t r o l r e c o m m e n d a t i o n s . h t m l ? accessed 2020 mar 19. 7. centers for disease control and prevention. interim guidance on breastfeeding for a mother confirmed or under investigation for covid-19. available from: https://www.cdc. gov/coronavirus/2019-ncov/specific-groups/ p r e g n a n c y g u i d a n c e b r e a s t f e e d i n g . h t m l . accessed 19 feb 2020 8. coronavirus disease (covid-19) pandemic. who (updated 2020 april 21, 1:00pm cest). available from: https://www.who.int/ emergencies/diseases/n ovel-coronavirus-2019 study of thyroid lesions by fine needle aspiration cytology and its correlation with thyroid function test anuj poudel,a,c sk jainb.c —–————————————————————————————————————————————— abstract: introduction: fine needle aspiration cytology (fnac) of the thyroid gland has been widely and successfully utilized for diagnosis. assessment of thyroid pathology is even more informative if correlated with thyroid function tests (tft). this study aims to compare the efficacy of fine needle aspiration cytology with thyroid function tests in different thyroid lesions. methods: a descriptive study was carried out among the patients who presented with thyroid swelling visiting department of ear nose throat (ent) of lumbini medical college and teaching hospital (lmcth) from june 2012 to february 2013. the study population were selected on random basis. a total of fifty patients involved in the study and were sent to department of pathology for fnac and tft. results: most of the cases (44%) of thyroid swelling were from 21 to 40 years of age. among them, 86% were females. out of total respondents, 48% were found to be colloid goiter. 70% findings of fnac and tft were in accordance. conclusions: the findings of fnac and tft were found to be significantly associated (p value <0.05). keywords: fine needle aspiration • hyperthyroidism • hypothyroidism • thyroid function test ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer b professor c department of pathology lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. anuj poudel e-mail: dranuj2002@yahoo.co.in how to cite this article: poudel a, jain sk. study of thyroid lesions by fine needle aspiration cytology and its correlation with thyroid function test. journal of lumbini medical college. 2013;1(1):28-30. doi:10.22502/jlmc.v1i1.9. ___________________________________________________________________________________ j. lumbini. med. coll. vol 1, no 1, jan-june 2013 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v1i1.9 introduction: fnac of the thyroid gland is now wellestablished, first line diagnostic test for the evaluation of thyroid lesions with the main purpose of confirming the type of thyroid lesion and thereby, reducing unnecessary surgery.1 although there is a large body of world literature claiming the accuracy and usefulness of thyroid cytology, there is also evidence showing possible limitations and pitfalls of this procedure.2,3 in view of this, we compared cytomorphological details with thyroid function test (tft). we scrutinized the cases showing any discrepancy in cytology findings with tft with aim of establishing possible causes of the errors. methods: a descriptive study was conducted among 50 patients who presented with swelling in the thyroid region in the department of ent of lumbini medical college and teaching hospital (lmcth) during june 2012 to feb 2013. they were then sent to pathology department for tft and fnac. the procedure was explained to the patient and verbal consent was obtained prior to performing the procedure. these patients were subjected to fnac using 23/24-gauge needle and 10 cc sterilized and disposable plastic syringes after taking all aseptic precautions.4 all slides were stained by wright method and thyroid function test was performed by clia.5 diagnosis of cytological smears were done according to standard criteria defined by sidaway.6 cases with cytological and thyroid function tests disparity were selected and were re-evaluated for the detection of possible causes of failure. necessary descriptive statistics (percentage, frequency) including inferential statistics (pearson x2 test) to compare the association between categorical data 28 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np poudel a. et al. study of thyroid lesions by fine needle aspiration cytology and its correlation with thyroid function test. were calculated using spss 16. p-value <0.05 was regarded as statistically significant. results: among the total thyroid swelling cases, 86% were female and 14% were male (table 1). 44% of thyroid swelling cases were from the age group of 21 to 40 years (table 2). 58% and 42% patients had nodular and diffuse swelling respectively (table 3). among the fnac results, 48% colloid goiters were found in study population (table 4). 70% of thyroid function test results (t3, t4 and tsh) were in accordance to cytomorphological study (p value <0.05) and 30 % of results were not in accordance (table 5). table 1: cross tabulation of sex and tft table 2: age distribution of patients table 3: cross tabulation between swelling and tft table 4: cross tabulation between fnac and tft discussion: fnac is an inexpensive, simple and rapid method of obtaining pathological diagnosis that is particularly suitable for use in the resource-poor setting.7 the numerous diagnostic procedures currently available improve the anatomic, pathologic, radiologic and functional assessment of the thyroid swelling but may also lead to unjustified increase in cost with little practical gain, if not used rationally. as most of the hospitals lack some of these ancillary diagnostic investigations, fnac is still regarded as the single most accurate and cost-effective procedure. it is well known that a thyroid function results varies according to the different thyroid lesions. it can range from hypo to hyperthyroidism, euthyroidism to subclinical hypoand hyperthyroidism. in the present study, out of 50 cases of thyroid lesions, the findings of fnac and tft were in correlation with each other in 35 (70%) cases. in 15 (30%) cases, the findings of fnac were not in accordance with tft. out of 24 cases of colloid 29 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 poudel a. et al. study of thyroid lesions by fine needle aspiration cytology and its correlation with thyroid function test. jlmc.edu.np goiter, fnac and tft results were in correlation in 21 (87.5%) cases and findings were not in correlation in 3 (12.5%) cases. similar findings were found in thyroiditis. the fnac findings were well in correlation with tft in ten (76.9%) cases and in accordance in three (23.1%) cases. there are few studies that focused on cytomorphology and serologic correlation. singh n. conducted a study of 150 cases in jawaharlal institute of postgraduate medical education and research centre, which reported that fire flares and macrophages in fnac correlates positively with hyperthyroidism with p values of 0.002 and 0.005 respectively.8 results from our study also reflect the similar picture. chehade jm conducted a study at university of florida, college of medicine found that there was a high degree of concordance between serological and cytological findings of lymphocytic thyroiditis in people with nodular colloid goiter.9 similarly luiz hv reported a case of thyroid tuberculosis under fnac along with thyroid function which was consistent with subclinical hyperthyroidism that subsequently evolved into hypothyroidism.10 one of the most difficult aspects sometimes is to correlate cytomorphological details with that of tft when the findings do not correlate with each other as in our study 30% of cases were discordant. fnac can effectively diagnose thyroid lesions and the like malignant tumor of thyroid endocrine system papillary carcinoma. unfortunately, this is not always the case; the diagnosis of thyroid lesions and their clinical management is highly dependent upon many variables such as: the physical characteristics of thyroid lesion, operator experience (i.e., the individual performing fnac and interpreting the cytomorphology) and thyroid hormone replacement therapy.11-15 conclusion: there were significant correlations of results between tft and fnac although, some discordance was found between these two parameters. in spite of the high levels of awareness about performing tft and fnac, the level of awareness could not be matched by a corresponding high level of utilization by these tests. fnac and serological evaluation demonstrate cost advantage and high accuracy, benefits patient’s care and cost-containment efforts in the centers with limited diagnostic facilities. references: 1. orell sr. in: orell sr, sterrette gf, walters mn, whitakar d. (eds). manual and atlas of fine needle aspiration cytology (4th ed.). new delhi: churchill-livingstone; 2005. p.125-64. 2. hamburger ji, husain m, nishiyama r, nunez c, solomon d. increasing the accuracy of the fine needle biopsy for the thyroid nodules. arch pathol lab med. 1989;113:1035-41. 3. reagan lr, farkas t, dehner lp. fine needle aspiration of the thyroid: a cytohistologic correlation and study of discrepant cases.thyroid. 2004;14:35-41. 4. smit tj, sefali h, foster ea, reinhold rb. accuracy and cost-effectiveness of fine needle aspiration biopsy. am j surg.1985;149:540-5. 5. hall tl, layfield lj, philippe a, rosenthal dl. sources of diagnostic error in fine needle aspiration of thyroid. cancer.1989;63:718-25. 6. sidaway mk, delvecchio dm, knoll sm. fine needle aspiration of thyroid nodules: correlation between cytology and histology and evaluation of discrepant cases. cancer.1997;81:253-9. 7. das dk. fine needle aspiration cytology: its origin, development and present status with special reference to developing country, india. diagn cytopathol. 2003;28:345-51. 8. singh n, kumar s, negi vs, siddaraju n. cytomorphologic study of hashimoto’s thyroiditis and its serologic correlation: a study of 150 cases: acta cytol. 2009;53(5):507-16. 9. chehade jm, lim w, silverberg ab, mooradian ad. the incidence of hashimoto’s disease in nodular goiter: the concordance in serological and cytological findings. int j clin pract. 2010; 64(1):29-33. 10. luiz hv, pereira bd, silva tn, veloza a, matos c. thyroid tuberculosis with abnormal thyroid functioncase report and review of literature. endocr pract. 2013;21:1-15. 11. cronan jj. thyroid nodules: is it time to turn off the us machines? radiol. 2008;247:602-4. 12. kini sr. color atlas of differential diagnosis in exfoliative and aspiration cytopathology. philadelphia: lippincott williams & wilkins; 2011. xvii, p: 1015. 13. oertel yc. a pathologist’s comment on diagnosis of thyroid nodules by fine needle aspiration. j clin endocrino metabol. 1995;80:1467-8. 14. oertel yc. who should perform fine-needle aspirations? cytopathol. 1997;8:134-8. 15. oertel yc. fine-needle aspiration in the evaluation of thyroid neoplasm. endocr pathol. 1997;8:215-24. 30 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 01 june, 2020 accepted: 03 june, 2020 published: 07 june, 2020 aassistant professor, department of pediatrics, b-kathmandu medical college teaching hospital, kathmandu, nepal. corresponding author: smriti mathema e-mail: smritimathema@gmail.com orcid: https://orcid.org/0000-0002-3601-4274 how to cite this article: mathema s. the impact of covid-19 on immunization services. journal of lumbini medical college.2020;8(1):3 pages. doi: https:// doi.org/10.22502/jlmc.v8i1.366 epub: 2020 june 07._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.366 smriti mathema a,b the impact of covid-19 on immunization services there was a time when epidemics were of interest only to historians. in spite of the knowledge of the risks of emergent infectious diseases, coronavirus disease of 2019 (covid-19) managed to disrupt the entire world. this new virus has the capacity to evade, adapt, diversify and persist. human factors such as global travel, human-animal contact, urban crowding and ecological changes have helped favor the rapid spread. epidemics are known to eventually resolve, whether succumbing to societal action or having exhausted the supply of susceptible victims.[1] covid-19 too will be contained but it will leave a trail of devastating health consequences for lowand middle-income countries (lmic) including nepal. when governments responded in the hopes of slowing the course of the pandemic and reducing the total mortality, stringent controls were implemented, including school closures, bans on public gatherings, and other forms of isolation or quarantine.[2] in nepal, a nationwide complete lockdown commenced on the 24th march, 2020. this brought about a drastic decrease in demand for hospital services, mainly due to inaccessibility or the health care seekers’ apprehension of contracting the virus during a hospital visit. elective surgeries and procedures were temporarily discontinued and preventive care such as antenatal and well-baby visits came to a complete halt in majority of the institutions nationwide. although mortality rates for covid-19 appeared to be low in children and in women in the reproductive age,[3] these groups might be disproportionately affected by the disruption of routine health services, particularly in lmics. this pandemic has had a huge impact on ongoing preventive public health programs, including immunization services. in the wake of the lockdown, many health centers, both urban and rural, had no choice but to temporarily pause vaccination clinics. interruption in these routine immunization programmes, outreach services and preventive vaccination campaigns was further accentuated by the lack of definite decision from higher authority. the issue was made more complex by the break in supply and distribution chain and hesitation of vaccinators to continue their services. based on the research by john hopkins bloomberg school of public health[4], a press statement was released by the united nations children’s fund (unicef) in mid-may warning that researchers an estimated of 4000 children are in the risk of dying within the next six months in nepal alone. our country cannot afford to lose momentum on the decades of progress we have made to reduce child mortality rates. lost income, increased prices, and overburdened social safety nets will push vulnerable groups further into poverty and increase financial and other barriers to health-care access.[4] this study further explains how four health system components affect coverage of services: availability of health workers, availability of supplies and equipment, demand for services, and access to services. if we directly translate this into immunization services, it becomes clear on how the pandemic can affect the provision mathema s. the impact of covid-19 on immunization services. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 and utilization (figure 1). fig. 1. framework for the effects of health system components on coverage of immunization services. world health organization (who) released operational guidance for maintaining essential health services and adapting service delivery platforms to avoid interruptions.[5] the department of health services, ministry of health and population, nepal also eventually took out a statement in relation to recommencement of routine immunization services and set out important guidelines:[6] 1. maintain social distancing while conducting immunization services. 2. screening children for detection of ‘fever and dry cough’ prior to vaccination. 3. management of personal protection for safety of health care workers (hcw). 4. manage immunization to all targeted (15 months and below) children. 5. to inform and co-ordinate implementation of immunization services to local administration, local levels and all stakeholders. there were some institutions, such as kathmandu medical college teaching hospital, who were able to resume their vaccine clinics, however most failed to do so. there was an atmosphere of general confusion and a palpable lack of leadership and initiative. from a health worker’s perspective, they lacked clear instructions and struggled to find a way to commute to their respective workplaces. majority of them also had to deal with the uncertainty of their own safety and protection, whereas some were diverted to covid-19 activities. the country has to be even more prepared for what will happen in the years to follow, than the pandemic itself. there will be a rise in the proportion of malnourished children, in turn making them susceptible to infections and affecting childhood mortality in the long term. with international and domestic disruption of supply chains, there is bound to be a shortage of vaccines and essential treatments such as oral rehydration solution along with common antibiotics used in community-based integrated management of neonatal and childhood illnesses (cb-imnci). provision and utilization of reproductive and maternal care has had an adverse effect by the response to the pandemic which will give a secondary rise to neonatal sepsis. general well-being of children is at stake as millions of children are forced out of school, taking a toll on their mental health and making them more prone to child abuse. we may not experience the full immediate effects of decreased vaccination in countries with high coverage rates, as certain vaccines like haemophilus influenzae type b vaccine and pneumococcal conjugate vaccines have herd effect protection[7] which will gradually wane over the following months. however, even short gaps in vaccination coverage can result in overall declines in population coverage, and catch-up campaigns should be prioritized aftermath the covid-19 pandemic. [8] the longer that coverage reductions continue, the more lives will be lost and, vaccine preventable diseases like polio, diphtheria and measles will resurface. has the world done more collateral damage in a bid to stop the spread of covid-19? leaders should be taking immediate actions now, from accelerating work on treatment and vaccines to investing in disease surveillance and strengthening primary health care systems in lmics.[9] as the pandemic continues to weaken the health system and disrupt routine services, we should be prepared to deal with the health consequences which are likely to reverberate for decades to come. the choices our government and policy makers make would now be crucial to dictate the peak of child mortality rates and how quickly our nation would recover. conflict of interest: the author declares that no competing interest exists. funding: no funds were available for the study. references: 1. jones ds. history in a crisis lessons for covid-19. n engl j med. 2020; 382: 1681–1683. doi: https://doi.org/10.1056/nejmp2004361 2. markel h, lipman hb, navarro ja, et al. nonpharmaceutical interventions implemented by us cities during the 1918-1919. influenza pandemic. jama. 2007; 298 (6):644-654. doi: https://doi.org/10.1001/jama.298.6.644 3. who. report of the who–china joint mission on coronavirus disease 2019 (covid-19). geneva: world health organization; feb 28, 2020. https://www.who.int/docs/default-source/ coronaviruse/who-china-joint-mission-oncovid-19-final-report.pdf (accessed may 1, 2020). 4. roberton t, carter ed, chou vb, et al. early estimates of the indirect effects of the covid-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. lancet glob health. 2020 [epub ahead of print]. doi: https://doi.org/10.1016/ s2214-109x(20)30229-1 5. who. covid-19: operational guidance for maintaining essential health services during an outbreak. https://www.who.int/publicationsdetail/covid-19-operational-guidance-formaintaining-essential-health-services-duringan-outbreak (accessed may 1, 2020). 6. mohp, gon, 2020. (subject: in relation to routine immunization services), circulation letter issued by mohp, department of health services, may 2020 7. carter ed, tam y, walker n. impact of vaccination delay on deaths averted by pneumococcal conjugate vaccine: modeled effects in 8 country scenarios, vaccine 2019; 37: 5242–49. doi: https://doi.org/10.1016/j. vaccine.2019.07.063 8. who. guiding principles for immunization activities during the covid-19 pandemic: interim guidance. geneva: world health organization; 26 march 2020. https://apps.who. int/iris/handle/10665/331590 (accessed may 1, 2020). 9. gates b. responding to covid-19 — a oncein-a-century pandemic? n engl j med. 2020; 382:1677-1679. doi: https://doi.org/10.1056/ nejmp2003762 mathema s. the impact of covid-19 on immunization services. j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 jlmc.edu.np licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 03 june, 2020 accepted: 06 june, 2020 published: 11 june, 2020 aconsultant colorectal and general surgeon, james paget university hospital. bsenior lecturer, university of east anglia, uk. corresponding author: kamal aryal email: rlkamal2000@hotmail.com orcid: https://orcid.org/0000-0001-9300-5211 how to cite this article: aryal k. covid-19 in the ukexperience from the frontline. journal of lumbini medical college.2020;8(1):3 pages. doi: https://doi.org/10.22502/jlmc.v8i1.372 epub: 2020 june 11._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.372 kamal aryal a,b covid-19 in the ukexperience from the frontline start of the pandemic at the end of february, i was undertaking a mini fellowship on trans-anal total meso-rectal excision (tatme) in switzerland. the number of cases infected with corona virus disease (covid-19) and deaths were rising exponentially in italy. as the virus hit the uk, i was still able to complete ‘nontechnical skills for surgeons (notss) for trainees’ course at the deanery office at fulbourn, cambridge on the 13th of march 2020.[1] effect on personal life self isolation i had operating list on the 17th of march where an 81-year-old male having laparoscopic right hemicolectomy for cancer was listed. this patient was readmitted a week after being discharged from the hospital with collapse and it had become apparent that he acquired covid-19 in the surgical ward. fortunately, he recovered from this and remains well till date. the same day, my son had fever with some cough. i needed to selfisolate according to uk government guideline for two weeks as there was no facility for testing whether my son had contracted coronavirus or not. there were a lot of problems in getting food from the supermarket on the way back home as the shelves were empty, online food order was impossible but somehow, we managed with our friends delivering food for us at our front door. although i was self-isolating, i did all the work which was possible from home including annual review of competence progression (arcp) for general surgery specialty trainees and reorganization of the colorectal services at hospital. there were new updates coming from the specialty associations including association of surgeons of great britain and ireland (asgbi), association of colo proctologists of great britain and ireland (acpgbi), european association of endoscopic surgeons (eaes) and british association of gastroenterology (bsg). the advancement in surgery (ais) channel webinars organized in collaboration with chinese panelists sharing their experience with surgeons from all over the world was very useful.[2] as the colonoscopy and laparoscopic surgery were supposed to be aerosol generating, there was massive fear about these techniques. at one stage, i thought the laparoscopic surgery was dead! there was a talk about negative pressure theatres which are not available in uk. patients referred with suspected bowel cancer had to be diverted towards ct scan rather than colonoscopy for investigations. the number of covid-19 cases kept on rising. many people in italy kept on dying which remained the country with most deaths in europe for many weeks which was soon surpassed by uk. surgeries during pandemic we prepared colorectal service document for my hospital based on national guidelines during the pandemic.[3] the hospital complex had to be re-organized in red, yellow, and green areas. we continued with emergency surgeries but changed these to open and stopped laparoscopic surgery completely. conservative management with antibiotics rather than surgery were tried for aryal k. covid-19 in the ukexperience from the frontline jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 appendicitis and cholecystitis. we gave stomas for all colon/rectal resections rather than anastomosis. we cancelled all benign elective general surgeries which continues to be paused to present time. there was a pause for elective cancer resections for three weeks at the height of pandemic in late march and early april. then we restarted the colorectal cancer operations at clean area of the hospital. initially open surgery with stoma rather than anastomosis was performed for these cases. as the number of cases plateaued and started declining, the association of laparoscopic surgeons of great britain and ireland (alsgbi) issued position statement about laparoscopic surgery and there were good ways to mitigate risks of aerosolization during laparoscopic surgery.[4] in summary, the surgical pathway involves patients self-isolate for two weeks pre operatively (it was one week when we started), have covid screening including pcr ( polymerase chain reaction) testing 48 hours before anticipated surgery (used to do chest ct initially but this was dropped as the national guideline stated it as ‘not required’ in mid-may), surgery at clean operating theatres and green ward post operatively and selfisolation for two weeks after surgery. full personal protective equipment (ppe) was worn during the surgery. ideally, the staffs should have been tested periodically but it did not happen yet in our hospital. the consent forms were revised to include additional complications of covid-19. we were able to have no mortality so far amongst 15 elective cancer patients operated during the pandemic at my hospital. two laparoscopic stacks were available in our hospital stryker pneumoclear and air seal both have capabilities of filtering aerosol sizes as small as 0.01 micron [5]. all emergency admissions were covid-19 tested and we had re-introduced lap surgery for selected emergency operations in case by case basis if it was believed that the benefit of lap over open surgery was substantial. effect on referrals with suspected cancer with lockdown, the patients were asked not to travel to hospital unless necessary. there was a huge reduction in referral for patients with suspected bowel cancer to 25% of what we generally get. face to face consultations were replaced by telephonic and video consultations. in the primary care, more emphasis was placed in fecal immunochemical testing (fit) to triage patients with altered bowel habit – value more than 100 being significantly raised needing investigation as soon as possible. although, ct scans were used rather than colonoscopies for investigations at the height of pandemic, more and more colonoscopies were being performed with necessary precautions.[6] personal protective equipment (ppe) i was on call for a week at the beginning of april. the ffp3 testing took quite a while for me to be fitted with ffp3, 3m 1873 mask. also, further full protection such as face shield should be worn. i needed to do open ileo-caecal resection for ileocaecal crohn’s as an emergency. as i tried to stop bleeding using diathermy there was production of visible smoke. despite suction connected to this diathermy, some must have escaped and travelled to any staff present in the theatre including myself. the virus particles may travel to patient from staff in theatres some of whom may be virus carriers. there was ffp3 mask but there was no proper face shield. the visor provided was not good enough as the viral particles could easily travel to face via the side and top of the visor. i was immediately given face shield as i raised this issue with the chief executive and the infection control in the hospital. covid positive patient needing major surgery dilemma whether to operate or not i was asked to operate a 72-year-old male covid-19 positive patient, who had acute severe colitis and was not responding well to medical treatment. as i approached him, i could hear his typical breathing which sounded to me as something was stuck in his throat. the decision to operate upon him was abandoned because it was believed that the risk of mortality is double for patients going to ward and four times if going to icu (intensive care unit) ventilated compared with current predicted mortality scores for covid-19 positive patients undergoing surgery. the reported crude post-operative mortality rate remains 20-25% for covid positive patients. [7,8] the patient succumbed to death later that night. present condition and future as the number of covid-19 cases plateaus and hopefully declines, the hospital and our surgical cases go up. referrals with suspected cancer is going up as the lockdown is gradually released. the challenge now is to perform colonoscopy in all the patients who have been waiting for several months. we are managing the surgical cases for cancer who are in need of surgery. careful case selection based on priority of disease, vulnerability of the patient and environmental factors are key factors taken into account on case selection and operation.[9] we are at the time of uncertainty. there is a fear that we may get another surge of cases in uk. it is worrying; the number of cases is going up in nepal and nearly 10 patients have died at the time of writing (june 4, 2020). in the uk, the number of nepalese who have died has already exceeded 50. putting upon the emphasis of “test, trace and track” i hope will help to diagnose and contain the spread of virus thereby reducing the number of cases. i am of optimism that we will beat this pandemic. let’s hope invention of a cure is not too far away! conflict of interest: author declares that no competing interest exists. funding: no funds were available for the study. references: 1. non-technical skills for surgeons (notss). available from: https://www.rcsed.ac.uk/professional-support-development-resources/learning resources/non-technical-skills-for-surgeonsnotss 2. covid-19 perspectives from wuhan: johnson & johnson institute collaboration shares learnings from chinese medical experts. 2020 apr 23. available from: https://jnjinstitute. com/en-us/news/covid-19-perspectives-wuhan-johnson-johnson-institute-collabora tion-shares-learnings-chinese-medical-experts 3. acpgbi, 2020. considerations for multidisciplinary management of patients with colorectal cancer during the covid-19 pandemic. march 26 2020. available from: https://www.acpgbi.org.uk/news/considerations-for-multidisciplinary-management-of-patients-with-colorectal-cancer-during-the-covid-19-pandemic/ 4. laparoscopy in the covid 19 environment alsgbi position statement. 2020 apr 22. available from: https://www.alsgbi.org/2020/04/22/ l a p a r o s c o p y i n t h e c o v i d 1 9 e n v i r o n ment-alsgbi-position-statement/ 5. resources on smoke and gas evacuation during open, laparoscopic and endoscopic procedures. 2020 jun 3.available from: https://eaes.eu/covid19-statements/resources-on-smoke-gas-evacuation-during-open-laparoscopic-and-endoscopic-procedures-updated/ 6. joint acpgbi, bsg and bsgar considerations for adapting the rapid access colorectal cancer pathway during covid-19 pandemic. 2020 apr 10. available from: https://www.bsg.org. uk/covid-19-advice/covid-19-advice-for-healthcare-professionals/joint-acgbbi-bsg-and-bsgarconsiderations-for-adapting-the-rapid-accesscolorectoral-cancer-pathway-during-covid-19pandemic 7. covidsurg collaborative. mortality and pulmonary complications in patients undergoing surgery with perioperative sars-cov-2 infection: an international cohort study. lancet. 2020;[epub ahead of print]. pmid: 32479829 doi: https:// doi.org/10.1016/s0140-6736(20)31182-x 8. lei s, jiang f, su w, chen c, chen j, mei w, et al. clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection. eclinicalmedicine. 2020;21 [epub ahead of print]. pmid: 32292899 pmcid: pmc7128617 doi: https://doi.org/10.1016/j.eclinm.2020.100331 9. resumption of elective colorectal surgery during covid-19 updated acpgbi considerations on surgical prioritisation, patient vulnerability and environmental risk assessment. 2020 apr 28. available from: https://www.acpgbi.org.uk/content/uploads/2020/05/updated-acpgbi-considerations-on-resumption-of-elective-colorectal-surgery-during-covid-19-v17-5-20.pdf aryal k. covid-19 in the ukexperience from the frontline j. lumbini. med. coll. vol 8, no 1, jan-june 2020j. lumbini. med. coll. vol 8, no 1, jan-june 2020 jlmc.edu.np j. lumbini. med. coll. vol 8, no 1, jan-june 2020 baral s, et al. baral s, et al. axial torsion and meckel’s diverticulitis: a diagnostic conundrum licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 31 march, 2020 accepted: 3 may, 2020 published: 21 may, 2020 a lecturer b resident c department of obstetrics and gynecology, manipal teaching hospital, pokhara, nepal. corresponding author: anjali subedi adhikari e-mail: anzee739@gmail.com orcid: https://orcid.org/0000-0002-9809-6180__________________________________________________ abstract introduction: acute pancreatitis is a rare event in pregnancy. hypertriglyceridemia induced acute pancreatitis accounts for the second most common cause in pregnancy. this rare event has a high maternal and fetal mortality of 20% and 50% respectively. case report: a 21-year-old woman, g2p0+1 at 26 weeks period of gestation presented to obgyn emergency in a state of shock with history of sudden onset of severe epigastric pain and multiple episodes of vomiting for one day and absent fetal movement for six hours. immediate fluid resuscitation was done. her reports showed increased hematocrit, leukocytosis, serum lipase and amylase elevated to > 200u/l. ultrasonography showed bulky pancreas with intrauterine fetal death. with the diagnosis of acute pancreatitis with fetal demise, she was managed conservatively in intensive care unit by fasting, nasogastric aspiration, intravenous fluids, antibiotics, analgesics and heparin. she was intubated on the third day for increasing tachypnea. her lipid profile showed elevated triglyceride> 1000 mg/dl and was started on oral hypolipidemic drugs. pregnancy was terminated vaginally by misoprostol and was discharged on 19th day. conclusion: hypertriglyceridemia induced acute pancreatitis in pregnancy has an increased maternal and fetal complication. key words: acute pancreatitis, hypertriglyceridemia, pregnancy case reporthttps://doi.org/10.22502/jlmc.v8i1.321 anjali subedi adhikari,a,c sonam gurungb,c hypertriglyceridemia induced acute pancreatitis in pregnancy: a case report how to cite this article:how to cite this article: adhikari as, gurung s. hypertriglyceridemia induced adhikari as, gurung s. hypertriglyceridemia induced acute pancreatitis in pregnancy: a case report. journal of acute pancreatitis in pregnancy: a case report. journal of lumbini medical college. 2020;8(1):4 pages. doi: https://lumbini medical college. 2020;8(1):4 pages. doi: https://doi.doi. org/10.22502/jlmc.v8i1.321org/10.22502/jlmc.v8i1.321 epub: 2020 may 21. epub: 2020 may 21. introduction: acute pancreatitis (ap) is a rare event in pregnancy, incidence ranging from 1in 1000 to 1 in 3333 pregnancies.[1]hypertriglyceridemia induced ap accounts for the second most common cause in pregnancy, gallstone being the first one.[2] hypertriglyceridemia is a well known phenomenon of pregnancy occurring due to physiologic changes in sex hormone levels. gestational hypertriglyceridemia-induced acute pancreatitis occurs in pregnant women usually with preexisting abnormalities of lipid metabolism.[3] this rare event has a very profound effect in pregnancy with high maternal and fetal mortality (20% and 50% respectively.[4] with the advancement in diagnosis, intensive treatment and neonatal care, the mortality has significantly decreased to 0%-3%. [5] case report: a 21-year-old woman, g2p0+1 at 26 weeks period of gestation presented to obgyn emergency with complaints of sudden onset of severe epigastric pain and multiple episodes of vomiting for one day with no history of fever and jaundice. she also complained of absent fetal movement for six hours, however there was no history of lower abdominal pain, vaginal leaking, bleeding or hypertension. she was booked at a private hospital and had history of admission for hyperemesis gravidarum at 17 weeks. she had been managed conservatively with j. lumbini. med. coll. vol 8, no 1, jan-june 2020 adhikari as, et al. adhikari as, et al. hypertriglyceridemia induced acute pancreatitis in pregnancy: a case reporthypertriglyceridemia induced acute pancreatitis in pregnancy: a case report jlmc.edu.np intravenous (iv) fluids and antiemetic medications. she had one spontaneous abortion one year back. she had no history of diabetes, dyslipidemia, gall stone in the past and no family history suggestive of hypertriglyceridemia. at the time of examination, she was ill looking, drowsy and dehydrated. her blood pressure was not recordable and she was tachypneic and tachycardic. on abdominal examination, there was generalized distension with tenderness more on epigastrium. on obstetric examination, uterus was 26 weeks and relaxed. however fetal heart sound could not be heard. pelvic examination confirmed she was not in labor. chance of abruption was ruled out clinically and by ultrasonography (usg). she was kept on oxygen, catheterized and immediately resuscitated with iv colloids and crystalloids successfully. blood investigations were sent. reports showed hb was 17.2 gm%, total count was raised to 14000/ mm3, amylase and lipase raised to 734 u/l and 395 u/l respectively. arterial blood gas analysis revealed metabolic acidosis. liver function test, renal function test and blood sugar were within normal limits. usg of abdomen showed bulky pancreas (fig.1), obstetric scan confirmed intrauterine fetal death (iufd) and chest x-ray showed diffuse bilateral lung infiltrates (fig. 2). so, diagnosis of acute pancreatitis with septic figure 1. usg showing swollen pancreas. shock with iufd was made. she was shifted to intensive care unit (icu) where central venous line was accessed to monitor her fluid balance. she was kept nil by oral with nasogastric tube aspiration and managed with oxygen, iv fluids, ionotropes, analgesics, low molecular weight heparin and antibiotics. figure 2. chest x-ray showing bilateral lung infiltrates. however, on her second day, as she got tachypneic, she was intubated. pregnancy was terminated by using repeated doses of vaginal misoprostol. lipid profile was sent which showed total cholesterol-284mg% (<200) triglyceride (tgl)-1329mg% (<150) hdl-15mg% (3060) ldl-46(<100) vldl-266(<40). so, it was confirmed that it was hyper triglyceride induced acute pancreatitis. after two days, patient was extubated and was started on hypolipidemic drug rovastatin and was advised for fat free diet. she was improving both clinically and biochemically but on day seven, she again developed tachypnea and was reintubated. her chest x-ray showed bilateral diffuse lung infiltrates and her lipid profile showed tgl of 483 mg% which had decreased significantly. she was extubated the next day and fenofibrate was added. patient then improved gradually and was discharged after nineteen days on oral hypolipidemic drugs to follow up regularly for lipid levels. discussion: hypertriglyceridemia induced acute pancreatitis in pregnancy is a rare event accounting to 1%-7% of gestational pancreatitis.[6] it is usually common in women with pre-existing abnormal lipid metabolism. however, our case had no significant j. lumbini. med. coll. vol 8, no 1, jan-june 2020 adhikari as, et al. adhikari as, et al. hypertriglyceridemia induced acute pancreatitis in pregnancy: a case reporthypertriglyceridemia induced acute pancreatitis in pregnancy: a case report jlmc.edu.np medical or family history of dyslipidemia. in pregnancy due to increased estrogen, there is increased production of triglyceride rich lipoprotein and decrease in clearance of triglyceride due to suppression of lipoprotein lipase activity in liver and adipose tissue. the level of triglyceride is maximum in third trimester and may increase by two to four folds than in non-pregnant level. so the incidence of pancreatitis is more common in third trimester (52%).[7,8] when the levels of tgl are high, there is hydrophilic degradation leading to formation of cytotoxic fatty acid that destroys the acinar cells and vascular endothelium of pancreas. along with this, increased chylomicrons increase the viscosity of blood leading to capillary obstruction. this in turn leads to ischemia, acidosis and activation of trypsinogen. these physiological changes might have been exacerbated by underlying abnormal lipid metabolism which was undiagnosed prenatally leading to pancreatitis in our case. diagnosis of ap is difficult in pregnancy. the common symptoms of pancreatitis like epigastric pain, nausea, vomiting of various degrees usually mimic common ailments of pregnancy and this can delay in diagnosis and treatment, which can further increase maternal and fetal morbidity and mortality. however, it may also present with severe manifestations like metabolic acidosis, sepsis and shock like in our case. but obstetric causes like preeclampsia, abruptio placenta, obstetric cholestasis, acute fatty liver of pregnancy, and uterine rupture should be ruled out.[9] for the diagnosis, significant rise in amylase and lipase > 200u/l respectively has higher sensitivity and specificity. usg further aids in the diagnosis which is safe in pregnancy. however, if usg is inconclusive, mri is preferred over ct scan due to adverse effects of ionising radiation of ct scan to the live fetus. management of pancreatitis in pregnancy is multidisciplinary involving obstetrician, surgeon, physician, anesthesiologist and radiologist. the management protocol in pregnancy is not different from that of non-pregnant population. it includes supportive treatment including fasting, iv fluids, analgesics, antibiotics, parenteral nutrition and fat free diet once acute state is treated. specific to hypertriglyceridemia induced pancreatitis, insulin and low molecular weight heparin has to be used as they increase the activity of lipoprotein lipase and lower the tgl levels immediately. hypolipidemic drugs take weeks to lower down the increased tgl levels. the tgl level also decreases after the delivery of baby and placenta. in cases not responding to above management, plasmapheresis can be done. there is no standardized guideline published concerning the most effective way for delivery in women with ap during pregnancy to reduce maternal and neonatal mortality and morbidity. the decision depends on the gestational age and the severity of ap. when vaginal delivery is possible, it is preferable to limit the risk of superinfection necrosis associated with laparotomy used for cesarean sections. however, pregnancy should be terminated by caesarean delivery as soon as possible in case of tgl induced pancreatitis because of the significantly increased risk of maternal and fetal mortality.[9] our case presented at 26 weeks period of gestation with iufd, so pregnancy was terminated by medical induction of labor, which also aided in fall of triglyceride levels. maternal and fetal complications are high in acute pancreatitis. maternal morbidity and mortality are common due to complications of pancreatitis itself like hypovolemic shock, acute respiratory distress syndrome (ards), disseminated intravascular coagulation (dic) and rarely is due to preeclampsia, eclampsia secondary to ap.[10] our case presented with hypovolemic shock. otherwise with early diagnosis, good supportive treatment in present scenario, the complications are dismal. the common fetal complications are abortion if present in first trimester, preterm labor and intrauterine fetal death (iufd). our case presented with iufd as mother had developed shock with metabolic acidosis. during the literature search, few case reports of pregnancy complicated by hypertriglyceridemia induced ap were found. in case reports by gupta et al.[10] and shreelatha et al.[7], patients presented at third trimester with acute epigastric pain with stable vitals and live pregnancy which is a common presentation. however, our case presented in mid j. lumbini. med. coll. vol 8, no 1, jan-june 2020 adhikari as, et al. adhikari as, et al. hypertriglyceridemia induced acute pancreatitis in pregnancy: a case reporthypertriglyceridemia induced acute pancreatitis in pregnancy: a case report jlmc.edu.np trimester in shock with metabolic acidosis with iufd, which is atypical presentation. in contrary, jeon et al.[5] published a case report where patient presented at 22 weeks with twin pregnancy with mild epigastric pain but the patient deteriorated and died within 24 hours of admission due to necrosis of pancreas secondary to hypertriglyceridemia induced ap, which is a dreadful complication. however, our case gradually improved with conservative management despite severe symptoms and this may be due to absence of secondary complications of ap. conclusion hypertriglyceridemia induced gestational pancreatitis, a rare event, is associated with increased maternal and fetal morbidity and mortality. its management always requires a multidisciplinary approach, early diagnosis and treatment for better outcome. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. james d, steer p, weiner c, gonik b. high risk pregnancy: management options. 4th edition. st. louis: saunders; 2010. 2. ducarme g, maire f, chatel p, luton d, hammel p. acute pancreatitis during pregnancy: a review. j perinatol. 2014;34(2):87–94. pmid: 24355941. doi: https://doi.org/10.1038/ jp.2013.161 3. qihui c, xiping z, xianfeng d. clinical study on acute pancreatitis in pregnancy in 26 cases. gastroenterology research and practice. 2012;aricle id 271925:1-5. doi: https://doi. org/10.1155/2012/271925 4. pitchumoni cs, yegneswaran b. acute pancreatitis in pregnancy. world j gastroenterol. 2009;15(45):5641-6. pmid: 19960559. doi: https://doi.org/10.3748/ wjg.15.5641 5. jeon hr, kim sy, cho yj, chon sj. hypertriglyceridemia-induced acute pancreatitis in pregnancy causing maternal death. obstet gynecol sci. 2016;59(2):14851. pmid: 27004207. doi: https://doi. org/10.5468/ogs.2016.59.2.148 6. gan si, edward al,symonds cj,beck pl.hypertriglyceridemia-induced pancreatitis a case-based review.world j gastroenterol. 2006;12(44):7197-202. pmid: 17131487. doi: https://doi.org/10.3748/wjg.v12. i44.7197 7. sreelatha s, nayak v, nataraj. acute pancreatitis in pregnancy. indian journal of clinical practice. 2012;23(4):231–2. available from: http://medind.nic.in/iaa/t12/ i9/iaat12i9p231.pdf 8. ntzeros k, fragiadakis i, stamatakos m. acute pancreatitis in pregnancy — up to date. open journal of obstetrics and gynecology. 2014;4(2):81–9. doi: http://dx.doi. org/10.4236/ojog.2014.42015 9. cruciat g, nemeti g, goidescu i, anitan s, florian a. hypertriglyceridemia triggered acute pancreatitis in pregnancy – diagnostic approach , management and follow-up care. lipids health dis. 2020;19(2):1–6. doi: https://doi.org/10.1186/s12944-019-1180-7 10. gupta n, ahmed s, shaffer l, cavens p, blankstein j, presentation c. severe hypertriglyceridemia induced pancreatitis in pregnancy. case reports in obstetrics and gynecology. 2014;article id 485493:1-5. doi: https://doi.org/10.1155/2014/485493 successful management of quadruplet pregnancy following spontaneous conception: a rare case report deepak shrestha,a,d babita thapa,a,d shreyashi aryal,a,d buddhi kumar shrestha,b,d kiran panthee,a,e balkrishna kalakhetic,e —–————————————————————————————————————————————— abstract: introduction: when more than two fetuses simultaneously develop in the uterus, it is called higher order multiple pregnancy. the incidence of such pregnancies ranges from 0.01% to 0.07%. case report: we report a case of 26-yearold g2p1l0d2 with previous history of preterm vaginal twin delivery, diagnosed to have quadruplet pregnancy. she was admitted at 28 weeks of gestation for safe confinement. at 33 weeks of gestation, emergency cesarean section was conducted with outcome of two female and two male babies with quadriamniotic and quadrichorionic placenta, without any intra and post-operative complications. conclusion: a multidisciplinary approach with good neonatal care facilities is warranted for a better outcome in higher order multiple pregnancies. keywords: high-risk pregnancy • multiple pregnancy • pregnancy outcome • quadruplet pregnancy ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer b assistant professor c associate professor d department of obstetric and gynecology lumbini medical college teaching hospital, palpa, nepal e department of pediatrics lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. deepak shrestha e-mail: thecups814@gmail.com how to cite this article: shrestha d, thapa b, aryal s, shrestha bk, kalakheti b, panthee k. successful management of quadruplet pregnancy following spontaneous conception: a rare case report. journal of lumbini medical college. 2016;4(1):46-9. doi: 10.22502/jlmc.v4i1.88. ___________________________________________________________________________________ j. lumbini. med. coll. vol 4, no 1, jan-june 2016 case report jlmc.edu.np https://doi.org/10.22502/jlmc.v4i1.88 introduction: when more than two fetuses simultaneously develop in the uterus, it is termed higher order multiple pregnancy.1 it is rare, incidence ranging from 0.01% to 0.07% and constitutes a high risk pregnancy.1 with the introduction of fertility drugs, newer assisted reproductive techniques (art) and childbearing at older ages, the incidence of multiple pregnancies has dramatically increased.2-4 however, spontaneous quadruplet pregnancies are exceptional with a reported incidence of one in 512,000 to one in 677, 000 births.5,6 compared to singleton pregnancies, the maternal mortality and morbidity in quadruplet pregnancies are considerably greater. the perinatal mortality and morbidity are also relatively high primarily due to prematurity.1 here we report such a case of 26 years g2p1l0d2 with spontaneous conception of quadruplet pregnancy and successful outcome of two female and two male babies. case report: a 26-years g2p1l0d2 lady, married for three years, was diagnosed to have a quadruplet pregnancy with quadriamniotic quadrichorionic placenta by a 13-weeks ultrasonography in an outreach clinic. it was her planned spontaneous pregnancy. she had had a previous preterm twin vaginal delivery with early neonatal deaths. her second degree maternal relative also had a history of twin deliveries. she was comprehensively counseled regarding the potential maternal and fetal risks, both short term and long term, with options for selective 46 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 shrestha d. et al. successful management of quadruplet pregnancy following spontaneous conception: a rare case report. jlmc.edu.np fetal reduction. the couple decided to continue the pregnancy. she was then followed up regularly in the clinic till the end of 2nd trimester. she had received two doses of tetanus toxoid injection and was on iron and calcium supplementation. at 28 completed weeks of gestation, she was admitted to our hospital for safe confinement. barring occasional respiratory discomfort, she did not complain of any other complications. on examination, her abdomen was over distended with multiple fetal parts palpable. three fetal heart sounds were distinctly audible on auscultation. vaginal examination revealed a tubular, closed and uneffaced cervix. she was continued on hematinics and calcium supplementation. micronized progesterone was added to provide uterine quiescence. for expediting fetal lung maturity, steroid (dexamethasone six mg 12 hourly for a total of four doses intramuscularly) was given at 28 weeks. regular fetal surveillance was done with bi-weekly ultrasound and weekly umbilical artery doppler velocimetry. at 33 weeks of gestation, she went into labour and emergency cesarean section was done with an outcome of two female and two male babies (fig. 1). the placenta was quadriamniotic and quadrichorionic weighing 1200 grams combined. total blood loss measured 500 ml. intra and postoperative periods were uneventful. all the four babies were transferred to neonatal intensive care unit (nicu) (fig. 2) for supportive therapy and two were transferred to mother side on 16th day. the patient was discharged with four live babies on her 40th postoperative day. details of the four babies at the time of birth is given in table 1. a b c fig 1: a. placenta of 1st and 4th quadruplets b. placenta of 3rd quadruplet c. placenta of 2nd quadruplet (color picture available online) fig 2: all the four babies together in nicu. (color pic available online) discussion: although a dramatic rise in the incidence of multiple gestations seems to be there due to the use of ovulation induction drugs and in vitro fertilization, spontaneous quadruplet pregnancy is still very uncommon.2-4,7 as per hellin rule, the incidence is one in 512,000 to one in 677,000 births, and is associated with greater maternal and perinatal mortality and morbidity.5,6 nnadi et al. has reported the incidence of such higher order multiple pregnancies ranging from 0.01% to 0.07% of all pregnancies.7 till 1999, only 128 sets of quadruplet pregnancy were recorded across the world.8 in nepal, only two such cases have been reported before in newspaper media, thus making it one of its first kind to be published in literature. the case here had not received any assisted reproduction. however, she had had previous history of twin preterm vaginal deliveries. that her family history was also positive for multiple pregnancies, suggests familial predisposition. in resource constrained countries, it is usually as a result of racial predisposition.5 el-tabbakh gh. has reported a similar case with spontaneous quadruplet pregnancy with a personal and family history of multiple pregnancies.9 the management of quadruplet pregnancy poses a challenge to obstetricians as all the complications of pregnancy, labour, and delivery are exaggerated.10 maternal complications as preeclampsia, gestational diabetes mellitus, cardio respiratory embarrassment, and preterm labour are well documented. in our case, occasional respiratory discomfort was noted. at 33 weeks of gestation she went into preterm labour necessitating emergency cesarean section. 47 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 jlmc.edu.np shrestha d. et al. successful management of quadruplet pregnancy following spontaneous conception: a rare case report. the management of higher order pregnancy requires special care and multidisciplinary approach.11 the early involvement of neonatologists and anesthesiologists with nicu back up was instrumental in resulting a better outcome. the main fetal complication of higher order multiple pregnancies is prematurity with its concomitant increase in perinatal mortality and morbidity.1,12 as in our case, more than 90% of the cases end in premature deliveries.6 it has been well established that chorionicity rather than zygosity determines the outcome in multifetal pregnancies mainly because of increased risk of transfusion syndromes in addition to problems of prematurity.13 because of quadrichorionic and quadriamniotic placentation, no such complications were encountered in our case. the average gestational age at delivery for twins is 35 weeks, triplets 32.2 weeks and quadruplets 29.9 weeks.6,14 quadruplet pregnancy carrying to term is rare and occurs in less than 3%.1 this presents the greatest challenge to obstetricians as there is no clear cut approach to its management. bed rest, beta-mimetics, progestogens and elective cervical cerclage have all been reported to have a beneficial effect in prolonging pregnancy in some literatures, but the results are yet to be substantiated by controlled trials.6,15,16 our patient was conservatively managed with bed rest and progesterone supplementation however cervical cerclage was not placed. the preferred method of delivery of quadruplet pregnancies is elective cesarean section. this is because of increased risk of fetal malpresentations and difficult intrapartum fetal monitoring associated with the condition.5,16 higher order multiple pregnancies delivered by cesarean section have a lower perinatal mortality and morbidity compared to vaginally delivered ones.17 though planned for an elective cesarean section at 34 weeks, the preterm onset of labour at 33 weeks in our case forced an emergency section. owing to a long hospital stay, operative interference, prolonged nicu stays and expenses for the care of neonates, higher order multiple pregnancy is economically taxing. hence in most resource poor countries, multiple births are not always welcome, while quadruplets are often seen as an abnormality.15 our case belonged to a poor socioeconomic background. the media coverage they received did throw them into limelight for sometime but it did not raise a sufficient fund. the hospital support in terms of logistics and nicu care and some personal and institutional donations helped them cover a substantial percentage of the expenses but not entirely. studies show the socio-economic status of the families does influence outcome, and media coverage does not always improve their financial status.13 selective fetal reduction early in pregnancy should therefore always be offered wherever available though some prefer to continue the pregnancy as in ours. conclusion: this is a rare case of successful quadruplet spontaneous pregnancy. early ultrasonographic documentation, regular clinical, biophysical and radiological monitoring, early hospitalisation, and cesarean section as the mode of delivery were crucial in resulting a favorable outcome. the most important complication to look for is preterm labour leading to fetal prematurity, which mostly cannot be avoided despite measures. the tremendous efforts put by neonatologists post delivery was pivotal in the overall outcome. thus, higher order multiple pregnancies, though uncommon, when occur, place great responsibilities on the clinicians and family both. a well co-ordinated multidisciplinary approach with good birth preparedness is not only mandatory but has also been shown to be effective in improving outcomes. conflict of interest: none declared. quadruplet sex weight (grams) presentation apgar scores at 1', 5' time of birth first male 1500 breech 7/10, 9/10 3:44 am second male 1250 cephalic 7/10, 9/10 3:46 am third female 1700 cephalic 6/10, 8/10 3:47 am fourth female 1250 breech 7/10, 8/10 3:49 am table 1: details of the four babies at time of birth 48 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 shrestha d. et al. successful management of quadruplet pregnancy following spontaneous conception: a rare case report. jlmc.edu.np references: 1. umeora ou, aneziokoro ea, egwuatu ve. higher‑order multiple births in abakiliki, southeast nigeria. singapore med j. 2011;52:163‑5. 2. from the centers for disease control and prevention. contribution of assisted reproduction technology and ovulation‑inducing drugs to triplet and higher order multiple births, united states, 1980‑1997. jama. 2000;284(3):299–300. 3. kiely jl, kleinman jc, kiely m. triplets and higher‑order multiple births: time trends and infant mortality. am j dis child. 1992;146(7):862–8. 4. barr s, poggi s, keszler m. triplet morbidity and mortality in a large case series. j perinatol. 2003;23(5):368–71. 5. ogunowo t, oluwole o, aimakhu co, ilesanmi ao, omigbodun ao. term quadruplet pregnancy: a case report. niger j surg rsch. 2004;6:56‑8. 6. goldman ga, dicker d, peleg d, goldman ja. is elective cerclage justified in the management of triplet and quadruplet pregnancy? aust nzl j obstet gynaecol. 1989;29:9‑11. 7. nnadi d, ibrahim a, nwobodo e. spontaneous monochorionic tetra‑amniotic quadruplet pregnancy at term. j basic clin reprod sci. 2013;2:57‑9. 8. begum h, moniruddin abm, jahan s. quadruplet pregnancy: a rare occurrence. the orion medical journal. 2008 may;30:570‑1. 9. el‑tabbakh gh, broekhuizen ff. spontaneous quadruplet pregnancy in a woman with a personal and family history of spontaneous twin and triplet pregnancy ‑ a case report. j reprod med. 1994 feb;39(2):134‑6. 10. nwobodo ei, bobzom dn, obed j. twin births at the university of maiduguri teaching hospital: incidence, pregnancy complications and outcome. niger j med. 2002;11:67‑70. 11. abotalib z. quadruplet pregnancy following a single course of clomiphene citrate. an expensive success. saudi medical journal. 2000;21(3):294‑6. 12. de carte l, cammus m, foulon w. monochorionic high order multiple pregnancies and multifetal pregnancy reduction. obstet gynaecol. 2002;20:561‑3. 13. pector ea. ethical issues of high‑order multiple births. newborn infant nurs rev. 2005;5:69‑76. 14. ron‑el r, mor z, weinraub z, schreyer p, bukovsky i, dolphin z, et al. triplet, quadruplet and quintuplet pregnancies: management and outcome. acta obstet gynaecol scand. 1992;71:347‑50. 15. doyle p. the outcome of multiple pregnancies. hum reprod. 1996;11:110‑20. 16. newman rb, luke b. multifetal pregnancy. in: a handbook for care of the pregnant patient. philadelphia: lippincott williams and wilkins; 2000. p. 36‑49. 17. lipitz s, reichman b, paret g, modan m, shalev j, serr dm, et al. the improving outcome of triplet pregnancies. am j obstet gynecol. 1989;161(5):1279–84. 49 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 24 may, 2020 accepted: 28 may, 2020 published: 30 may, 2020 a senior adjunct lecturer, b -medical student, cmonash university, malaysia. dconsultant obstetrics and gynaecology, columbia asia hospital, iskandar puteri, malaysia. corresponding author: quek yek song e-mail: yeksong@msn.com orcid: https://orcid.org/0000-0001-6029-9823 how to cite this article: song qy, ling mjn. covid-19 pandemic: an unseen’s evolution war. journal of lumbini medical college. 2020;8(1):4 pages. doi: 8(1):4 pages. doi: https://doi.org/10.22502/jlmc.v8i1.354 epub: 2020 may epub: 2020 may 30._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.354 quek yek song,a,c,d michelle jia ni ling b,c covid-19 pandemic: an unseen’s evolution war this is a new beginning. it started just like a fiction movie. in december 2019, a new cluster of pneumonia caused by the 2019 novel coronavirus (2019-ncov) was first identified in wuhan, china. [1] without any mercy, it became a pandemic and left no time for grief. it was not only life-threatening but also challenged our healthcare system, economy, culture, lifestyle and belief. it forced us to make changes. we need to evolve, and we must evolve. malaysia, a multi-ethnicity and multireligious country which is located in southeast asia, has a population of 32 million with a median age of 28.9 years in 2019.[2] according to the observatory of economic complexity, malaysia has experienced rapid globalization and is the 19th leading exporter in the world.[3] it is an upper-middle-income country with a gross domestic product (gdp) of 370 billion usd in 2019,[4] of which 4.5% is funded to the healthcare system.[5] malaysia has an efficient and widespread two-tier healthcare system which consists of a government-based universal healthcare system and a co-existing private healthcare system. in 2018, the infant mortality rate was 6.7 deaths per 1000 live births,[6] while the maternal mortality ratio was 23.5 deaths per 100,000 live births.[7] the life expectancy was 76.22 years in 2019[8] which is favorable when compared to the united states and western europe. the universal healthcare system provides specialist services at a very low cost, with an average of usd 10 per visit. due to the long waiting list, the private specialist healthcare compliments the system to reduce the workload. with an indomitable spirit for 60 years, malaysia is ranked first as the world’s best healthcare category, scoring 95 out of 100 in the international living annual global retirement index.[9] although being ranked 49th in the world health organization’s ranking in 2019,[10] malaysia has showcased remarkable recovery rates as compared to the western part of the world. this shows that the standard of healthcare, infrastructures and the availability of test kits do not necessarily mean winning the war in fighting against corona virus disease (covid-19). the covid-19 outbreak started in malaysia since 25 january, 2020.[11] while going through the political transitional period, the confirmed case in malaysia had once peaked in the southeast asia region, with triple-digit cases recorded per day and was benchmarked with italy. movement control order (mco) was implemented on 18 march 2020 to break the chain of the transmission of the virus. during the mco period, normal business, schools, entertainment and recreation activities were on hold with law applied to keep people home while the essential services remain. malaysians started to practise social distancing, hand hygiene and wearing face masks. a prediction from an international financial service holding company, jp morgan, was that there will be a surge of covid-19 cases which might reach an approximate of 6300 total cases in mid-april.[12] song qy, et al. covid-19 pandemic: an unseen’s evolution war jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 gratifyingly, with the implementation of mco, malaysia has successfully flattened the curve and reduced to a total case of 5571 with 22 new cases and 59 recovery cases on 17 may, 2020. malaysia has been ranked fourth in a global public opinion survey on the government response to covid-19, coming after china, vietnam and uae on par with india. [13] malaysia is also ranked fourth on the strictest response in southeast asia after vietnam, laos and philippines with singapore being eighth in line.[14] however, a new outbreak will occur if there is any tiny shortfall. from mid-may, malaysia has moved into the conditional mco which allows more businesses and services to resume while being monitored closely. quarantine and screening will be implemented if there is any new cluster identified while continuously providing education to the public on the importance of social distancing, hand washing, and the wearing of face mask. the testing capacity has reached 26,000 samples a day across 48 testing facilities in malaysia. the public also plays an important role in combating the covid-19 pandemic through funding, production of ppe suits for front-liners, food preparation for the poor and homeless while adhering to the rules and regulations of mco. designated government and university hospitals have been selected as covid-19 centers while transferring the non-covid-19 cases to other hospitals, stopping most if not all elective admissions and operations. furthermore, the government has converted the malaysia agro exposition park into a gigantic temporary makeshift hospital for the covid-19 patients in three days. it consists of 604 beds, pharmacy, x-ray services, a pathology laboratory, occupational health, safe services, and a dietician.[15] as part of malaysia’s private healthcare system, columbia asia hospitals also play an active role as front-liners. the discussion will be focusing on the obstetrics and gynecology (o&g) service provided in columbia asia hospital iskandar puteri in johor bahru. it is one of the busiest o&g department among the columbia asia hospitals in malaysia with an average of 1300 deliveries annually. as a non-covid-19 healthcare center, proper and massive screenings are done to identify and transfer any suspected or high-risk covid-19 cases to covid-19 designated centers for further management. a questionnaire needs to be completed with the temperature checked before anyone can enter the hospital’s premises. the patient’s family is not allowed to enter the hospital premises unless the patient is 36 weeks and beyond or their presence is needed for any discussion. this has successfully reduced the crowd in the hospital and good social distancing is being practised. universal covid-19 pcr testing is carried out for all patients admitted to the hospital, including the o&g patients. this secondary screening mechanism aims to protect all patients in the hospital by identifying any new or suspected covid-19 cases, be it symptomatic or asymptomatic. this can be achieved with insurance coverage or patients paying out-of-pocket. this helps to break the chain and is parallel to the government’s universal screening effort. with the referral of suspected or confirmed case to a covid-19 center for further management, unnecessary ppe or n95/nk95 wastage can be avoided to overcome the shortage of ppe worldwide. in addition, the hospital and all clinical staff are able to function at maximum capacity due to reduced risk of exposure, quarantine and section being lockdown for disinfection. however, extra precautions, management with full ppe and standardized disinfecting techniques are being applied for those with unknown or pending status. the hospital is divided into two divisions as the covid-19 negative or green zone section and the high-risk section. all single bedded rooms have been utilized as isolation rooms. covid-19 pcr test becomes the passport for patients to be transferred to the green zone section. all hospital clinical staff including consultants are divided into two teams to ensure that there is a continuity of the service in case any staff needs to be isolated due to any possible exposure to suspected covid-19 cases. staff are provided with scrubs for clinical use and are encouraged to change their attire before leaving the hospital premises. fortunately, since the execution of mco from 18 march, 2020 till date, there is no case reported in this hospital. this has resulted in more patients willing to come forward to receive healthcare services and admission in our hospital. nevertheless, the system can be ameliorated before the availability of covid-19 vaccines. a faster and cheaper universal covid-19 screening kit should be in place to prevent any future outbreak, especially in identifying any carrier, aside from primary screening sources such as history taking and contact tracing. a standardized, well-practised standard operating procedure which includes reporting of all suspected and confirmed cases must be strictly adhered to by all clinical staff. all surgical procedures including deliveries should be screened to protect all clinical staff, facilities and also to reduce the risk of intubation and minimally invasive surgery. aerosol or virus contamination became a new risk factor that needs to be considered when designing future medical devices or hospital facilities. more cost-effective analysis and studies need to be carried out to weigh the pros and cons of any further development. this is a new beginning and we shall evolve for betterment. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. fei zhou, ting yu, ronghui du, guohui fan, ying liu, zhibo liu, et al. clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. lancet 2020; 395: 1054–62. doi: https://doi.org/10.1016/s0140-6736(20)305663 2. mahidin mu. current population estimates, malaysia, 2018-2019. department of statistics, malaysia, official portal. 2019 july 15. available from: https://www.dosm.gov.my/v1/index. php?r=column/cthemebycat&cat=155&bul_ id=awjzrkj4uedkcuzpt2tvt090snpy dz09&menu_id=l0pheu43nwjwrwvszklwdzq4tlhuut09 3. simoes a. visualizations, malaysia. the observatory of economic complexity. 2017. available from: https://oec.world/en/profile/country/mys/ 4. malaysia gdp 1960-2019 data. trading economics. 2020. available from: https://tradingeconomics.com/malaysia/gdp 5. code blue. health care financing: national health insurance or tax-based system? code blue. 2019 mar 11. available from: https://codeblue.galencentre.org/2019/03/11/health-care-financing-national-health-insurance-or-tax-basedsystem/ 6. plecher h. infant mortality rate in malaysia 2018. statista. 2020 jan 29. available from: https://www.statista.com/statistics/807002/infant-mortality-in-malaysia/. 7. hirshmann r. malaysia maternal mortality ratio 2011-2018. statista. 2019 nov 4. https://www. statista.com/statistics/642032/malaysia-maternal-mortality-ratio/ 8. malaysia life expectancy 1950-2020. macrotrends. 2020. available from: https://www.macrotrends.net/countries/mys/malaysia/life-expectancy 9. lim s. from english-speaking doctors to affordable healthcare: malaysia ranks 1st in healthcare category of global retirement index. business insider malaysia, 2019 feb 7. available from: https://www.businessinsider.my/from-englishspeaking-doctors-to-affordable-healthcare-masong qy, et al. covid-19 pandemic: an unseen’s evolution war jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 laysia-ranks-1st-in-the-healthcare-category-ofa-2019-global-retirement-index 10. tandon a, murray cjl, lauer ja, evans db. measuring overall health system performance for 191 countries. world health organization, gpe discussion paper series: no. 30, page 18. accessed from: https://www.who.int/healthinfo/ paper30.pdf?ua=1 11. covid-19 chronology in malaysia. bernama, 2020 mar 17. available from: https://www. b e r n a m a . c o m / e n / g e n e r a l / n e w s _ c o v i d 1 9 . php?id=1821902 12. jp morgan: malaysia’s covid-19 strategy far exceeds asian, some european peers. new straits times. 2020 march 25. available from: https:// www.nst.com.my/business/2020/03/577996/ jp-morgan-malaysias-covid-19-strategy-far-exceeds-asean-some-european-peers 13. bernama. malaysia ranked 4th in public opinion survey on govt response to covid-19. the edge markets. 2020 may 8. available from: https://www.theedgemarkets.com/article/malaysia-ranked-4th-public-opinion-survey-govt-response-covid19 14. pfordten d. malaysia’s response to covid-19 ranked fourth strictest in sea. the star. 2020 apr 12. available from: https://www.thestar. com.my/news/nation/2020/04/12/malaysia039sresponse-to-covid-19-ranked-fourth-strictest-insea 15. khairulrijal r. covid-19: maeps transformed into massive makeshift hospital. new strait times. 2020 apr 4. available from: https:// www.nst.com.my/news/nation/2020/04/581248/ c o v i d 1 9 m a e p s t r a n s f o r m e d m a s s i v e makeshift-hospital jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 song qy, et al. covid-19 pandemic: an unseen’s evolution war j. lumbini. med. coll. vol 8, no 2, july-dec 2020 nakarmi r, et al. phytobezoar: a rare cause of small bowel obstruction.nakarmi r, et al. phytobezoar: a rare cause of small bowel obstruction. 284 jlmc.edu.np ___________________________________________________________________________________ submitted: 31 may, 2020 accepted: 28 december, 2020 published: 31 december, 2020 ajunior consultant bsenior consultant cregistrar ddepartment of general and laparoscopic surgery, manmohan memorial medical college and teaching hospital. corresponding author: rajiv nakarmi e-mail: rajivnakarmi31@gmail.com orcid: https://orcid.org/0000-0003-2205-1784_______________________________________________________ abstract: introduction: small bowel obstruction is a common condition encountered in surgical practice. however, obstruction due to phytobezoars is a rarity. until recently, phytobezoars were incidental findings during surgery. however, advances in imaging have eased the diagnosis by precisely identifying and locating the etiology. case report: an 86-year-old lady presented to the emergency room with abdominal pain, distension, and inability to pass stool and flatus. subsequent workup showed features of small bowel obstruction complicated with sepsis and worsening of preexisting respiratory co-morbidity. exploration revealed a phytobezoar causing the bowel obstruction. conclusion: phytobezoar, though uncommon, should always be thought of while treating a case of intestinal obstruction in the elderly age group. surgery is the mainstay of treatment. however, preexisting co-morbid condition plays avital role in the outcome. keywords: phytobezoar, small bowel obstruction, sepsis case reporthttps://doi.org/10.22502/jlmc.v8i2.364 rajiv nakarmi,a,d muza shrestha,b,d sunder maharjanc,d phytobezoar: a rare cause of small bowel obstruction how to cite this article:how to cite this article: nakarmi r, shrestha m, maharjan s. phytobezoar: a rare cause nakarmi r, shrestha m, maharjan s. phytobezoar: a rare cause of small bowel obstruction. journal of lumbini medical college. of small bowel obstruction. journal of lumbini medical college. 2020;8(2):284-287. doi: 2020;8(2):284-287. doi: https://doi.org/10.22502/jlmc.v8i2.364. epub: 2020 december 31.epub: 2020 december 31. introduction: small bowel obstruction (sbo) is a commonly encountered surgical condition, frequently due to post-operative adhesions and inguinal hernia. however, sbo caused by bezoars is uncommon and approximately accounts for only 0.4–4%.[1] the term bezoar refers to an intraluminal mass in the gastrointestinal system caused by the accumulation of indigestible ingested materials, such as vegetables, fruits, and hair. it is called “panzehr” in arabic and “padzhar” in persian, which means antidote.[2,3]bezoars are named according to the material they are made of: a trichobezoar consists of hair; a phytobezoar of vegetable and fruit residues; a lactobezoar is formed from dairy products; a pharmacobezoar is caused by medications; a polybezoar is caused by ingested foreign bodies and biliary bezoars caused by bile stasis following hepatobiliary or gastric diversion surgery.[3,4,5] case report: an 86-year-old lady presented to the emergency department (ed) with the chief complaints of abdominal pain for four days followed by generalized abdominal distension for three days. the pain was initially intermittent and relieved by over the counter painkiller, but it had gradually worsened to an unbearable state on the day of presentation for which she was rushed to the hospital. she also gave history of inability to pass stool and flatus for two days. she further complained of nausea but denied any episode of vomiting. she had no history of weight loss, fever, previously altered bowel habit. she was a known case of chronic obstructive pulmonary disease under medication with recurrent exacerbation. she had undergone cholecystectomy 35 years back. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 nakarmi r, et al. phytobezoar: a rare cause of small bowel obstruction.nakarmi r, et al. phytobezoar: a rare cause of small bowel obstruction. 285 jlmc.edu.np on examination she looked anxious. her blood pressure at the time of presentation was 70/50 mm of hg, pulse rate was 98/min, respiratory rate was 30/min and temperature was 990f. laboratory test revealed leucocytosis of 14000/mm3. per abdominally, she had central distension, generalized tenderness and rebound tenderness with increased bowel sound on auscultation. the initial abdominal x-ray supine film showed distended central bowel loops (fig.1) with multiple air fluid levels in erect film (fig.2). a contrast-enhanced computed tomography (cect) scan was done for confirmation which showed features of small bowel obstruction with transition point at terminal ileum. with the provisional diagnosis of acute small bowel obstruction with sepsis, emergency explorative laparotomy was performed after appropriate resuscitation. intraoperatively, a hard phytobezoar was found approximately 8cm proximal to the ileocecal junction with dilated proximal and collapsed distal ileum. no adhesions at the site of obstruction or stricture were seen. around 300ml of reactive fluid was present in the peritoneal cavity. enterotomy with removal of the bezoar was done followed by decompression and closure of enterotomy. postoperatively, the patient was kept in elective ventilation. but on the fifth post-operative day, due to ongoing sepsis and exacerbation of co-morbid chest condition she developed type ii respiratory failure. fig. 1: plain x-ray abdomen: supine: showing distended bowel loops. fig. 2: plain x-ray abdomen: erect: showing multiple air fluid level. discussion: the most common type of bezoar is phytobezoar, which consists of indigestible food residue, such as cellulose and hemicellulose. bezoars are responsible for 0.4%-4% of cases of mechanical intestinal obstruction, although the true incidence is not known.[6, 7]there are several predisposing factors that can contribute to the formation of phytobezoars. gastric motility disorders and hypoacidity after gastric surgery are the basis of bezoar formation. bezoars located in the stomach can pass through to the small intestines easily and cause symptoms of intestinal obstruction, especially in patients with pyloric dysfunction after a pyloroplasty or wide gastrojejunostomy, resulting in a wide gastric outlet.[3,8] in a study of 42 cases, kement et al.[9] reported that previous gastric surgery was the most important factor predisposing to bezoar formation, with a rate of 48%. in their series, krausz et al.[10] and bowden et al.[11]reported rates of 20% to 93%. bezoar-associated ileus is more common in cases undergoing surgery for ulcer treatment, although this has become rarer with the introduction of proton pump inhibitors.[11] in patients who have had surgery for ulcer treatment, a vagotomy accompanied by a partial gastrectomy is the most important factor predisposing to bezoar formation.[12] a vagotomy and partial gastrectomy reduce gastric acidity, negatively affecting peptic activity. furthermore, the antrum has an important role in the mechanical digestion of ingested food. the pylorus also prevents ingested food from passing through the small intestine as bolus, contributing to digestion. in this regard, the risk of bezoar formation was higher in patients who had a pyloroplasty and antrectomy. [9,10] the time taken for a bezoar to form after gastric surgery ranges from nine months to 30 years. [10] bezoars can also form primarily in the small intestine when a mechanical factor alters the small intestinal passage, such as a diverticulum, stricture, or tumor.[9]primary bezoars of the small intestine almost always cause intestinal obstruction. the most common location of obstruction is the terminal ileum.[13] high-fiber foods such as celery, pumpkins, grape skins, prunes, and especially persimmons are a risk factor for bezoar formation.[9,10] persimmons, which means the “god of fruits” in j. lumbini. med. coll. vol 8, no 2, july-dec 2020 nakarmi r, et al. phytobezoar: a rare cause of small bowel obstruction.nakarmi r, et al. phytobezoar: a rare cause of small bowel obstruction. 286 jlmc.edu.np greek, are the fruit of plants in the genus diospyros. immature persimmons contain tannins, which form an adhesive-like substance when they encounter acids and hold other food residues, causing bezoar formation.[9] krausz et al.[10]and erzurumlu et al.[12]reported that 17% to 91% of bezoars in their series were caused by persimmons. other factors predisposing to bezoar formation include systemic diseases such as hypothyroidism causing impaired gastrointestinal motility, postoperative adhesions, diabetes mellitus, guillain-barré syndrome, and myotonic dystrophy. personal factors such as swallowing a large amount of food without sufficient chewing due to dental problems, especially in the elderly, the use of medications slowing gastrointestinal motility, and renal failure are also predisposing factors.[4,12]this patient had chewing problem due to loss of most of the teeth. erzurumlu et al. suggested that bezoar formation could occur without any predisposing factors.[12] the most common symptom of bezoarinduced sbo is abdominal pain (96–100%) as seen in this patient. other common symptoms include nausea and vomiting.[12] however, these symptoms were not evident in this patient. primary small bowel phytobezoars almost always present as sbo. they usually are impacted in the narrowest part of the intestine especially in the terminal ileum and ileocecal valve as was found in our patient. the phytobezoar was impacted at the terminal ileum. it is interesting to note that more than half of reported cases with phytobezoars had a history of gastric surgery. the patient denied any previous gastrointestinal related surgery. plain supine x-ray typically shows a classic obstructive pattern of sbo but rarely to detect bezoars. occasionally, the outline of bezoar can be made out, which is difficult to differentiate from abscess or feces in the colon. the only evidence that we found in plain x-ray of our patient was small bowel loop dilatation (fig.1). the cause of sbo can be diagnosed by ct in 73– 95% of patients. ct shows intraluminal mass with mottled gas appearance associated with dilated small bowel proximal to the obstruction. the diagnostic accuracy of ct scan to diagnose bezoar-induced sbo is around 65–100%.[14] ct findings of our patient were also consistent with the bezoar-induced small bowel obstruction. the treatment of choice for sbo due to phytobezoar is surgery. the surgical management is easily performed by fragmenting the bezoar and milking it down to the cecum without enterotomy. in a retrospective study fragmenting and milking bezoar was successful in 24 cases (53%). [15] conclusion: phytobezoar, though uncommon, should always be kept in mind while dealing with such cases especially in elderly people. the diagnosis is often challenging and often delayed leading to increase in morbidity and mortality. surgery either open/ laparoscopic is the treatment of choice. prevention is the best form of treatment and intake of indigestible food residues should be avoided by the elderly people as they tend to have more digestion problems or cannot chew food properly. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 nakarmi r, et al. phytobezoar: a rare cause of small bowel obstruction.nakarmi r, et al. phytobezoar: a rare cause of small bowel obstruction. 287 jlmc.edu.np references: 1. teng h, nawawi o, ng k, yik y. phytobezoar: an unusual cause of intestinal obstruction. biomed imaging interv j. 2005;1(1):e4. pmid: 21625276. doi: https://doi.org/10.2349/ biij.1.1.e4 2. senol m, ozdemir zü, sahiner it, ozdemir h. intestinal obstruction due to colonic lithobezoar: a case report and a review of the literature. case rep pediatr. 2013; 2013:854975. pmid: 23424701. doi: https:// doi.org/10.1155/2013/854975 3. williams rs. the fascinating history of bezoars. med j aust. 1986;145(11-12):613-4. pmid: 3540541. 4. andrus ch, ponsky jl. bezoars: classification, pathophysiology, and treatment. am j gastroenterol. 1988;83(5):476-8. pmid: 3284334 5. chintamani, durkhure r, singh jp, singhal v. cotton bezoar--a rare cause of intestinal obstruction: case report. bmc surg. 2003;3(0):5. pmid: 12956890. doi: https:// doi.org/10.1186/1471-2482-3-5 6. altintoprak f. gastric outlet syndrome associated with a recurrent trichobezoar: report of a case. turk j gastroenterol. 2010;21(4):471-2. pmid: 21332010. doi: https://doi.org/10.4318/ tjg.2010.0143 7. ashfaq a, madura ja 2nd, chapital ab. an unusual case of biliary bezoar causing small bowel obstruction in a patient with ampullary diverticulum and stapled gastroplasty. bmj case rep. 2014;2014:bcr2014207455. pmid: 25498113. doi: https://doi.org/10.1136/bcr2014-207455 8. macari m, megibow a. imaging of suspected acute small bowel obstruction. semin roentgenol. 2001;36(2):108-17. pmid: 11329653. doi: https://doi.org/10.1053/ sroe.2001.22827 9. kement m, ozlem n, colak e, kesmer s, gezen c, vural s. synergistic effect of multiple predisposing risk factors on the development of bezoars. world j gastroenterol. 2012;18(9):9604. pmid: 22408356. doi: https://doi. org/10.3748/wjg.v18.i9.960 10. krausz mm, moriel ez, ayalon a, pode d, durst al. surgical aspects of gastrointestinal persimmon phytobezoar treatment. am j surg. 1986;152(5):526-30. pmid: 3777332. doi: https://doi.org/10.1016/0002-9610(86)90221-7 11. bowden ta jr, hooks vh 3rd, mansberger ar jr. the stomach after surgery. an endoscopic perspective. ann surg. 1983;197(6):63744. pmid: 6859976. doi: https://doi. org/10.1097/00000658-198306000-00001 12. erzurumlu k, malazgirt z, bektas a, dervisoglu a, polat c, senyurek g, et al. gastrointestinal bezoars: a retrospective analysis of 34 cases. world j gastroenterol. 2005;11(12):1813-7. pmid: 15793871. doi: https://doi.org/10.3748/ wjg.v11.i12.1813 13. ezzat rf, rashid sa, rashid at, abdullah km, ahmed sm. small intestinal obstruction due to phytobezoar: a case report. j med case rep. 2009;3(0):9312. pmid: 20062741. doi: https://doi.org/10.1186/1752-1947-3-9312 14. oh sh, namgung h, park mh, park dg. bezoar-induced small bowel obstruction. j korean soc coloproctol. 2012;28(2):89-93. pmid: 22606648. doi: https://doi.org/10.3393/ jksc.2012.28.2.89 15. bedioui h, daghfous a, ayadi m, noomen r, chebbi f, rebai w, et al. a report of 15 cases of small bowel obstruction secondary to phytobezoars: predisposing factors and diagnostic difficulties.gastroenterol clin biol. 2008;32(6-7):596-600. pmid: 18487032. doi: https://doi.org/10.1016/j.gcb.2008.01.045 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 29 may, 2020 accepted: 31 may, 2020 published: 03 june, 2020 aprofessor and head, department of internal medicine, bpublic health consultant, csenior radiologist, dprofessor, department of psychiatry, eformer regional advisor, funiversal college of medical sciences, bhairahawa, nepal. gkarachi, pakistan. hmemon hospital, karachi, pakistan. ib.p. koirala institute of health sciences, dharan, nepal. jworld health organization, south east regional office, bangladesh. corresponding author: rano mal piryani e-mail: rano.piryani@gmail.com orcid: https://orcid.org/0000-0003-2574-7226 how to cite this article: piryani rm, piryani s, piryani s, shakya dr, huq m. covid-19 and lockdown: be logical in relaxing it. journal of lumbini medical college. 2020;8(1):4 pages. doi: https://doi.org/10.22502/ jlmc.v8i1.361 epub: 2020 june 03. _______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.361 rano mal piryani,a,f suneel piryani,b,g shomeeta piryani,c,h dhana ratna shakya,d,i muzaherul huq e,j covid-19 and lockdown: be logical in relaxing it lockdown cambridge dictionary defines ‘lockdown’ as a situation in which people are not allowed to enter or leave a building or area freely because of an emergency.[1] merriam-webster outlines three definitions of lockdown: a) the confinement of prisoners to their cell for all or most of the day as a temporary security measure, b) an emergency condition in which people are temporarily prevented from entering or leaving a restricted area during a threat of danger and c) a temporary condition imposed by governmental authorities as during the outbreak of an epidemic disease in which people are required to stay at their homes and refrain from or limit activities outside the home involving public contact.[2] our focus, here, is on lockdown strategy adopted to contain corona virus disease 2019 (covid-19) pandemic. lockdown strategy adopted to contain covid-19 pandemic as of may 28, 2020 (11.52 gmt), the covid-19 has affected 213 countries and territories around the world and two international conveyances infecting more than 5.8 million with approximate deaths of 0.357 million.[3] the covid-19 has almost swept around the world but the responses to contain it is greatly varied from country to country. more than 21 weeks into the covid-19 pandemic, lockdown has become a global response to it.[4] lockdown is among the non-pharmacological interventions adopted by most of the countries in various scales to contain the virus from spreading to other parts of the country. in south africa, tens of thousands of troops have been brought to enforce one of the world’s strictest lockdowns, while countries like south korea and taiwan have managed to contain their outbreaks without merely closing anything.[5] lockdown is done to flatten the curve and get prepared to face the continuing epidemic. merely locking down the population without other interventions such as infection control and preventive measures, social distancing, robust testing, isolating and treating the infected, contact tracing and quarantining, will take nowhere because lots of problems are associated with the lockdown. it is an expensive intervention leading to closure of businesses and leading to steep rise in unemployment rates. it further aggravates inequality.[4] anderson et al., have developed simulation of transmission model of covid-19. they mentioned that social distancing compounded with piryani rm, et al. covid-19 and lockdown: be logical in relaxing it jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 other non-pharmacological measures flattens the curve. these measures prevent transmission from symptomatic and asymptomatic but there is risk of resurgence following lifting of interventions.[6] this important aspect must also be kept in mind as there is no vaccine or effective antiviral drug likely to be available soon. lockdown in south asia almost no nation has been spared as covid-19 has swept around the globe but responses to contain it is not same in every country. quarantines and lockdowns have become ubiquitous, but there is great variance in their strictness. three densely populated countries of south asia: india, pakistan, bangladesh are under lockdown (limited-partialcomplete) since the mid-march, 2020. they have adopted similar strategies but could not yet succeed in flattening the curve as expected. they however, delayed the rapid surge. there is still uncertainty of what will happen after relaxation.[7,8] the number of reported new cases and deaths has been increasing, not only in these three country *first case reported jan 2020 feb 2020 mar 2020 apr 2020 may 28, 2020 total afghanistan feb 24 arrived from iran 0 1 173 1997 10,865 13,036 bangladesh mar 6 arrived from italy 0 0 51 7616 32654 40, 321 bhutan mar 6 arrived from usa 0 0 4 3 24 31 india jan 30 arrived from china 1 2 1394 33466 124,391 159,054 maldives mar 6 arrived from italy 0 0 18 450 989 1,457 nepal jan-13 arrived from china 1 0 4 52 985 1042 pakistan feb 26 arrived from iran 0 4 1934 14535 44,754 61, 227 sri lanka jan 26 arrived from china 1 0 142 520 808 1,4 71 table 1. number of new cases reported month wise jan-may 28,2020 at 11.52 gmt. countries, but also in other five countries of southeast asia as depicted in table 1.[3] lockdown has impacted life and livelihood in many ways. gupta et al., mentioned that migrant workers in india, pakistan and nepal are crushed by poverty as earnings come to an abrupt halt in the lockdown forced by the covid-19 pandemic. [9] there is enormous effect of lockdown in terms of livelihood on daily wager, contractual staff, taxi or private and public transport workers, small and medium business men, and other skilled or unskilled workers who depend on day to day work and earnings.[9] there has been significant reduction in emissions of greenhouse gases during the lockdown making the environment cleaner and pleasant. levels of particulate matter (pm10) dropped by up to 44% in the parts, 24 hours of lockdown in the megalopolis. distant himalayan peaks are vividly visible through clear blue skies from in many south asian cities in this lockdown period for the first time in many years.[10] with the start of monsoon, there is a fear of surge of other infectious diseases like dengue, malaria and scrub typhus.[11,12] lockdown has made us realize the potential of online learning, distance learning, webinars and meetings through online available applications like zoom, google classroom, teams etc. the serious impact on physical and mental health of fellow citizens especially children and elderly due to lockdown should not be overlooked.[13] in fact, it has affected everyone, every sector, every class of society, more vulnerable being poor, disabled and socially deprived class. is adversity a solution? there is a dilemma as to when the pandemic would end. according to historians, pandemics predictably have two types of endings: the medical which occurs when the incidence and death rates significantly fall, and the social when the epidemic of fear about the disease fades.[14] the chief of world health organization (who) remarked “lifting lockdowns does not signal the end of covid-19. countries must now ensure that they can detect, test, isolate and care for every case and trace every contact”.[15] there is an uncertainty on how long the lockdown can and should be permitted. at some point in time, people will be forced to defy all rules and come out due to the economic crisis despite the fear of this invisible virus. if the workplaces open up, there is a fear of rapid spread of infection from asymptomatic carriers to others. in such cases the symptomatic cases be tested, isolated and treated. a few critically ill with severe infection would require hospitalization. although mortality cannot be denied, the risk-benefit ratio of natural herd immunity of the population by being exposed to the virus is to be considered. in the current scenario where the pharmacological therapy to treat is yet to be discovered, timely and mandatory contact tracing of all symptomatic cases and acting upon them quickly as per who guidelines is the only way out that should be adopted by all the countries.[16] conclusion: lockdown is not a permanent solution; however, it has produced positive impact in slowing the curve and offered sufficient time for the countries to prepare and face the ongoing pandemic with many uncertainties. the mitigation strategies in south asia should focus to reduce risks of transmission versus the deprivation and hunger resulting from prolonged economic disruption. it is better to invest in low-cost preventive measures to improve physical distancing, such as continue stopping of international travel, reducing the number of people at religious and social gatherings, universal masking using non-medical cloth masks for the community, focus on measures protecting elderly, permit individuals restricted working hours for income generation, information campaigns for personal hygiene, physical distancing and hand washing. as lockdowns are relaxing and physical distancing measures are lessened; proactive surveillance, case detection and contact tracing with isolation and quarantine will be required to prevent a dramatic resurgence of covid-19 cases. in long run we have to live with covid-19. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. piryani rm, et al. covid-19 and lockdown: be logical in relaxing it jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 references: 1. cambridge dictionary [online]. cambridge university press. available at: https://dictionary. cambridge.org/dictionary/english/lockdown accessed on 2020 may 7. 2. “lockdown,” merriam-webster dictionary. available from: https://www.merriam-webster. com/dictionary/lockdown accessed on 2020 may 31. 3. covid-19 coronavirus pandemic. available from: https://www.worldometers.info/ coronavirus/ accessed on 2020 may 31. 4. ren x. pandemic and lockdown: a territorial approach to covid-19 in china, italy and the united states. eurasian geography and economics. 2020; [epub ahead of print]. doi: https://doi.org/10.1080/15387216.2020.1762103 5. tales from the lockdown: how covid-19 has changed lives around the world. available at: https://foreignpolicy.com/2020/05/07/ lockdown-covid-19-changed-lives-around-theworld/# accessed on 2020 may 8. 6. anderson rm, heesterbeek h, klinkenberg d, hollingsworth td. how will country-based mitigation measures influence the course of the covid-19 epidemic? the lancet. 2020; 395:931-934. doi: https://doi.org/10.1016/ s0140-6736(20)30567-5 7. covid-19: south asia keeps its fingers crossed. deccan herald. 2020 apr 19. available from: https://www.deccanherald.com/specials/sundayspotlight/coronavirus-south-asia-keeps-itsfingers-crossed-827234.html accessed on 2020 apr 28. 8. banerjee a. covid-19: the curious case of the dog that did not bark. med j dy patil vidyapeeth. 2020; [epub ahead of print]. doi: https://doi. org/10.4103/mjdrdypu.mjdrdypu_225_20 9. gupta j, ebrahim zt, bhushal r. are we animals? migrants bear brunt of south asiaʼs lockdown. 2020 apr 20. the third pole. available from: https://www.thethirdpole.net/ en/2020/04/20/locked-in-migrant-workers-ofsouth-asia-cannot-see-a-way-out/ accessed on 2020 apr 28. 10. johnson r. south asian cities see clear blue skies appear during lockdown. your weather. 2020 apr 28. https://www.yourweather.co.uk/ news/trending/south-asian-cities-see-clear-blueskies-appear-during-lockdown.html accessed on 2020 apr 28. 11. adhikari n, subedi d. the alarming outbreaks of dengue in nepal. tropical medicine and health. 2020;48:5 doi: https://doi.org/10.1186/s41182020-0194-1 12. wangdi k, kasturiaratchi k, nery sv et al. diversity of infectious aetiologies of acute undifferentiated febrile illnesses in south and southeast asia: a systematic review. bmc infectious diseases 2019;19:577. doi: https:// doi.org/10.1186/s12879-019-4185-y 13. shakya dr. observation and lesson from psychiatry help-line of a teaching hospital in eastern nepal during covid-19 pandemic lockdown. clin med. 2020; 2(1):cim-02-1021. available from: http://www.medtextpublications. com/open-access/observation-and-lesson-frompsychiatry-help-line-of-a-teaching-hospital-427. pdf 14. new york times. when will the covid-19 pandemic end? and how? the economic times. 2020 may 11. available at: https://health. economictimes.indiatimes.com/news/industry/ when-will-the-covid-19-pandemic-end-andhow/75674711 accessed on 2020 may 12. 15. lifting lockdowns does not signal the end of covid-19: who chief. un news. 2020 apr 20. available from: https://news.un.org/en/ story/2020/04/1062172 16. in south asia, there is no safety net against the pandemic. new statesman world review. 2020 april 8. available from: https://www. newstatesman.com/world/asia/2020/04/southasia-there-no-safety-net-against-pandemic accessed on 2020 apr 28. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 piryani rm, et al. covid-19 and lockdown: be logical in relaxing it j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 09 may, 2020 accepted: 24 may, 2020 published: 15 june, 2020 a lecturer, department of obstetrics and gynaecology, b assistant professor, department of obstetrics and gynaecology, c resident doctor, department of obstetrics and gynaecology, d lumbini medical college teaching hospital, palpa, nepal. e patan academy of health sciences, lalitpur, nepal. corresponding author: kritina singh e-mail: kritinasingh@outlook.com orcid: https://orcid.org/0000-0002-0122-161x_______________________________________________________ –————————————————————————————————————————— abstract: introduction: maternal age is an important determinant of pregnancy outcome. women aged 35 years or more at their first pregnancy are considered high risk as they are associated with increased adverse maternal and perinatal outcomes. methods: a retrospective, comparative study was carried out over a period of two years in a tertiary center. each elderly primigravida was matched with two primigravid women aged 20-34 years who delivered during the same period. secondary data on obstetric outcomes (diabetes, oligohydramnios, polyhydramnios, hypothyroidism), postpartum complications (post-partum hemorrhage, post-partum eclampsia) and perinatal outcome (intra-uterine growth restriction, prematurity, congenital anomalies, and neonatal death)of 82 elderly primigravidae (study group) was compared with 164 younger primigravida (control group) delivered during the period of study. the chi square test and fisher’s exact test were used for statistical analysis and p value of <0.05 was taken as level of significance. results: during the study period, there were 15,012 deliveries and 82 of these were elderly primigravidae giving an incidence of 0.55%. the mean age of the elderly primigravidae was 36.8±2.16 years. the study group had more antepartum complications with preterm labor, diabetes in pregnancy, hypertensive disorders in pregnancy, multiple pregnancy and polyhydramnios (p<0.05). seventy-one elderly primigravidae were delivered by caesarean section, the commonest indication being maternal request. the study group had higher incidence of post-partum hemorrhage but no perinatal mortality of significant proportion. conclusion: maternal age at the first pregnancy influences pregnancy and neonatal outcome. hence, elderly primigravidae should be considered as high risk and followed up accordingly. keywords: elderly primigravidae, maternal age, pregnancy outcome original research articlehttps://doi.org/10.22502/jlmc.v8i1.331 kritina singh,a,d prashant shrestha,b,e jeena baaniya,a,e prashansa gurung c,e pregnancy outcome among primigravidae aged 35 years and above: a comparative study how to cite this article:how to cite this article: singh k. pregnancy outcome among primigravidae aged 35 years singh k. pregnancy outcome among primigravidae aged 35 years and above: a comparative study. journal of lumbini medical and above: a comparative study. journal of lumbini medical college. 2020;8(1): 5 pages. doi: college. 2020;8(1): 5 pages. doi: https://doi.org/10.22502/jlmc.https://doi.org/10.22502/jlmc. v8i1.331v8i1.331. epub: 2020 june 15.. epub: 2020 june 15. introduction: maternal age and parity have been considered among the key determinants in obstetric performance and pregnancy outcomes. the extremes of reproductive life and parity have been widely associated with increased adverse obstetric outcomes. [1] in 1958, the council of “international federation of obstetrics and gynecology” adopted age of 35 years or more for elderly primigravida.[2] elderly women are at a higher risk of several complications including malpresentations, malpositions, induction of labour, hypertensive disorders of pregnancy (hdp), diabetes mellitus, antepartum hemorrhage (aph), prolonged labour, instrumental deliveries, increased caesarean section rate and postpartum hemorrhage (pph).[3] with increase in maternal age oocyte quality gets poorer which causes risk of chromosomal anomaly, aneuploidy and spontaneous abortion.[2] in addition, perinatal complications are reported to be higher in this patient population.[4] j. lumbini. med. coll. vol 8, no 1, jan-june 2020 singh k, et al. pregnancy outcome among primigravidae aged 35 years and above: a comparative study. jlmc.edu.np in recent years, many women defer marriage and child bearing till they are in their late thirties in order to seek education and career. this trend has delayed the number of women undergoing their first pregnancy before 35 years.[4] hence, this study aimed to evaluate the obstetric and perinatal outcomes among this subset of obstetric population. methods: this was a retrospective, comparative study carried out in the department of obstetrics and gynecology, patan academy of health sciences, patan, nepal. the data collection was done from 25th november 2019 to 25th december 2019 from the medical record section during which the data of women delivered from 1st january 2017 till 31st december 2018 were collected. the ethical clearance was taken from the institutional review committee prior to commencement of the study. the labour ward register was revisited and all the primigravidae aged 35 years and more who had delivered during the study period were identified. those known to have diagnosed heart disease and bronchial asthma were excluded. for each elderly primigravida taken as a case, the next two primigravidae aged 20-34 years that delivered were included as controls. the case to control ratio was taken as 1:2. the case files were retrieved from the records department and studied retrospectively. all the relevant demographic information was recorded in a preformed performa. the clinical information recorded were age, type of pregnancy (single/multiple), obstetric outcome (hdp, diabetes, aph, oligohydramnios, polyhydramnios, hypothyroidism), postpartum complications (pph, postpartum eclampsia) and perinatal outcome (intrauterine growth restriction, prematurity, congenital anomalies, and neonatal death). the data thus collected were entered to and analyzed with statistical package for social sciences (spsstm) software version 20. descriptive statistics like mean and standard deviation were used to describe quantitative data and, frequencies with percentages were used for qualitative data. independent ‘t’ test, chi-square test and fisher’s exact test were used for statistical analysis as applicable. a p value of <0.05 was taken as level of significance. results: there were a total of 15,012 deliveries out of which 82 (0.55%) were elderly primigravidae. as controls, 164 primigravidae aged 20-34 years were taken. the mean age in the case group was 36.8+2.15years and in the control group, 25.61+3.25 years. the highest age in the case group was 46 years. nineteen women had infertility treatment in the case group among which 11 had undergone invitro fertilization (ivf) and eight had intrauterine insemination (iui). in the control group, only two women had infertility treatment with iui. there were two triplets and three twin pregnancies among the study group which were the result of ivf. table 1 shows that the incidence of preterm labor, diabetes in pregnancy, hdp, multiple pregnancy and polyhydramnios were statistically significantly higher in the study group than in the table 1. comparison of complications in the antenatal period. type of complications study group (n=82) control group (n=164) statistics preterm labor 12 (14.63%) 10 (6.09%) x2 (1,246) = 4.892, p=0.027 diabetes in pregnancy 10 (12.20%) 6 (3.65%) x2(1, 246)=6.551, p= 0.010 hdp 22 (26.82%) 8 (4.87%) x2 (1,246) = 24.60, p<0.001 iugr# 9 (10.97%) 14 (8.53%) x2(1, 246)=0.384, p= 0.536 iufd# 1 (1.21%) 0 (0%) p = 0.333* hypothyroidism 11 (13.41%) 12 (7.31%) x2(1,246)=2.398, p = 0.121 aph 1 (1.21%) 1 (0.60%) p = 0.556* oligohydramnios 11 (13.41%) 14 (8.53%) x2 (1,246) = 1.425, p=0.233 polyhydramnios 4 (4.87%) 0 (0%) p = 0.012* multiple pregnancy 5 (6.09%) 2 (1.22%) p = 0.043* *fischer exact test, #iugr: intrauterine growth restriction, #iufd: intrauterine fetal death j. lumbini. med. coll. vol 8, no 1, jan-june 2020 singh k, et al. pregnancy outcome among primigravidae aged 35 years and above: a comparative study. jlmc.edu.np control group (p<0.05). table 2 compares the mode of delivery between the study and control groups. cesarean section was statistically significantly higher in the study group (p<0.001). table 3 shows that the study group had statistically significant (p<0.05) proportion of pph. the above table showed no statistically significant differences in the neonatal outcome in the study group on comparison to the control group. there were two neonatal deaths in the study group. one was due to prematurity and multiple congenital anomalies whereas the other one was due to extreme prematurity (25 weeks of gestation). one neonatal death in the control group was also due to prematurity. discussion: the prevalence of primigravidae aged 35 years or above in this study was 0.55% which is almost similar to 0.42% and 0.69% reported by bako b et al.[4] and anozie ob et al.[5] respectively in nigeria. however the prevalence were higher in studies conducted by ikeanyi em al.[1] and ojule jd et al.[6] accounting for 1.44% and 1.6% respectively. the lower prevalence in this study is probably because in developing country like ours, women get married at an earlier age and start family before they are 35 years. the current study showed an increased risk of hdp, diabetes in pregnancy, multiple pregnancy and polyhydramnios among the elderly primigravidae during the antenatal period. these findings are similar to those of anozie ob et al.[5] which reported high incidence of hdp and diabetes mellitus among elderly primigravidae. similarly, the preterm delivery rate was significantly higher in the elderly primigravidae compared to the younger primigravidae. ojule jd et al.[6] and anozie ob et al.[5] have also reported increased rate of preterm delivery. this may be due to early induction in the study group because of associated antenatal complications requiring early delivery. however, table 2. comparison of mode of delivery between the groups. mode of delivery study group (n=82) control group (n=164) statistics vaginal 10 (12.20%) 102 (62.20%) x2(1, 246)=54.899, p<0.001 instrumental 1 (1.21%) 3 (1.83%) p=1.00* lscs# elective 29 (35.37%) 7 (4.27%) x2 (1, 246) = 54.899, p<0.001 emergency 42 (51.21%) 52 (31.70) *fischer exact test, #lscs: lower segment caesarean section table 3. comparison of postpartum complications between the groups. complications study group (n=82) control group (n=164) statistics pph 6 (7.31%) 2 (1.22%) x2(1, 246) = 6.460, p=0.011 postpartum eclampsia 1 (1.21%) 0 (0%) p=0.333* *fischer exact test table 4. comparison of neonatal outcome in the study and control groups. complications study group (n=82) control group (n=164) statistics low birth weight (<2.5kg) 15 (18.30%) 16 (9.75%) x2(1, 246) = 3.617, p=0.057 congenital malformation 1 (1.21%) 0 (0%) p=0.333* neonatal death 2 (2.44%) 1 (0.60%) p=0.258* *fischer exact test j. lumbini. med. coll. vol 8, no 1, jan-june 2020 singh k, et al. pregnancy outcome among primigravidae aged 35 years and above: a comparative study. jlmc.edu.np pegu b et al. [2] and bako b et al. [4] have reported that preterm delivery was not statistically significant in their study groups. this could be due to the small sample size in both the study groups. we also found a significant increase in the rate of caesarean delivery (p<0.001) in elderly primigravidae women when compared to the women aged 20-34 years. this is in agreement with the findings of other researchers.[1,2,4,5,8] out of 82 deliveries in the study group 71 were by caesarean section and the commonest indication was advanced maternal age with treated subfertility and maternal request. the reason for this may be because of anxiety and stress associated with long period of infertility. however, the difference in instrumental delivery was not statistically significant. postpartum hemorrhage was more in the study group which was statistically significant (p<0.05). however in the study by pegu b et al.[2] pph cases in the study group was not statistically significant. similarly other studies have shown increased incidence of pph but not significant statistically.[1,4,5,9] the neonatal outcome among the elderly primigravida is generally controversial, some reported increase in neonatal death[5], while others did not.[1,2,4,7]. our study revealed no statistically significant difference in terms of low birth weight, neonatal death and congenital malformation. the limitations of this study include its retrospective nature and its ability to assess the outcomes of only viable pregnancies. since the study population included only women who gave birth at patan hospital, the results may not be generalized. conclusion: maternal complications were more during pregnancy in advanced maternal age requiring increased need for early delivery and caesarean section. therefore, advanced maternal age is definitely ahigh risk group with adverse obstetric and perinatal outcomes. however, these problems can be overcome and one can expect a good pregnancy outcome. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 singh k, et al. pregnancy outcome among primigravidae aged 35 years and above: a comparative study. jlmc.edu.np references: 1. ikeanyi em, onyiriuka an. advanced maternal age at the first pregnancy and obstetric performance: a retrospective study. pacific journal of medical sciences. 2014;13(1):21-31. available from: https://www.pacjmedsci.com/ pjmsvol13no1aug2014.htm 2. pegu b, gaur bps. elderly primigravida and a comparative analysis of their pregnancy outcome with younger primigravida. international journal of research in medical sciences. 2018;6(11):3478-81. doi: http://dx.doi. org/10.18203/2320-6012.ijrms20184402 3. moses v, dalal n. pregnancy outcome in elderly primi gravidas. international journal of reproduction, contraception, obstetrics and gynecology. 2016;5(11):3731–5. doi: http:// dx.doi.org/10.18203/2320-1770.ijrcog20163519 4. bako b, umaru i, geidam ad, garba ma. pregnancy outcome in elderly primigravidae at the university of maiduguri teaching hospital, maiduguri, nigeria babagana. international journal of medicine and medical sciences. 2013;3(7):476-80. available from: https://www. researchgate.net/publication/257568030 5. anozie ob, mamah je, esike cu, asiegbu og, lawani lo, eze jn, et al. pregnancy outcome among elderly primigravidae: a fiveyear review at abakaliki, ebonyi state, nigeria. journal of clinical and diagnostic research. 2019;13(1):qc01-qc04. available from: https:// www.jcdr.net/articles/pdf/12431/37879_ ce[ra1]_f(ac_sl)_pf1(ab_km)_pn(sl). pdf 6. ojule jd, ibe vc, fiebai po. pregnancy outcome in elderly primigravidae. ann afr med. 2011;10(3):204–8. pmid: 21912003. doi: https://doi.org/10.4103/1596-3519.84699 7. vasanthakumari kp, retnamma nv. outcome of pregnancy in elderly primigravida. journal of medical science and clinical research. 2017;5(1):29523-28. doi: https://dx.doi. org/10.18535/jmscr/v5i10.176 8. paliwal v, desai r, jodha bs. “pregnancy outcome in elderly gravida” paripex indian journal of research. 2017;6(3):14-15. avaialble from: https://www.worldwidejournals. com/paripex/recent_issues_pdf/2017/march/ march_2017_1491812107__05.pdf 9. al ghailani a, gowri v, al hoqani fas, al belushi akm, islam mm. obstetric complications and adverse pregnancy outcomes among elderly primigravidae of age 35 years and above in oman. clinical obstetrics, gynecology and reproductive medicine. 2019;5(3):1-5. doi: https://doi.org/10.15761/cogrm.1000254 fatal salmonella typhi necrotising fasciitis following intra-articular steroid injection sagar narang,a,c prakash sapkotab,d —–————————————————————————————————————————————— abstract: intra-articular steroids administration in the absence of aseptic precautions can have disastrous consequences. immunocompromised patients are at an increased risk of developing infections following such procedures. salmonella has been infrequently reported as a causative organism for necrotising fasciitis. gram negative endotoxemia with disseminated intravascular coagulation resulted in fatality in this patient. the case study is being presented to emphasise the need for aseptic precautions and sterile techniques while administering intra-articular steroids, to have a low threshold towards treating early joint infections expeditiously, and to consider possibility of a gram negative organism as a cause of septicaemia and necrotising fasciitis especially in debilitated patients. keywords: necrotising fasciitis • salmonella • steroid injection ——————————————————————————————————————————————— ___________________________________________________________________________________ a associate professor b lecturer c department of orthopedics and traumatology lumbini medical college teaching hospital, palpa, nepal d department of surgery lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. sagar narang e-mail: sagarnarang@jlmc.edu.np how to cite this article: narang s, sapkota p. fatal salmonella typhi necrotising fasciitis following intra-articular steroid injection. journal of lumbini medical college. 2013;1(2):125-7. doi:10.22502/jlmc.v1i2.36. ___________________________________________________________________________________ j. lumbini. med. coll. vol 1, no 2, july-dec 2013 case report jlmc.edu.np https://doi.org/10.22502/jlmc.v1i2.36 introduction: intra-articular steroid injections are routinely used by trained orthopaedic surgeons in the management of rheumatoid, gouty and osteoarthritis patients, painful conditions like adhesive capsulitis of the shoulder, plantar fasciitis, medial and lateral epicondylitis of the elbow. minor complications like pain and inflammation at injection site are not uncommon following such injections. rarely infection may occur, especially in immunocompromised patients. development of necrotising fasciitis (nf) following intra-articular steroid infiltration is extremely rare. only five such cases have been reported previously in international literature.1-5 the bacterial isolates in these cases were either streptococci or staphylococci. very few cases of salmonella nf have been reported in literature.6-11 this is probably the first reported case of salmonella nf following intra-articular steroid injection. salmonella nf can be managed with antibiotics and supportive therapy when detected early. the patient presented here came to us moribund, in the stage of endotoxic shock when disseminated intravascular coagulation (dic) had already set in. she later, succumbed to multi-system organ failure. family members of the deceased were informed that the data concerning this case would be submitted for publication, and they consented. case report: local steroid injections are often administered by inadequately trained medical personnel, probably without due consideration being given to strict aseptic conditions. the presented case is an extreme form of an infective complication resulting in a fatality. a 56-year-old lady presented to our emergency service in a toxic state. her blood pressure was 90/60 mm hg, she was febrile (101°f) and delirious. pallor, dehydration, tachycardia (120 beats/min) and tachypnea (respiratory rate 25/min) were present. resuscitative measures were started and preliminary blood investigations sent. examination of her left leg, showed open surgical incisions, consistent with those made for compartment release, located on the antero-lateral and posteromedial aspects. both the incisions were infected, with necrotic subcutaneous tissue and fascia present throughout the length of the 125 j. lumbini. med. coll. vol 1, no 2, july-dec 2013 jlmc.edu.np narang s. et al. fatal salmonella typhi necrotising fasciitis following intra-articular steroid injection wound (fig.1). the left leg felt firm to palpation, and induration involved the leg and extended to posteromedial aspect of proximal thigh. bone-deep pressure sores were present over the sacrum (5 cm x 5 cm) and both greater trochanters (8 cm x 5 cm). two months earlier, the patient developed left knee pain, and attended a local hospital. she was diagnosed as osteoarthritis left knee and advised intra-articular steroid injection for her symptoms. the injection was administered by a health-care provider in his clinic. two days later, the patient developed swelling and increasing pain on knee movement. analgesics (aceclofenac 100 mg twice a day) were used for five days without any improvement. the knee swelling increased and extended towards the left leg. the patient was taken back to the same clinic, where she was reassured that the swelling would gradually subside on rest, analgesics and limb elevation. this management was continued for next two weeks. as the patient's general condition deteriorated, she was admitted to hospital x. a diagnosis of post-injection cellulitis left leg was made. she was administered intravenous antibiotics (amoxicillin sodium + clavulanate potassium 1.2 gm thrice a day) for two weeks. no improvement resulted, and she developed fever. she was then transferred to hospital y, where she was diagnosed as pyomyositis of calf muscles with compartment syndrome. two-incision fascial release of leg compartments was performed under general anesthesia, as an emergency. intravenous antibiotics (cefepime one gm twice a day) were started. soon after, kidney derangement developed. family members declined further treatment and took the patient home. this was at five weeks following the intra-articular injection. intravenous antibiotics and regular dressing of leg were continued for next three weeks. during this period the patient continued to deteriorate. she developed pressure sores over her sacrum and trochanteric regions. it was in this state that she presented to our emergency. the patient at presentation had haemoglobin of 6.2 g/dl (normal range = 12-15 g/dl), total leukocyte count of 5.4 x 103/mm3 (normal range =4-11 x 103/ mm3), platelets 0.96 x 105/ mm3 (normal range =1.54.0x105/mm3), bleeding time of 5 minutes (normal range = 2-9 minutes), prothrombin time of 30 seconds (control = 12 seconds). serum creatinine was 2.1 mg/ dl (normal range =0.6-1.1 mg/dl), urea was 135 mg/ dl (normal range = 7-21 mg/dl), sodium was 140.4 meq/l (normal range = 135-145 meq/l), potassium was 3.3 meq/l(normal range = 3.5-5.0 meq/l) and blood sugar was 101 mg/dl (normal range = 80-110 mg/dl). blood cultures were sent. attempted venous cannulation in cubital fossa resulted in a purulent ooze on puncturing the antebrachial fascia. a central venous catheter was inserted, intravenous cefepime one gm twice a day and intravenous teicoplannin 400 mg once a day started. with support of inotropes her blood pressure was stabilised and five units of whole blood were transfused. patient's family was informed of a dismal prognosis, and the patient was shifted to operation theatre for emergency hip disarticulation in an attempt to debulk the septic focus. a racquet-shaped incision was made around the left hip. there was evidence of subcutaneous fat necrosis with intravascular coagulation seen in superficial veins (fig.2). all the fascial septa were necrotic, with large purulent collections in thigh compartments, deep veins were thrombosed. the hip was disarticulated, and left lower limb removed (fig. 3a, 3b). muscles and superficial layers were closed over a corrugated rubber drain and stump dressing applied (fig.4). the pressure sores over the trochanteric and sacral regions were debrided and dressed. the patient was shifted to intensive-care unit on ventilator support. inotropes and antibiotics were continued. twenty four hours post surgery, the patient developed pneumonia and sudden hyperglycemia (blood glucose 358 milligrams per decilitre). she started bleeding from the surgical wound and vagina. her blood pressure dropped to 40/30 mm hg. despite inotrope support, she succumbed to multi-system organ failure 36-hours after surgery. her blood cultures subsequently grew salmonella typhi sensitive to ciprofloxacin and ceftizoxime. discussion: necrotising fasciitis (nf) is a progressive infectious process involving devitalisation of fascia and subcutaneous tissue, which becomes life threatening if not diagnosed and treated early. the infective process leading to fascial necrosis is the result of a mixed bacterial infection caused by aerobic and anaerobic bacteria. the pathogens most commonly involved are group a streptococci, staphylococcus aureus, peptostreptococcus and enterobacteriaceae.12 fasciitis necroticans is a rare disease and most of the patients developing it, have pre-existing conditions rendering them susceptible to infections.9 these contributory factors include diseases like systemic lupus erythematosus, multiple myeloma, chronic steroid use, chronic use of immunosuppressive medications. severe pain disproportionate to local findings associated with systemic toxicity should raise the suspicion of necrotising fasciitis.13 salmonella infection is usually associated with asymptomatic enteric carriage, gastroenteritis fig 1: patient with necrotising fasciitis of left lower limb following intra-articular left knee steroid injection. presence of necrotic fascia present in surgical incisions and subcutaneous fat necrosis at the knee level is evident. 126 j. lumbini. med. coll. vol 1, no 2, july-dec 2013 narang s. et al. fatal salmonella typhi necrotising fasciitis following intra-articular steroid injection jlmc.edu.np and enteric fever. extra-intestinal manifestations include endovascular infection, osteomyelitis, septic arthritis, and myonecrosis.10,14,15 patients with underlying malignancy, diabetes, sickle cell disease, hiv infection and those on corticosteroids and immunosuppressive medications are at a greater risk of invasive salmonella infections.10 the synovium is a particular metastatic focus of salmonella infection especially in immunocompromised patients.16 complex lipopolysaccharides present in outer cell membrane of salmonella behave as endotoxin. this freely circulating endotoxin activates both coagulation and fibrinolytic systems. dic is produced during endotoxemia by combination of vasoconstriction, platelet damage, vascular endothelial damage and inhibition of local fibrinolysis.17 conclusion: acute flare up of arthritis in cases of osteoarthritis knee can be managed conservatively with oral nsaids for short periods, and occasionally intra-articular steroid injections are administered. the steroid injection should be done taking all due anti-septic precautions. the older age-group of immunocompromised patients presenting with a tender knee may have underlying infection, which may flare up on injection of steroid. such cases should be screened and investigated thoroughly before planning an injection treatment. if an unsuspected infection flares up, it should be diagnosed early and treated appropriately. salmonella typhi is an uncommon cause of septic arthritis and necrotising fasciitis. early joint aspiration and blood cultures may help detect the causative organism and control the infective process. salmonella infection usually responds to third generation cephalosporin. dic represents the end-point of endotoxemia. gram negative sepsis should not be allowed to progress to this irreversible stage. fig 2: operative wound showing presence of fat globules in the purulent exudates and evidence of intravascular coagulation noted in the thrombosed veins. figure 3a, 3b : operative photographs showing disarticulation of left hip. fig 4: amputation stump following disarticulation references: 1. birkinshaw r, o’ donnel j, sammy i. necrotizing fasciitis as a complication of steroid injection. j accid emerg med. 1997;14:52-4. 2. regev a, weinberger m, fishman m, samra z, pitlik sd. necrotizing fasciitis caused by staphilococcus aureus. eur j clin microbiol infect dis. 1998;17:101-3. 3. hofmeister e, engelhardt s. necrotizing fasciitis as a complication of injection into greater trochanteric bursa. am j orthop. 2001;30:426-7. 4. unglaub f, guehring t, fuchs pc, perez-bouza a, groger a, pallua n. necrotizing fasciitis following therapeutic injection in a shoulder pain. orthopade. 2005;34:250-2. 5. fanfarillo f, pace f, maida r, pignata d, cergua g. necrotizing fasciitis following intra-articular steroid injection: case report and review of the literature. geriatr gerontol int. 2012;12(2):353-5. 6. rosser a, swallow g, swann ra, chapman c. salmonella enteritidis necrotising fasciitis in a multiple myeloma patient receiving bortezomib. int j haematol. 2010;91(1):149-51. 7. luo cw, liu cj. neck abscess and necrotizing fasciitis caused by salmonella infection: a report of 2 cases. j oral maxillofac surg. 2007;65(5):1032-4. 8. khawcharoenporn t, apisarnthanarak a, kiratisin p, mundy lm. salmonella group c necrotizing fasciitis: a case report and review of the literature. diagn microbiol infect dis. 2006;54(4):319-22. 9. andriessen mj, kotsopoulos am, bloemers fw, strack van schijndel rj, girbes ar. necrotizing fasciitis caused by salmonella enteritidis. scand j infect dis. 2006;38(1112):1106-7. 10. suwannaroj s, mootsikapun p, vipulakorn k, nanagara r. salmonella group d arthritis and necrotizing fasciitis in a patient with rheumatoid arthritis and diabetes mellitus. j clin rheumatol. 2001;7(2):83-5. 11. sanchez c, capell s, casanovas a, admetlla m, sitges-serra a. necrotizing fasciitis caused by salmonella enteritidis. scand j infect dis. 1984;16(3):321-2. 12. 12. wong ch, chang hc, pasupathy s, khin lw, tan jl, low co. necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. j bone joint surg am. 2003;85a(8):1454-60. 13. hasham s, matieucci p, stanley pr, hart nb. necrotising fasciitis. bmj. 2005;330(7495):830-3. 14. jorring s, kolmos hj, klareskov b. myonecrosis in the leg caused by salmonella enteritidis. scand j infect dis. 1994;26(5):619-21. 15. santos-juanes j, lopez-escobar m, galache c et al. haemorrhagic cellulitis caused by salmonella enteritidis. scand j infect dis. 2005;37(4):309-10. 16. chen jy, luo sf, wu yj, wang cm, ho hh. salmonella septic arthritis in systemic lupus erythematosus and other systemic diseases. clin rheumatol. 1998;17(4):282-7. 17. glover sc, smith cc, porter ia. fatal salmonella septicaemia with disseminated intravascular coagulation and renal failure. j med microbiol. 1982;15(1):117-21. 127 lmc journal vol. 2.indd 102 study on nutri onal status of children under 5 years in palpa district, nepal: special reference to baal vita karki dk, lall bs and paul v department of community medicine, lumbini medical college, tansen, pravas, nepal corresponding author: dr. dk karki, , department of community medicine, lumbini medical college teaching hospital and research centre, pravas, p.o.box-5, tansen-11, palpa, nepal abstract background: malnutri on is a pathological state resul ng from a rela ve or absolute defi ciency or excess of one or more essen al nutrients. malnutri on is a major underlying cause of the child morbidity and mortality in nepal. adequate nutri on is a fundamental right for every human being. malnourished child is depriving from physical and mental development. objec ves: to assess the nutri onal status of children under 5 years and to fi nd out the knowledge and prac ce regarding micronutrient powder “baal vita”. materials and methods: descrip ve cross sec onal community based study was conducted in palpa district. a total of 390 respondents at the age of 6-59 months were selected with the help of mul stage sampling. through anthropometry, prevalence of underweight, stun ng and was ng was determined. results: prevalence of underweight, stun ng and was ng was 25.9%, 27.2% and 7.3% respec vely. the associa on between age of the mother at the birth of the children and nutri onal status of children is not sta s cally signifi cant. majority of the children (80.5%) used to take junk foods some mes, followed by 16.7% very o en and 2.8% children never used to take. majority of the children (52.6%) were taken the micronutrient powder (fi rst course) but the coverage of second course of micronutrient powder was 29.5% followed by third course coverage only 18.9%. conclusion: the nutri onal status of children in this study was found to be sa sfactory because compared to the millennium development goals (mdgs) target but the coverage of micronutrient powder is low. keywords: underweight, stun ng, was ng, malnutri on, waterlow’s and gomez classifi ca on introduction malnutri on is one of the major public health problems in developing countries including nepal, remains a serious obstacle to child survival, growth and development. it does not only directly aff ect the children by reducing their physical and mental performance but makes the situa on worse by making the children suscep ble to infec on, slower recovery and higher mortality.1 it is one of the foremost underlying causes of the child morbidity and mortality. malnutri on increases the risk of a child dying due to common infec ons such as pneumonia, diarrhoea, measles, and malaria by over 50%. according to who, nearly 55% of below fi ve years children’s death worldwide are caused by malnutri on. among those who survive, inadequate nutri on reduces cogni ve growth. not only severe malnutri on, but also mild to moderate malnutri on increases the risk of a child dying due to common infec ons. around 40% under fi ve mortality results from diarrhoea or acute respiratory infec on; which are curable in fi rst stage with simple home remedies when nutri onal status is good. 2 there are many factors that directly or indirectly cause malnutrition among children. children who suff er from repeated episodes of diarrhoea or acute respiratory infec ons (ari) are more likely to suff er from malnutri on which leads to insuffi cient intake of calories, proteins, vitamins and minerals.3 children below 5 years and especially those aged 6 months to 24 months are at par cular risk. the common types of malnutrition in nepal are: protein energy malnutrition, iodine deficiency disorders, iron deficiency anemia and vitamin a deficiency. government of nepal, ministry of health and population has implemented many nutri onal interven on programmes. one of them is micronutrient powder or “baal vita” programme with the aim of reducing malnutrition specially micronutrient defi ciency at the age of 6 months 24 months. it provides one packet of “baal vita” per day and contains vitamin a (400 mcg), thiamine (0.5 mg), ribofl avin (0.5 mg), pyridoxin (0.5 mg), cynacobalamin (0.9 mcg), vitamin c (30 mg), vitamin d3 (5 mcg), vitamin e (5 mg), folic acid (150 mcg), niacin (6 mg), coppercupric gluconate (0.56 mg), iodine-potassium iodide (90 mcg), iron-ferrous fumarate (1010 mg), zink (4.1 mg) and selenium (17 mcg). it is started when child reaches 6 months of age providing one packet per day for 2 months. a er gap of 4 months, in 12 months again started for 2 months, again at the age of 18 months 60 packets are provided. original article l m coll j 2013; 1(2): 102-104 103 table 1: nutri onal status of the children (weight for age)* nutri onal status frequency percentage normal (90-110%) 289.0 74.1 mild malnutri on (gr. i) (75-89%) 79 20.3 moderate malnutri on (gr. ii) (60-74%) 20 5.1 severe malnutri on (gr. iii) (≤60%) 2 0.5 total 390 100.0 *weight for age calculated according to gomez classifi cation (who standard) the nutri onal status of children in nepal has improved over the past 15 years and is close to achieving the millennium development goals (mdgs) target of reducing the percentage of underweight children to 29 percent by 2015. the percentage of stunted children declined by 14 percent between 2001 and 2006 and declined by an addi onal 16 percent between 2006 and 2011. a similar pa ern is observed for the percentage of underweight children reduced by 9 percent between 2001 and 2006, 26 percent between 2006 and 2011. similarly, the percentage of was ng declined by 15 percent between 2006 and 2011.4 the millennium development goals (mdgs) will never be met without signifi cant accelera on in addressing under nutri on as one of the primary cause of child mortality. materials and methods descrip ve cross sec onal community based study was conducted where mul stage sampling technique was used. palpa district was selected purposively, out of 65 vdc, 13 vdcs were selected randomly. out of 9 wards, 3 wards were selected randomly. a er that, 10 respondents selected from each ward by using random table. thus a total of 390 respondents at the age of 6-59 months were selected where the face to face interview was taken to mother of child by using structural ques onnaire. anthropometric measurement was taken by taking weight in kilogram, with the help of weighing machine, height was measured in cm with the help of measuring tape and mid upper arm circumference (muac) of le hand was measured by using measuring tape (shakir tape). nutri onal status was determined by calcula on of weight for age (underweight), height for age (stun ng) and weight for height (was ng) by using waterlow’s and gomez classifi ca on. tabula on and analysis of data: a er collec on of data, data were entered into the sta s cal package for social science (spss). analysis and interpreta on of data were done in detail with the help of sta s cal measures accordingly. dura on of the study: the period of data collec on was 1st june, 2013 to 30 november, 2013. results majority of respondents (95.14%) had ownership of radio, followed by 76.45% had television at home and only 4.74% were subscribers of newspaper. radio (16.11%), television (13.91%) were the sources of informa on about nutri on. majority of children (74.1%) were normal in weight but around one quarter (20.3%) were mild malnourished fallowed by 5.1% were moderate malnourished and very few (0.5%) were severe malnourished. majority of the children (72.8%) were normal in height but around one quarter (22.3%) were mildly impaired, followed by 3.8% were moderately impaired and 1% severely impaired as well as was ng (weight for height) were 7.3%. majority of the children (87.1%) were normal and 12.9% were 1st degree, mild malnourished among the 6-11 months children, similarly among 18-23 months children, half (50%) were normal and half were 1st degree, mild malnourished, but few (9.1%) among 24-29 months children were 3rd degree, severe malnourished. around one third (32.84%) children were 1st degree mild malnourished who were born to mothers 15-17 years of age and remaining were normal whereas majority of children (90.91%) were 2nd degree, moderate malnourished born to mothers 24-26 years of age, less than 1% (0.78) were 3rd degree, severe malnourished borne to mother 21-23 years of age. however the associa on between age of the mother at the birth of the children and nutri onal status of children is not sta s cally signifi cant. majority of the children (80.5%) used to take junk foods table 2: nutri onal status of the children (height-for-age) p://mohp.gov.np/english/fi les/ new_publica ons/9-1frequency percent normal (>95%) 284 72.8 mild impaired (87.5%-95%) 87 22.3 moderate impaired (80%-87.5%) 15 3.8 severely impaired (<80%) 4 1.0 total 390 100.0 *height for age according to waterlow’s classifi cation dk karki et al 104 journal of lumbini medical college some mes, followed by 16.7% very o en, 2.8% children never used to take. there is no association between consumption of junk food and malnutrition. majority of mothers (77.9%) had heard about the micronutrient powder, but around one quarter (22.1%) mothers had not heard about it. majority of the children (52.6%) were taken the fi rst course of micronutrient powder but the coverage of second course of micronutrient powder was 29.5% and followed by third course coverage was only 18.9%. all mothers who qui ed it, reported that taste of micronutrient powder is not good and child does not want to con nue. table 3: nutri onal status of children by age age of the children in months weight for age total normal 1st deg 2nd deg 3rd deg 6-11 87.1% 12.9% .0% .0% 100.0% 12-17 96.4% 3.6% .0% .0% 100.0% 18-23 50.0% 50.0% .0% .0% 100.0% 24-29 90.9% .0% .0% 9.1% 100.0% 30-35 91.7% .0% 8.3% .0% 100.0% 36-41 64.3% 17.9% 16.1% 1.8% 100.0% 48-53 23.5% 61.8% 14.7% .0% 100.0% 54-59 98.5% 1.5% .0% .0% 100.0% total 74.1% 20.3% 5.1% .5% 100.0% table 4: nutri onal status of the children by age of the mother at birth of the child age of the mother at birth (year) weight for age normal 1st deg 2nd deg 3rd deg 15-17 67.16% 32.84% 0% 0% 18-20 79.24% 19.68% 0.54% 0.54% 21-23 75.97% 16.28% 6.98% 0.78% 24-26 9.09% 0% 90.91% 0 total 74.10% 20.25% 5.13% 0.52% χ² cal = 1.86, df = 9, χ² tab=14 (not signifi cant) discussion 41 percent of children below 5 years of age are stunted, 29 percent are underweight and 11 percent of children suff er from was ng in nepal (ndhs, 2011). these fi ndings are li le similar to fi nding of present study where stun ng is 27.2%, underweight 25.9% and was ng 7.3%. this fi gure was quite low than the study conducted in eastern nepal where it was reported as 61% underweight.5 another study conducted in jirel community in jiri vdc, dolakha to assess the nutri onal status of children age group between 12 months to 60 months. it was found that 64% had mild to moderate malnutri on. another study, the prevalence of stun ng in primary school children in pokhara valley was found 14.9% which is higher than present study.7 this study shows most of the children (92.1%) were from hindu and few were from buddhist. these fi ndings were similar to religion wise distribu on of popula on of nepal where 80.6% of the total popula on was hindu and 10.7% of the popula on was buddhist.8 this study represents that majority of the children were from joint family. half percent of mothers were primary level, one third mothers were secondary level and very few (9%) were illiterate. around one third (32.84%) children were 1st degree mild malnourished who were born to mothers 15-17 years of age and remaining were normal. majority of children (90.91%) were 2nd degree, moderate malnourished born to mothers between 24-26 years of age. however the associa on between age of the mother at the birth of the children and nutri onal status of children was not sta s cally signifi cant. on contrary, the study conducted in dhankuta district of nepal found maternal age more than 35 years at pregnancy, was a risk factor for stun ng and underweight in children.9 this study reveals that coverage of micronutrient powder, fi rst, second and third courses are 52.6%, 29.5% and 18.9% respec vely. conclusion the nutri onal status of children in this study were found to be sa sfactory because compared to the millennium development goals (mdgs) target of reducing the percentage of underweight children age 6-59 months to 29 percent by 2015, which is already achieved in this district before 2015 but government has launched micronutrient powder programme which coverage is very low. therefore the importance of micronutrient powder should be disseminate to all people, focus on awareness about it, should be contribute from all the sectors and taste should be modifi ed. reference 1. nepal demographic and health survey 2006, family health division, department of health services 2. national nutrition policy and strategy, ministry of health and population, government of nepal. 2008. retrieved from: http://mohp.gov.np/english/files/ new_publica ons/9-1nutri on-policy-and-strategy.pdf 1. unicef. atlas of south asian children and women. 1996. unicef, rosa. nepal. 3. mishra vk, retherford rd. women’s education can improve child nutri on in india. in bulle n na onal family health survey, interna onal ins tute for popula on sciences, mumbai, 2000:15.4. 4. popula on division, ministry of health and popula on, department of health services, government of nepal. nepal demographic and health survey (ndhs), 2011. available from: h t t p : / / w w w. m o h p . g o v. n p / e n g l i s h / p u b l i c a t i o n /ndhs%202011%20full%20 version.pdf 5. shakya sr, bhandary s and pokharel pk. nutri onal status and morbidity pattern among governmental primary school children in the eastern nepal. kathmandu univ med j 2004; 2: 307-14 6. chapagain rh, adhikari ap, dahal r et al. a study on nutri onal status of under fi ve jirel children of eastern nepal. j nhrc. 2005; 3: 2. 7. pradhan e, leclerg sc, khatry sk. child growth: a window to child health in the terai, nnips monograph, 1991, 1 : 19-21. 8. sta s cal pocket book, his majesty’s government of nepal, na onal planning commission, kathmandu, nepal, 2002; 5, 15,159. 9. sapkota vp, gurung ck. prevalence and predictors of underweight, stunting and wasting in under-five children. j nhrc 2009; 7(15): 120-6. characteristics of patients with tuberculous pleural effusion in rural nepal ms paudel,a,c anjana kafle,b,d bishal kc,a,c sahadev prashad dhungana,a,c anuj poudel,a,e shamsuddina,c —–————————————————————————————————————————————— abstract: introduction: tuberculosis (tb) is a major cause of mortality and morbidity in developing countries. tubercular pleural effusion is the second most common form of extra pulmonary tuberculosis (eptb), superseded in prevalence only by lymph node tuberculosis. pleural effusion occurs in approximately 5% of patients with tb. the purpose of this study was to assess the demographic characteristics of patients presenting with pleural effusion in rural nepal. methods: a retrospective study was conducted with all the cases diagnosed and admitted with pleural effusion at lumbini medical college and teaching hospital from april 2011 to march 2013 of all the cases diagnosed and admitted with pleural effusion were included in the study. hundred cases diagnosed with pleural effusion by clinical examination or chest x-ray or ultrasonography’s (usg) of the chest were included in the studied. the following parameters patients demographic profile, causes of pleural effusion, location (unilateral/bilateral), hemoglobin and complete blood count, sputum stain and culture sensitivity, monteux test, chest x-ray and usg findings and pleural fluid analysis (biochemical, hematological, microbiological and cytological) were analyzed by using spss 21. results: out of 100 cases, the cause of pleural effusion in 59 patients was tuberculosis, 14 by malignancy, next 14 by para pneumonic effusion, 12 by congestive cardiac failure and three cases by alcoholic liver disease. patients with tuberculous pleural effusion were younger, predominantly males, had unilateral effusion, lower blood hemoglobin, lower pleural fluid neutrophils, higher pleural fluid adenosine deaminase (ada) levels and higher level of pleural fluid to serum protein ratio as compared to the patients with non-tuberculous effusion. conclusion: tuberculosis is the most common cause of pleural effusion in patients of rural nepal. keywords: adenosine • deaminase • extrapulmonary • exudative • malignancy ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer b medical officer c department of medicine, lumbini medical college teaching hospital d department of obg, lumbini medical college teaching hospital e department of pathology, lumbini medical college teaching hospital corresponding author: dr. anjana kafle e-mail: kafle_anjana@hotmail.com how to cite this article: paudel ms, kafle a, chettri bk, dhungana sp, poudel a, shamsuddin. characteristics of patients with tuberculous pleural effusion in rural nepal. journal of lumbini medical college. 2013;1(1):31-4. doi:10.22502/jlmc.v1i1.10. ___________________________________________________________________________________ j. lumbini. med. coll. vol 1, no 1, jan-june 2013 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v1i1.10 introduction: tuberculosis (tb) is a major cause of mortality and morbidity in developing countries. tuberculous pleural effusion is the second most common form of extrapulmonary tuberculosis(eptb), superseded in prevalence only by lymph node tuberculosis. pleural effusion occurs in approximately 5% of patients with tb.1 the incidence of eptb is rising with the rise in pandemic of human immunodeficiency virus (hiv). the diagnosis of tuberculous pleural effusion is difficult as extrapulmonary specimens have very few bacilli and consequently are associated with low sensitivity of acid fast bacillus (afb) smear and culture. pleural effusions are classified into transudative or exudative.2,3 exudative pleural effusions require further evaluation to differentiate among tuberculosis, malignancy and para pneumonic effusion which are the major causes in patients.4-6 methods: this retrospective study was carried out 31 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np paudel ms. et al. characteristics of patients with tuberculous pleural effusion in rural nepal in patients over the age of 14 years, admitted to the medical ward at lumbini medical college and teaching hospital (lmcth), palpa, from april 2011 to march 2013. all patients who were admitted with a diagnosis of pleural effusion were included. the study was approved by the institutional review committee. data was retrieved from the medical record section. information on regarding the diagnosis, comorbidities and results of biochemical analysis of blood and pleural fluid was noted. patients were classified as having effusion due to tuberculosis, malignancy, pneumonia, congestive cardiac failure or liver disease. rests of the causes were classified as others. data were also obtained regarding sputum examination and pleural fluid cytology in all patients. results were analyzed using statistical package for social sciences (spss 21). continuous data were expressed as mean, standard deviation (sd), median and interquartile range (iqr), and a categorical variable as number (%). in case of continuous variables, t-test/mann-whitney test was applied as appropriate to see the difference in average between the groups. similarly, chi square analysis was performed to test differences in proportions of categorical variables between two or more groups. the cut-off value for significance was considered to be p<0.05. results: one hundred patients were included in the study. fifty nine patients were diagnosed as tuberculous pleural effusion, 14 had malignant pleural effusion, 14 had parapneumonic effusion, 10 had effusion due to congestive cardiac failure and three had liver disease. the patients were divided into two groups. more than 50% of cases were diagnosed as tuberculous pleural effusion (n=59) whereas 41 cases were under non-tuberculous pleural effusion. table 1 shows that the patients with tuberculous effusion were younger than the patients with non-tuberculous pleural effusion (p=0.03). patients with tuberculous pleural effusion were more commonly males (p=0.04), had lower levels of hemoglobin (p=0.01) and the effusion was more commonly unilateral (0.001) as compared to the patients with non–tuberculous pleural effusion. pleural fluid analysis was also significantly different between the two groups with patients with tuberculous pleural effusion having higher pleural fluid level of adenosine deaminase (ada) (p=0.001), higher differential lymphocyte count (p=0.04), lower differential neutrophil count(p=0.02), higher pleural fluid lymphocytes to neutrophils ratio (p=0.02) and higher pleural fluid to serum protein ratio (p=0.006). table 1: comparison between tuberculous and non-tuberculous pleural effusion 32 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 paudel ms. et al. characteristics of patients with tuberculous pleural effusion in rural nepal jlmc.edu.np the most common symptoms presented in patients with tuberculous pleural effusion were cough(54.2%), fever (50.1%) and shortness of breath (38.9%). in patients with malignant pleural effusion, most common symptom was weight loss (100%) whereas cough was most common symptom in patients with parapneumonic effusion (table 2). only four (6.7%) patients with tuberculous pleural effusion had sputum positive for acid fast bacillus (afb) and none had afb stain positive in the pleural fluid. twenty eight percent of patients with tuberculous pleural effusion had chronic obstructive pulmonary disease (copd) and 16.9 % had diabetes mellitus (dm). while, 42.8% of patients with malignancy had underlying copd and 21.4 % had dm (table 3). discussion: this is a retrospective study evaluating the etiology of pleural effusion in patients of rural nepal. tuberculosis was identified as the most common cause of pleural effusion and it resulted most commonly into a unilateral pleural effusion. as compared to the patients with non tuberculous effusion, patients with tuberculous effusion were younger, more commonly males, had higher levels of lymphocytes, lower levels of neutrophils, higher level of lymphocyte to neutrophil ratio and higher levels of ada in pleural fluid. the ratio of pleural table 3: comorbidities in patients with pleural effusion (n=100) table 2: symptoms at presentation in patients with pleural effusion (n=100) fluid to serum protein was higher in patients with tubercular effusion. coughs, fever, shortness of breath and chest pain were the major presenting complains of patient with tubercular effusion. copd and dm were the major comorbidities in this group of patients. only four patients with tuberculous pleural effusion had sputum positive pulmonary tuberculosis. of all the causes of pleural effusion, tuberculosis is identified as the most common cause in many studies.7,8,10,11 in a retrospective study from malaysia, the most common cause of pleural effusion was tuberculosis and 70.4% of patients in this study were males.9 tuberculosis is also more common in younger patients and malignancy is the important cause of pleural effusion in older patients.9-11 these results are similar to that observed in this study. increased level of lymphocytes was seen in tubercular pleural effusion in various studies.12,13 adenosine deaminase (ada) level >36u/l is seen in patients with tuberculosis and level >100u/l is not see in other causes of pleural effusion.14 a combined use of pleural fluid ada level of 50u/l with lymphocyte/neutrophil ratio of 0.75 or greater has been shown to have increased specificity for diagnosis of tubercular pleurisy.15 our patients with tubercular pleural effusion had mean ada level of 53.9u/l and mean lymphocyte to neutrophil ratio of 16. in 1972, pleural fluid to serum protein ratio of 33 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np paudel ms. et al. characteristics of patients with tuberculous pleural effusion in rural nepal >0.5 was described as one of the criteria for diagnosis of exudative pleural effusion.16 we identified that mean level of pleural fluid to serum protein ratio was higher in patients with tubercular effusion as compared to non-tubercular effusion. most tubercular pleural effusions, unlike pulmonary tuberculosis present as an acute illness. cough (93.8%), temperature above 100⁰f (85.7%) and chest pain (77.5%) are the three major presenting complaints in patient with tuberculous pleurisy.17 in patients with human immunodeficiency virus (hiv) infection there is increased incidence of development of tuberculous pleural effusion as compared to the immune competent individuals.18,19 presence of dm also increases the risk of active tuberculosis.20 similarly, copd patients have a threefold increased hazard ratio of developing active tuberculosis that is mainly dependent on an increased risk of pulmonary tb.21 we identified the presence of copd in 28.8% and dm in 16.9% of patients with tubercular pleural effusion. none of the patients in our study had hiv infection. a prospective study in 2006 has identified the presence of pulmonary tuberculosis in 31% of patients with tuberculous pleuritis by analysis of sputum and bronchial washings.22 we found that only 4 (6.7%) patients of tubercular pleural effusion were sputum positive for tuberculosis. this study has a few limitations. this is a single center retrospective study in limited number of patients and an analysis of the serum and pleural fluid lactate dehydrogenase were not performed. conclusion: this retrospective study provides data on the causes of pleural effusion in patients of rural nepal. it emphasizes that tuberculosis is the most important cause of pleural effusion in this area and should be considered in any adult patient with unilateral pleural effusion. abbreviation: ast = aspartate amino transferase alt = alanine amino transferase tlc = total leukocyte count ada = adenosine deaminase copd = chronic obstructive pulmonary disease dm = diabetes mellitus htn = hypertension ihd = ischemic heart disease references: 1. dye c. global epidemiology of tuberculosis. lancet 2006; 367: 938-40. 2. chetty kg. transudative pleural effusions. clin chest med 1985; 6: 49-54. 3. light rw. diagnostic principles in pleural disease. eur respir j 1997; 10: 476-81. 4. storey dd, dines de, coles dt. pleural effusion: a diagnostic dilemma. j am med assoc 1976; 236: 2183-6. 5. gannels jj. perplexing pleural effusion. chest 1978; 47: 390-3. 6. keshmiri m, hashemzadeh m. use of cholesterol in differentiating of exudative and transudative pleural effusions. med j islamic republic ir 1997; 2: 187-9. 7. khan fy, alsamawi m, yasin m et al. etiology of pleural effusion among adults in the state of qatar: a 1-year hospitalbased study. east mediterr health j 2011; 7: 611-8. 8. heidari b, bijani k, eissazadeh m, heidari p. exudative pleural effusion: effectiveness of pleural fluid analysis and pleural biopsy. east mediterr health j 2007; 13: 765-73. 9. liam ck, lim kh, wong cm. causes of pleural exudates in a region with a high incidence of tuberculosis. respirol 2000; 5: 33-8. 10. valdes l, alvarez d, valle jm, pose a, san jose e. the etiology of pleural effusions in an area with high incidence of tuberculosis. chest 1996; 109: 158-62. 11. kalaajieh wk. e_ ology of exudative pleural effusions in adults in north lebanon. can respir j 2001; 8: 93-7. 12. pettersson t, riska h. diagnostic value of total and differential leukocyte counts in pleural effusions. acta med scand 1981; 210: 129-35. 13. light rw, erozan ys, ball wc jr. cells in pleural fluid: their value in differential diagnosis. arch intern med 1973; 132: 854-60. 14. verma sk, dubey al, singh pa, tewerson sl, sharma d. adenosine deaminase (ada) level in tubercular pleural effusion. lung india 2008; 25: 109-10. 15. burgess lj, maritz fj, le roux i, taljaard jj. combined use of pleural adenosine deaminase with lymphocyte/ neutrophil ratio, increased specificity for the diagnosis of tuberculous pleuritis. chest 1996; 109: 414-19. 16. light rw, macgregor mi, luchsinger pc, ball wc jr. pleural effusions: the diagnostic separation of transudates and exudates. ann intern med 1972; 77: 507-13. 17. berger hw, mejia e. tuberculous pleurisy. chest 1973; 63: 88-92. 18. batungwanayo j, taelman h, allen s, bogaerts j, kagame a, van de perre p. pleural effusion, tuberculosis and hiv-1 infection in kigali, rwanda. aids 1993; 7: 73-9. 19. light rw. update on tuberculous pleural effusion. respirol 2010; 15: 451-8. 20. jeon cy, murray mb. diabetes mellitus increases the risk of active tuberculosis: a systematic review of 13 observational studies. plos med 2008; 5: e152. 21. inghammar m, ekbom a, engstrom g et al. copd and the risk of tuberculosis a population-based cohort study. plos one 2010; 5: e10138. 22. kim h, lee h, kwon s et al. the prevalence of pulmonary parenchymal tuberculosis in patients with tuberculous pleuritis. chest 2006; 129: 1253-8. 34 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 godar st, et al. prevalence and risk factors of hypertensive retinopathy in hypertensive patients in a tertiary hospital of gandaki province of nepal. 270 jlmc.edu.np ___________________________________________________________________________________ submitted: 07 june, 2020 accepted: 22 december, 2020 published: 30 december, 2020 aassistant professor, department of ophthalmology, bprofessor, department of ophthalmology, cmanipal college of medical sciences, pokhara, nepal. corresponding author: srijana thapa godar e-mail: drsrijanathapa@gmail.com orcid: https://orcid.org/0000-0002-0699-2464_______________________________________________________ abstract: introduction: hypertensive retinopathy is one of the major complications of hypertension. presence of hypertensive retinopathy may be an indicator of presence of other complications too. this study aimed to determine the prevalence and risk factors of hypertensive retinopathy in hypertensive patients in a tertiary care hospital in nepal. methods: this was a hospital based cross-sectional study conducted among 95 hypertensive patients aged 30 years and above. standard proforma was used to collect socio-demographic and clinical variables of the patients. detailed eye examination including fundus evaluation under mydriasis was done on all patients and hypertensive retinopathy was graded according to keith-wagener-barker classification. statistical analysis was carried out using epi-info 7. results: the mean age of the study sample was 59.74±15.11 years. the prevalence of hypertensive retinopathy was 38.95%. among the patients with hypertensive retinopathy, the prevalence of grade i, ii, iii and iv retinopathies were 7.36%, 17.89%, 10.52% and 3.15% respectively. there was statistically significant association between hypertensive retinopathy and controlled blood pressure and treatment of hypertension. however, there was no statistically significant association between hypertensive retinopathy and gender, duration of hypertension, residence, family history, history of smoking and diet. conclusion: uncontrolled blood pressure and untreated patients of hypertension were the significant risk factors for hypertensive retinopathy. early diagnosis and treatment of hypertension is essential to prevent loss of vision. keywords: hypertension, hypertensive retinopathy, prevalence, risk factors original research articlehttps://doi.org/10.22502/jlmc.v8i2.374 srijana thapa godar,a,c khem raj kaini b,c prevalence and risk factors of hypertensive retinopathy in hypertensive patients in a tertiary hospital of gandaki province of nepal how to cite this article:how to cite this article: godar st, kaini kr. prevalence and risk factors of hypertensive retinopathy in hypertensive patients in a tertiary hospital of gandaki province of nepal. journal of lumbini medical college. 2020;8(2):270-274. doi: https://doi.org/10.22502/jlmc.v8i2.374 epub: 2020 december 30. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: hypertension leads to numerous disabling complications.[1]who has warned that the developing countries are sitting on a time bomb of non-communicable diseases and hypertension is one of them.[2] the retinal circulation undergoes a series of pathophysiological changes in response to elevated blood pressure.[3] these changes are manifested clinically as a spectrum of signs referred to as hypertensive retinopathy.[4] keith et al. devised a fourgrade classification system for hypertensive retinopathy, with increasing severity based on arterial characteristics and retinopathy (‘keith-wagener-barker system’).[5] the 3-years survival rate was 70% for patients with grade 1 hypertensive retinopathy compared to 6% with grade 4 retinopathy.[6] the prevalence of hypertensive retinopathy was 58.93% in nepal.[7] limited studies of hypertensive retinopathy have been conducted in nepal. the study showing the association of hypertensive retinopathy with different clinical and socio-demographic variables is lacking in nepal. the aim of the study was to j. lumbini. med. coll. vol 8, no 2, july-dec 2020 godar st, et al. prevalence and risk factors of hypertensive retinopathy in hypertensive patients in a tertiary hospital of gandaki province of nepal. 271 jlmc.edu.np determine the prevalence of hypertensive retinopathy in a tertiary care hospital. this study also evaluated the association of hypertensive retinopathy with different clinical and sociodemographic variables. methods: this was a hospital based cross-sectional study conducted in ophthalmology out-patient department of manipal college of medical sciences, pokhara, nepal from july 2019 to december 2019. ethical approval was taken from the institutional review committee of the institute before the initiation of the study. the sample size was calculated by using the formula zpq/d2 (where; p=prevalence, 58.93[7], q=100-p, 41.07%; d=margin of error, 10%). the sample size according to this formula was 93. adding two more sample (2% as non response rate), the final sample size was calculated to be 95. hypertensive patients aged 30 years and above were included in the study sample. patients with other systemic diseases like diabetes mellitus or any ocular disease like corneal or lens opacities that cause media haze resulting difficulty in fundus assessment were excluded from the study. informed consent was taken from all the patients. a detailed history and examination was carried out including fundus examination under mydriasis with direct ophthalmoscope, +78 d lens and +20 d lens and hypertensive retinopathy was graded according to keith-wagener-barker classification. the data was entered and analyzed with epi-info version 7. qualitative data were presented in frequency and percentage. chi square test was applied for statistical analysis. the p-value less than 0.05 was considered statistically significant. results: a total of 95 hypertensive patients were enrolled in the study. the mean age of the study sample was 59.74 years (±15.11 years). there was no statistically significant association between mean age of patients with hypertensive retinopathy (58.43±16.13 years) and without hypertensive retinopathy (60.58±14.50 years) (p-value=0.51). the prevalence of hypertensive retinopathy was 38.95%. among the patients with hypertensive retinopathy, the prevalence of grade i, ii, iii and iv retinopathies were 7.36%, 17.89%, 10.52 and 3.15% respectively (table 1). table 1. frequency of hypertensive retinopathy. hypertensive retinopathy number (%) yes grade i 7 (7.36) grade ii 17 (17.89) grade iii 10 (10.52) grade iv 3 (3.15) no 58 (61.05) the relationship between hypertensive retinopathy with different variables was showed in table 2. the prevalence of hypertensive retinopathy was 37.7%, 31.2% and 46.2% in the patients having duration of hypertension of less than 5 years, 5 to 10 years and more than 10 years respectively. there was statistically significant association between hypertensive retinopathy and controlled blood pressure and treatment of hypertension. however, there was no statistically significant association between hypertensive retinopathy and gender, duration of hypertension, residence, family history of hypertension, history of smoking and diet of the study samples. discussion: in this study, the prevalence of hypertensive retinopathy was 38.95%. among the patients with hypertensive retinopathy, the prevalence of grade i, ii, iii and iv retinopathies were 7.36%, 17.89%, 10.52 and 3.15% respectively. one study conducted in bangladesh showed the prevalence of hypertensive retinopathy was 29.9%. grade i hypertensive retinopathy was maximum 14.7% and grade iv hypertensive retinopathy was minimum 0.3%.[8] several other studies found low prevalence of hypertensive retinopathy.[9,10,11] the low prevalence of hypertensive retinopathy in those studies may be due to good blood pressure control and patients had duration of hypertension of less than five years. however, one study done in nepal noted high prevalence of hypertensive retinopathy (56.5%). [12] other studies also found high prevalence of hypertensive retinopathy in hypertensive patients. [13-18] the high prevalence of hypertensive retinopathy may be due to late presentation of the patients to the hospital, uncontrolled hypertension, patients not taking antihypertensive medication regularly and lack of awareness of hypertension in the society. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 godar st, et al. prevalence and risk factors of hypertensive retinopathy in hypertensive patients in a tertiary hospital of gandaki province of nepal. 272 jlmc.edu.np in the current study, the prevalence of hypertensive retinopathy was high (46.2%) in the hypertensive patients whose duration of hypertension was more than ten years. the study done in bangladesh noted higher hypertensive retinopathy in those with duration of hypertension more than five years.[8] in this study, 74.1% of hypertensive retinopathy was seen in those whose blood pressure was not controlled. similarly other studies also observed that hypertensive patients whose blood pressure was uncontrolled more likely to develop retinopathy than individuals whose blood pressure was controlled with medications.[9,19] however, one study conducted in bangladesh noted higher rate of hypertensive retinopathy in controlled blood pressure patients (31.36% vs 27.03%).[8] in this study, the mean age of the sample was 59.74 years. different other studies noted the mean age of the patients was 60.58 years, 60.24 years and 51.80 years.[8,12,13] in our study, the male had more hypertensive retinopathy than female patients. similarly, other studies also noted that male had more hypertensive retinopathy as compared to female.[8,12,13] however, one study found hypertensive retinopathy more in female than in male.[20] the variation may be explained by differential distribution in risk factors (e.g. genetic predisposition, dietary factors and lack of physical activities). the study has few limitations. the crosssectional design of the study was the obvious limitation of this study which does not measure causal association. this study was hospital-based study conducted in one geographical area only. hence, further large-scale analytical study in different regions of nepal is required. the study recommends routine ophthalmological examination of every hypertensive patient. the study also recommends holistic management of hypertensive patients jointly by physician and ophthalmologist to prevent blindness. prompt control of hypertension and regular treatment would be helpful to avoid complications. table 2. relationship between hypertensive retinopathy with different variables. variables retinopathy total odds ratio chi square p-value no (%) yes (%) gender female 28 (62.2) 17 (37.7) 45 1.09 0.04 0.82 male 30 (60.0) 20 (40.0) 50 duration of hypertension (in years) <5 33 (62.3) 20 (37.7) 53 * 0.99 0.67 >10 14 (53.8) 12 (46.2) 26 5-10 11 (68.8) 5 (31.2) 16 residence rural 18 (54.5) 15 (45.5) 33 0.66 0.90 0.34 urban 40 (64.5) 22 (35.5) 62 family history no 20 (51.3) 19 (48.7) 39 0.49 2.65 0.10 yes 38 (67.9) 18 (32.1) 56 h/o smoking no 34 (60.7) 22 (39.3) 56 0.96 0.006 0.93 yes 24 (61.5) 15 (38.5) 39 diet non-vegetarian 43 (58.9) 30 (41.1) 73 0.66 0.61 0.43 vegetarian 15 (68.2) 7 (31.8) 22 controlled blood pressure yes 51 (75.0) 17 (25.0) 68 8.57 19.57 <0.001 no 7 (25.9) 20 (74.1) 27 treatment of hypertension no 9 (39.1) 14 (60.9) 23 0.30 6.13 0.01 yes 49 (68.1) 23 (31.9) 72 *odds ratio cannot be calculated. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 godar st, et al. prevalence and risk factors of hypertensive retinopathy in hypertensive patients in a tertiary hospital of gandaki province of nepal. 273 jlmc.edu.np conclusion: the prevalence of hypertensive retinopathy was 38.95%. uncontrolled blood pressure and untreated patients of hypertension are the significant risk factors for hypertensive retinopathy. there is a need to educate hypertensive patients about the need to comply with treatment and have regular ocular examination. early diagnosis and treatment of hypertension is essential to prevent loss of vision. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available for the study. references: 1. hajjar i, kotchen jm, kotchen ta. hypertension: trends in prevalence, incidence, and control. annu rev public health. 2006;27(0):465-90. pmid: 16533126. doi: https://doi.org/10.1146/ annurev.publhealth.27.021405.102132 2. national institute of health, national high blood pressure education program. the fifth report of the joint national committee on detection, evaluation, and treatment of high blood pressure (jnc v). arch intern med. 1993;153(2):154-83. pmid: 8422206. doi: https://doi.org/10.1001/ archinte.1993.00410020010002 3. wong ty, mitchell p. hypertensive retinopathy. the new england journal of medicine. 2004;351(0):2310-7. doi: https://doi. org/10.1056/nejmra032865 4. tso mo, jampol lm. pathophysiology of hypertensive retinopathy. ophthalmology. 1982;89(10):1132-45. pmid: 7155524. doi: https://doi.org/10.1016/s0161-6420(82)34663-1 5. keith nm, wagener hp, barker nw. some different types of essential hypertension: their course and prognosis. am j med sci. 1974;268(6):336-45. pmid: 4616627. doi: https://doi.org/10.1097/00000441-19741200000004 6. wong ty, klein r, klein be, tielsch jm, hubbard l, nieto fj. retinal microvascular abnormalities and their relationship with hypertension, cardiovascular disease, and mortality. surv ophthalmol. 2001;46(1):59-80. pmid: 11525792. doi: https://doi.org/10.1016/ s0039-6257(01)00234-x 7. karki kjd. incidence of ophthalmoscopic fundus changes in hypertensive patients. kathmandu univ med j. 2003;1(1):27-31. pmid: 16340257 8. mondal rn, matin ma, rani m, hossain mz, shaha ac, singh rb, et al. prevalence and risk factors of hypertensive retinopathy in hypertensive patients. journal of hypertension. 2017:6(2):1000241. doi: https://doi. org/10.4172/2167-1095.1000241 9. klein r, klein be, moss se, wang q. hypertension and retinopathy, arteriolar narrowing, and arteriovenous nicking in a j. lumbini. med. coll. vol 8, no 2, july-dec 2020 godar st, et al. prevalence and risk factors of hypertensive retinopathy in hypertensive patients in a tertiary hospital of gandaki province of nepal. 274 jlmc.edu.np population. arch ophthalmol. 1994;112(1):92-8. pmid: 8285901. doi: https://doi.org/10.1001/ archopht.1994.01090130102026 10. shantha gp, srinivasan y, kumar aa, salim s, prabakhar s, rajan ag, et al. can retinal changes predict coronary artery disease in elderly hypertensive patients presenting with angina? am j emerg med. 2010;28(5):617-21. pmid: 20579560, doi: https://doi.org/10.1016/j. ajem.2009.04.007 11. besharati mr, rastegar a, shoja mr, maybodi me. prevalence of retinopathy in hypertensive patients. saudi med j. 2006;27(11):1725-8. pmid: 17106550 12. pun cb, tuladhar s. profile of hypertensive retinopathy in a tertiary center in western nepal. journal of gandaki medical collegenepal. 2019;12(1):22-4. doi: https://doi. org/10.3126/jgmcn.v12i1.22607 13. adhikari bn, gautam ps, bekoju b, basnet s, bhandari h. association of hypertensive retinopathy with different serum lipid parameters in patients of essential hypertension: a hospital based study. journal of nobel medical college. 2018;7(2):50-7. doi: https://doi.org/10.3126/ jonmc.v7i2.22308 14. erden s, bicakci e. hypertensive retinopathy: incidence, risk factors, and comorbidities. clin exp hypertens. 2012;34(6):397-401. pmid: 22468968. doi: https://doi.org/10.3109/106419 63.2012.663028 15. kabedi nn, mwanza jc, lepira fb, kayembe tk, kayembe dl. hypertensive retinopathy and its association with cardiovascular, renal and cerebrovascular morbidity in congolese patients. cardiovasc j afr. 2014;25(5):228-32. pmid: 25629539. doi: https://doi.org/10.5830/ cvja-2014-045 16. kayange pc, schwering ms, manda cs, singini i, moyo vvp, kumvenda j. prevalence and clinical spectrum of hypertensive retinopathy among hypertension clinic patients at queen elizabeth central hospital in malawi. malawi med j. 2018;30(3):180-3. pmid: 30627353. doi: https://doi.org/10.4314/mmj.v30i3.9 17. manjomo rc, mwagomba b, ade s, ali e, ben-smith a, khomani p, et al. managing and monitoring chronic noncommunicable diseases in a primary health care clinic, lilongwe, malawi. public health action. 2016;6(2):60-5. pmid: 27358797. doi: https://doi.org/10.5588/ pha.16.0003 18. wood r, viljoen v, van der merwe l, mash r. quality of care for patients with non communicable diseases in the dedza district, malawi. afr j prim health care fam med. 2015;7(1):838. pmid: 26245609. doi: https:// doi.org/10.4102/phcfm.v7i1.838 19. klein r, klein be, moss se. the relation of systemic hypertension to changes in the retinal vasculature: the beaver dam eye study. trans am ophthalmol soc. 1997;95:329-50. pmid: 9440178. pmcid: http://www.ncbi.nlm.nih. gov/pmc/articles/pmc1298366/ 20. badhu bp, shrestha jk. hypertensive patients in eye opd, tuth. journal of institute of medicine 1998;20(0):188-92. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 17 may, 2020 accepted: 22 may, 2020 published: 22 may, 2020 a senior consultant, gi surgery & liver transplant, dayanand medical college & hospital, ludhiana, india. corresponding author: sanjay singh negi e-mail:drsanjaynegi@gmail.com orcid: https://orcid.org/0000-0002-2544-6303 how to cite this article: negi ss. india amidst covid-19 crisis: the good, the bad and the ugly. journal of lumbini medical college. 2020;8(1):4 pages. doi: 2020;8(1):4 pages. doi: https://doi.org/10.22502/jlmc.v8i1.346 epub: 2020 may epub: 2020 may 22_______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.346 sanjay singh negi a india amidst covid-19 crisis: the good, the bad and the ugly the good beating the statistics: with a population of over a billion, high population density with overcrowding especially in metropolis and underdeveloped health infrastructure, the projections for corona virus disease (covid-19) pandemic were not in favour of india. most statistical models had predicted over 5 lakh cases and more than 38,000 deaths and warned that india must prepare for a tsunami of covid-19 cases.[1] the situation appeared to be grimmer given that the incidence of diabetes, hypertension and respiratory diseases due to tuberculosis and air pollution is higher amongst indians which are known risk factors for severe disease and death due to covid-19.[2] however, as of may 14, 2020, the total number of confirmed covid-19 cases is 78003. with reported 2549 deaths, the case fatality rate (cfr) of 3.27% is currently one of the lowest in the world. global media is baffled with this ‘indian exception’ and numerous hypothesis have been put forth to explain the mystery behind india’s lower death rates including younger population, climate, exposure to malaria, high bcg vaccination rates, less virulent strain of virus and even under-reporting of deaths. though india might be missing some deaths and not diagnosing every patient correctly for covid-19 but everyone concurs that the fatalities are unarguably low since one cannot hide mass deaths.[3] at the same time with over 26235 (33.63%) recoveries, india seems to be widening the gap between death and recovery. finally, r0, which is the number of people that a single infected patient can transmit the virus to, is also down from 1.83 (mar 27-apr 6) to 1.23 (apr 13-may10). there are regional variations in these numbers with states like kerala managing to ‘flatten the curve’ despite low testing levels while others like maharashtra, delhi, gujrat and west bengal continue to struggle in their fight against the pandemic. the “bhilwara model” consisted of a complete curfew, house-tohouse surveys for cases, contact tracing, large-scale testing, and prevention of travel. the model helped in aggressively containing the disease and was successfully replicated in other places.[5] opportunity in adversity: the pandemic and consequent lockdown resulted in disruption of global supply chain thereby leading to reduction of inventory buffers and exposing vulnerabilities of indian industry’s supply chain. the current crisis provides valuable lessons to indian manufacturing sector to be self-sufficient and become globally competitive by going local (‘glocal’) thereby reducing dependency on china. there is no denying the fact that personal protective equipment (ppe) are essential armamentarium in the fight against covid-19. when pandemic hit india in february, the country was an importer of ppe and had no local manufacturing capability. however, consequent to concerted efforts in just two months india has emerged as the world’s second largest manufacturer of ppe producing over two lakh kits per day including development of world’s first reusable ppe suit.[6] indian pharmaceutical industry is ranked third largest in the world in terms of drug produced by volume and manufactures 60 percent of vaccines globally. during covid-19 crisis, india has helped many nations by providing drugs and has the potential to play the role of ‘pharmacy of the world’ in future.[7] negi ss. india amidst covid-19 crisis: the good, the bad and the ugly. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 human and nature healing: lockdown necessitated ‘work from home’ thereby giving the much-needed time for family-bonding and rekindled the sense of unity and empathy. it has also highlighted the fact that it is not the ‘cost of living’ that is expensive but rather the ‘cost of lifestyle’. in absence of human intervention, nature seems to be healing. pollution (air, water, noise, light) levels have lowered, the sky has become clearer, rivers have become cleaner, birds are chirpier and animals reclaiming space from human encroachment. these tasks could not be humanly achieved earlier even after investing billions of dollars.[8] the bad: asymptomatic paradigm: currently available data suggests that over 70% of patients infected with covid-19 are asymptomatic which is much higher than rest of the world. since such cases do not exhibit any symptoms, the real challenge is the difficulty in tracing and isolating them so that they do not transmit the virus to others. such cases can only be detected by extensive testing. this fact is of concern in surgical setting where such cases not only have the potential of spreading infection to healthcare workers but are themselves at higher risk of complications and death after surgery. the positive aspect is that such patients have stronger immunity and therefore develop milder form of the disease without any need for treatment. moreover, if such patients have sufficient antibody levels in their blood, they can become plasma donors and potentially save the lives of seriously ill patients. finally, once the proportion of such individuals becomes significant within the population (perhaps more than 60-70%), it will lead to the development of herd immunity. it is early days and only time will tell whether such a paradigm turn out to be a curse or blessing in disguise.[9,10] low testing rates: as compared to rest of the countries, the number of tests conducted in india per million population is woefully inadequate. this is further compounded by people refusing to be tested due to stigma attached to the disease. having said that, it is also a fact that testing the population is strategically, financially and logistically an impractical undertaking. in balance perhaps targeted, intelligent testing is a reasonable strategy. at the time of imposition of lockdown, india was conducting 539 tests per million people and ranked 52nd among countries in terms of the testing rates. the testing level has since been ramped-up with india now conducting 758 tests per million, making it the 24th ranked country in terms of tests per million as of may 3.[11] the indian council of medical research, has supported its strategy by stating that it is continuing to test despite low yield rate (number of positive cases detected for each test conducted) of 24 and has not so far paid a heavy price in terms of fatalities.[5] the ugly: economic lockdown: like rest of the world, lockdown has stalled the indian economy resulting in unemployment and shortages. the poorest of the poor have been hit the hardest resulting in ‘migrant worker crisis’ thereby exposing the deep economic divide between the haves and have-nots. hopefully, economic stimulus package of 266 billion usd (10% gdp, fifth-most substantial in the world) announced by the government might help the country’s economy tide over the crisis.[12] ‘infodemic’ crisis: as india is fighting its war against covid-19, there is an emerging threat of misinformation and fake news. this ‘infodemic’ is perhaps more dangerous than the threat of pandemic because such misinformation creates a sense of negativity, insecurity and panic amongst vulnerable and technologically-naive public. such misinformation mostly relates to causes, symptoms, spread and cures of covid-19, government documents and misrepresentation of comments, photos and videos of politicians, and conspiracy theories with communal angles. the problem is relevant since the number of active internet and social media users in india is second to china in the world. despite intensive efforts by social media giants and government to curb the menace, there is a pressing need for individual-based efforts at community level.[13,14] who will heal the healers: it is well accepted that healthcare workers are at risk of not only getting covid-19 infection but also developing severe form of disease. the situation is compounded not only by shortage of ppe but also by the misuse of this precious commodity by those who do not need it. so far, 548 doctors, nurses and paramedics have been infected in india with covid-19.[15,16] it is relevant since in addition to the risk of death, infected healthcare workers have to be quarantined and hospital has to be shut down, thereby increasing the burden on healthcare system. moreover, such healthcare workers may inadvertently spread the disease to other patients. to complicate matters healthcare workers have been physically attacked, abused, stigmatized, ostracized, denied accommodation by their landlords and their funerals attacked by mobs thereby denying them dignity even in death.[17,18] this one time the government has come to the rescue of healthcare workers by making harassment, physical assault and destruction of property cognizable and nonbailable offences during the period of epidemic.[19] however, the bigger question remains that what will happen to the safety of healthcare workers once the epidemic is over. how will the healers heal others unless they themselves feel safe first? in all probability, covid-19 is here to stay and is not going to disappear due to lockdown. lockdown has helped in containing the disease so far and given us the precious time to ramp up capacity to fight the disease and now every citizen has to follow the rules with a sense of social responsibility to keep us safe. there is no definitive drug or vaccine yet for covid-19. in keeping with the theory of survival of the fittest, we have to accept and adapt to this ‘new normal’ of maintaining social distancing, frequent hand wash, covering face with mask and avoiding gatherings. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. sharma r. projection: 38,220 deaths, 5.35 lakh covid-19 cases in india by mid-may. the new indian express. 2020 apr 23. available from: https://www.newindianexpress.com/ nation/2020/apr/23/projection-38220-deaths535-lakh-covid-19-cases-in-india-by-midmay-2134087.html 2. chotiner i. how covid-19 will hit india. the new yorker. 2020 apr 1. available from: https:// www.newyorker.com/news/q-and-a/how-covid19-will-hit-india 3. ganguly s. india must prepare for a tsunami of coronavirus cases. bbc news. 2020 mar 19. available from: https://www.bbc.com/news/av/ world-asia-india-51962813/india-must-preparefor-a-tsunami-of-coronavirus-cases 4. biswas s. india coronavirus: the ‘mystery’ of low covid-19 death rates. bbc news. 2020 apr 28. available from: https://www.bbc.com/news/ world-asia-india-52435463 5. khullar a. why india shouldn’t mimic the west in the fight against coronavirus. quartz india. 2020 apr 26. available from: available from: https://qz.com/india/1843604/india-shouldntmimic-the-us-or-europe-in-its-coronavirusfight/ 6. pti. india ramps up production of covid-19 protective gears, medical equipment. the week. 2020 may 1. available from: https://www. theweek.in/news/india/2020/05/01/india-rampsup-production-of-covid-19-protective-gearsmedical-equipment.html 7. dadhich a. the covid-19 pandemic and the indian pharmaceutical industry. european pharmaceutical review. 2020 apr 22. available from: https://www. e u r o p e a n p h a r m a c e u t i c a l r e v i e w . c o m / article/117413/the-covid-19-pandemic-and-theindian-pharmaceutical-industry/ 8. kashyap r. mother earth is rebooting. times of india. 2020 apr 25. available from: https:// timesofindia.indiatimes.com/readersblog/spicein-life/mother-earth-is-rebooting-14169/ 9. reddy ks. india’s high number of asymptomatic negi ss. india amidst covid-19 crisis: the good, the bad and the ugly. j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 jlmc.edu.np cases worrying, and herd immunity is far off. the print. 2020 apr 24. available from: https://theprint.in/opinion/indias-high-numberof-asymptomatic-cases-worrying-and-herdimmunity-is-far-off/407931/\ 10. thacker t. no symptoms in 80% of covid cases raise concerns. the economic times. 2020 apr 21. available from: http://www.ecoti.in/ oyeiky60 11. alexander s, devulapalli s. everything you wanted to know about india’s test numbers, in five charts. live mint. 2020 may 10. available from: https://www.livemint.com/news/india/ everything-you-wanted-to-know-about-india-stest-numbers-in-five-charts-11588956200820. html 12. web desk. how does modi’s covid-19 package compare to spending by other countries? the week [internet]. 2020 may 12. available from: https://www.theweek.in/ news/biz-tech/2020/05/12/how-does-modiseconomic-package-compare-to-spending-byother-countries.html 13. banerjee p. covid misinformation curve shows no signs of flattening. live mint. 2020 apr 27. available from: https://www.livemint.com/ news/india/covid-19-misinformation-curveshows-no-signs-of-flattening-11587888207849. html 14. kant a. the infodemic on social media around covid calls for a multi-pronged approach. the indian express. 2020 may 11. available from: https://indianexpress.com/article/opinion/ columns/coronavirus-fake-news-social-mediainfodemic-6403577/ 15. sabarwal h. 548 doctors, nurses, paramedics infected with covid-19 across india: report. hindustan times. 2020 may 6. available from: https://www.hindustantimes.com/indianews/548-docs-nurses-paramedics-infectedw i t h c o v i d 1 9 a c r o s s i n d i a r e p o r t / s t o r y o2pm3w2adm4g3pxi6tblkn.html 16. pandey v. coronavirus: india’s race against time to save doctors. bbs news. (2020 apr 13. available from: https://www.bbc.com/news/ world-asia-india-52215071 17. pandey v. coronavirus: india doctors ‘spat at and attacked’. bbc news. 2020 apr 3. available from: https://www.bbc.com/news/world-asiaindia-52151141 18. ellis-petersen h. mobs stop indian doctors’ burials: ‘covid-19 took his life, why take his dignity?’ the guardian. 2020 apr 29. available from: https://www.theguardian.com/ world/2020/apr/29/mobs-stop-indian-doctorsburials-covid-19 19. et bureau. cabinet okays ordinance to protect frontline workers. economic times. 2020 apr 22. available from: http://www.ecoti.in/8ivjez negi ss. india amidst covid-19 crisis: the good, the bad and the ugly. j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 jlmc.edu.np j. lumbini. med. coll. vol 8, no 2, july-dec 2020 pandey n, et al. estimating the height of an individual from the length of ulna in undergraduate students of a nepalese medical college. 185 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 09 june, 2020 accepted: 28 june, 2020 published: 22 july, 2020 a lecturer, department of anatomy, b professor, department of anatomy, c lumbini medical college teaching hospital, palpa, nepal. corresponding author: niraj pandey e-mail: drnp77@gmail.com orcid: https://orcid.org/0000-0001-9626-6353_______________________________________________________ abstract: introduction: estimation of height from bones plays an important role in identifying unknown bodies, parts of bodies, or skeletal remains. multiple anthropometric techniques have been used to estimate stature from skeletal remains by anthropologists, anatomists, and forensic experts. the ulna is a long bone often used for body height estimation, as it is mostly subcutaneous throughout its length and is easily approachable for measurement. methods: the present study was carried out on 100 (57 male and 43 female) undergraduate students of a medical college of the age group of 18 to 24 years. the parameters studied were height, length of right, and left ulna. the observations were analyzed by pearson’s correlation to examine the relationship between the length of ulna and height. results: the mean height of males was 174.54 ± 13.32 cm and of females was 156.01±11.19 cm. the mean length of the right ulna was 27.36 ± 2.12 cm (males) and 24.35±1.97 cm (females). the mean length of the left ulna was 27.29 ± 2.13 cm (males) and 24.06 ± 2.18 cm (females). pearson’s correlation showed a positive and statistically significant (p<0.001) relation between the length of the ulna and the height. the regression equation was derived to estimate the height of an individual from the length of the ulna. conclusion: the ulna bone length is an accurate parameter that can be used in estimating an individual's height. the regression equation derived in this study can be of great help to anatomists, clinicians, anthropologists, and forensic scientists. keywords: height estimation, identification, ulna length original research articlehttps://doi.org/10.22502/jlmc.v8i2.377 niraj pandey,a,c bandana padhee b,c estimating the height of an individual from the length of ulna in undergraduate students of a nepalese medical college how to cite this article:how to cite this article: pandey n, padhee b. estimating the height of an individual from pandey n, padhee b. estimating the height of an individual from the length of ulna in undergraduate students of a nepalese medical the length of ulna in undergraduate students of a nepalese medical college. journal of lumbini medical college. 2020;8(2): 185-189. college. journal of lumbini medical college. 2020;8(2): 185-189. doi: doi: https://doi.org/10.22502/jlmc.v8i2.377377. epub: 2020 july 22.. epub: 2020 july 22. introduction: anthropometry, the typical and the traditional tool of physical anthropology, provides the scientific methods and the techniques for estimating the various measurements and the observations on the living as well as the skeleton of man.[1] identification is recognition of a person and the primary characteristics of identification are age, sex and stature. stature can be estimated from skeleton. thus, the assessment of stature is considered to be important in identifying unknown human remain.[2] stature of an individual is defined as the height of the body in upright position which is measured from vertex to the foot. it is one of the most important and useful anthropometric parameters, which determines the physical identity of an individual.[3] the height can be indirectly estimated from different parts of the skeleton. estimating height from different parts of the human body has been an area of interest to anatomists, anthropologists and forensic experts.[4] ulna bone length is a reliable and accurate j. lumbini. med. coll. vol 8, no 2, july-dec 2020 pandey n, et al. estimating the height of an individual from the length of ulna in undergraduate students of a nepalese medical college. 186 jlmc.edu.np parameter for estimating the height of an individual because it is subcutaneous and surface landmarks such as olecranon and styloid process are easily palpable in bedridden and ill patients as well.the purpose of this study was done to estimate the height of an individual from the length of ulna and to derive regression formulas to estimate height. methods: this is a cross-sectional descriptive study conducted in the department of anatomy, lumbini medical college, nepal from 16th march 2020 to 30th april 2020. it was carried out in 100 (males=57 and females=43) randomly selected asymptomatic, healthy living nepalese medical students who were in the age group of 18 to 24 years. ethical approval was taken from the institutional review committee of the institute (irc-lmc 04c/20). informed consents were taken from all the participants. the sample size was calculated using the following formula, n= [zα+zβ /c] 2 +3 where n=total number of participants required zα and zβ= the standard normal deviate for α and β c=0.5 x ln {1+r / 1-r} r = expected correlation coefficient. for this study, the expected correlation coefficient (r) = 0.44, the effect of sample size based on the study done by pandey a et al.[5] with α=0.05 and the power of study=90%. the minimum sample size required was 50. a total of 100 participants were enrolled into the study through simple random sampling. the participants hailed from various places in nepal, but were living in pravas, palpa at the time of the study. the students with skeletal deformities, physical disabilities, past history of skeletal injuries or diseases affecting bones and joints and those who could not stand erect were excluded. the ulnar length was measured with help of a measuring tape from the tip of olecranon process to the tip of styloid process of ulna with elbow flexed and palm spread over opposite shoulder. the measurement of length of right and left ulna were taken separately for calculation. standing height was measured using a stadiometer against the wall on barefoot, with their heels together and the heels, buttocks and back touching the stadiometer. selection and information bias were minimized as much as possible because all the measurements were taken thrice and the mean value was obtained. the data was collected in a preformed proforma, entered to and tabulated in microsoft excel spreadsheet. statistical analysis was done using statistical package for social sciences (spsstm) software version 20. results: a total of 100 students of lumbini medical college (male=57, female=43) were studied. pearson’s correlation was used to predict the significant relationship between height and length of ulna of the students. in our study, the correlation coefficient (r) was 0.491(left ulna) (fig. 1) and 0.473 (right ulna) (fig. 2). following equations were derived to predict the stature (y). y=94.929 – 0.725 (length of right ulna) and y= 94.929+ 3.496 (length of left ulna). the other measurements are shown in table 1. fig. 1: correlation of height with length of left ulna in both sexes together. fig. 2. correlation of height with length of right ulna in both sexes together. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 pandey n, et al. estimating the height of an individual from the length of ulna in undergraduate students of a nepalese medical college. 187 jlmc.edu.np discussion: the regression formula derived using ulna length provides an alternate methodology for stature prediction in old and bedridden patients who cannot stand or those who suffer from vertebral column deformities.[6] many studies [7,8,9,10] have shown positive correlation of stature and different body parts dimension particularly long bones of the limb which has been found to be true in the present study with strong positive correlation between the stature and ulna lengths in both sexes. the correlation coefficient between the total height and ulna length was found to positive indicating a strong relationship between the two parameters. the positive correlation suggests if length of ulna increases or decreases, the height of the subject also increases or decreases and vice versa. in this study the mean height of males were higher than females (males: 166.57, females: 156.01), which was also observed in other studies done by illayaperumal i et al.,[6] mohanty bb et al.,[11] and prasad a et al.[12] in the present study, mean value of right ulnar length was 27.36 ± 2.12cm and that of left ulnar length was 27.29±2.13in men. our findings was similar to the study done by duyar and perlim[13] and avantika b et al.[14] in our study, the coefficient correlation (r) was 0.473 (right ulna) and 0.491(left ulna) and the study done in nepalese female adult population the correlation coefficient (r) of the height and the length of the left ulna was 0.55 and that for the right ulna was 0.463. [15] in our study, mean of height and length of ulna were higher in males similar to the study done by maryam et al.[16] the union of epiphyses of the bones takes place sooner in girls, on the other hand, bone in boys continues to grow two more years than girls.[17] the study done by mondal mk et al.[18] showed mean height was 164.32 cm, length of right ulna was 27.13 cm and length of left ulna was 27.01 cm and the correlation coefficient for right ulna was 0.78 and left ulna was 0.68. the mean ulnar length of male and females from our study also differed from those study done by emmanuel et al.[19] and charisi et al.[20] the linear regression equation of our study showed that y=94.929–0.725 (length of right ulna) and y=94.929+3.496 (length of left ulna) and to compare with the study done by mondal m ket al.[18] was y= 50.64+4.18 (length of right ulna) and y=76.28+3.25 (length of left ulna), the study done by pandey a et al.[5] was y=83.224+3.04 (length of right ulna) and y=81.06+3.14 (length of left ulna) and the study done by albrook[21] was y=88.94+3.06 (ulna length). conclusion: in the present study a positive correlation was found between height and length of ulna. simple linear regression equation derived could be used for estimation of height from ulna and vice versa. thus, the data of this study would be of practical use in medico-legal investigations and in anthropometry. although the sample size is not enough for representation of whole nepalese population but it will serve as a basis of comparison for future studies in nepalese population. acknowledgement: keshab raj bhandari, lecturer, department of community medicine, lumbini medical college, palpa, nepal. conflict of interest: the authors declare that no competing interests exist. financial disclosure: none. table 1. gender-wise variations in variables. gender minimum maximum mean ± sd males (n=57) length of right ulna (cm) 20.00 32.00 27.36 ± 2.12 length of left ulna (cm) 20.50 31.70 27.29 ± 2.13 height (cm) 152.40 182.88 174.54 ± 13.32 females (n=43) length of right ulna (cm) 20.00 29.00 24.35 ± 1.97 length of left ulna (cm) 20.00 30.00 24.06 ± 2.18 height 121.92 182.88 156.01 ± 11.19 total (100) length of right ulna (cm) 20.00 32.00 26.07 ± 2.54 length of left ulna (cm) 20.00 31.70 25.90 ± 2.68 height (cm) 121.92 182.88 166.57 ± 15.44 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 pandey n, et al. estimating the height of an individual from the length of ulna in undergraduate students of a nepalese medical college. 188 jlmc.edu.np references: 1. thummar b, patel zk, patel s, rathod sp. measurement of ulnar length for estimation of stature in gujarat. national journal of integrated research in medicine. 2011;2(2):36-40. available from: http://nicpd.ac.in/ojs-/index. php/njirm/article/view/1906 2. vij k. textbook of forensic medicine and toxicology: principles and practice. 5th ed. new delhi: elsevier india pvt ltd; 2005. 3. krogman wm, isçan my. the human skeleton in forensic medicine. 2nd ed. springfield: charles c. thomas publisher; 1986. 4. anupriya a, kalpana r. estimating the height of an individual from the length of ulna in tamil nadu population and its clinical significance. international journal of scientific study. 2016;4(1):252-57. available from: https:// www.ijss-sn.com/uploads/2/0/1/5/20153321/ ijss_apr_oa51.pdf 5. pandey a, radhika pm, shetty s. estimation of human stature from length of ulna in indian population. international journal of anatomy and research. 2017;5(1):3350-53. doi: https://dx.doi.org/10.16965/ijar.2016.473 6. ilayperumal i, nanayakkara, g, palahepitiya n. a model for the estimation of personal stature from the length offorearm. international journal of morphology. 2010;28(4):108186. doi: http://dx.doi.org/10.4067/s071795022010000400015 7. meitei nj, devi hs. estimation of stature using lower limb dimensions among maring males of manipur. the anthropologist. 2014;17(2):681-3. doi: https://doi.org/10.108 0/09720073.2014.11891478 8. gaur r, kaur k, airi r, jarodia k. estimation of stature from percutaneous lengths of tibia and fibula of scheduled castes of haryana state, india. annals of forensic research and analysis. 2016;3(1):1025-30. available from: https://www.jscimedcentral.com/forensic/forensic-3-1025.pdf 9. pearson k. iv. mathematical contribution to the theory of evolution. -v. on the reconstruction of the stature of prehistoric races. philosophical transactions of the royal society of london. series a, containing papers of a mathematical or physical character. 1892;192:169–244. doi: http://doi.org/10.1098/rsta.1899.0004 10. trotter m, gleser gc. estimation of stature from long bones of american whites and negros. am j phys anthropol. 1952;10(4):463514. pmid: 13007782. doi: https://doi. org/10.1002/ajpa.1330100407 11. mohanty bb, agrawal d, mishra k, samantsinghar p, chinara pk. estimation of height of an individual from forearm length on the population of eastern india. journal of medical & allied science. 2013;3(2):72-5. available from: https://jmas.in/articles/2013/3/2 12. prasad a, bhagwat vb, porwal s, joshi ds. estimation of human stature from length of ulna in marathwada region of maharashtra. international journal of biological & medical research. 2012;3(4):2337-41. available from: https://www.biomedscidirect.com/archives. php?issueid=13 13. duyar i, perlin c. estimating body height from ulna length: need of a population specific formula. eurasian journal of anthropology. 2010;1(1):11–17. available from: https:// www.researchgate.net/publication/279505980 14. bamne a, bamne sn, choursia rs, gohiya vk. estimation of stature from length of ulna in maharashtrian population. international journal of medical science and public health. 2015;4(1):65-9. available from: http:// citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.669.233&rep=rep1&type=pdf 15. sah rp, bhaskar rk. estimation of ulna length as a predictor of height in nepalese female adult population: an anthropometric study. janaki medical college journal of medical science. 2018;6(2):22-8. doi: https://doi.org/10.3126/ jmcjms.v6i02.22057 16. borhani-haghighi m, navid s, hassanzadeh g. height prediction from ulnar length in chabahar: a city in south-east of iran. romanian journal of legal medicine. 2016;24(4):304-7. available from: http://www.rjlm.ro/system/revista/40/304-307.pdf 17. cutler gb jr. the role of estrogen in bone j. lumbini. med. coll. vol 8, no 2, july-dec 2020 pandey n, et al. estimating the height of an individual from the length of ulna in undergraduate students of a nepalese medical college. 189 jlmc.edu.np growth and maturation during childhood and adolescence. the journal of steroid biochemistry and molecular biology. 1997;61(36):141-44. doi: https://doi.org/10.1016/ s0960-0760(97)80005-2 18. mondal mk, jana tk, das j, biswas s. use of length of ulna for estimation of stature in living adult male in burdwan district and adjacent areas of west bengal. journal of anatomy society of india. 2009;58(1):16-8. available from: http://medind.nic.in/jae/t09/i1/jaet09i1p16.pdf 19. ansah eo, abaidoo cs, diby t, tetteh j, appiah ak, ohene-djan o, et al. a preliminary anthropometric study of height and sex determination using percutaneous ulnar and femoral lengths. international journal of anatomy and research. 2017;5(1):3638-43. doi: https://dx. doi.org/10.16965/ijar.2017.127 20. charisi d, eliopoulos c, vanna v, koilias cg, manolis sk. sexual dimorphism of the arm bones in a modern greek population. journal of forensic science. 2011;56(1):1018. doi: https://doi.org/10.1111/j.15564029.2010.01538.x 21. albrook d. the estimation of stature in british and east african males. based on tibial and ulnar bone lengths, journal of forensic medicine 1961;8(0):15-28. pmid: 13682488 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 tiwari a, et al. fine needle aspiration versus fine needle capillary sampling technique in cyto-diagnosis of thyroid lesions. 195 jlmc.edu.np ___________________________________________________________________________________ submitted: 23 june, 2020 accepted: 04 august, 2020 published: 23 august, 2020 aassistant professor, departmentof pathology, blecturer, departmentof pathology, cprofessor, departmentof pathology, dlumbini medical college and teaching hospital, palpa, nepal. corresponding author: dr. archana tiwari e-mail: archana445@gmail.com orcid: https://orcid.org/0000-0002-9250-2731_______________________________________________________ abstract: introduction: in diagnosis of thyroid lesions, the negative pressure applied during fine needle aspiration cytology (fnac) frequently produces bloody smears. this results in a compromise in cellular concentration and architecture which may lead to improper interpretation. fine needle capillary sampling cytology (fncc), on the other hand, avoids active aspiration as it depends on capillary tension to collect tissue samples in the needle bore. this study evaluated the diagnostic performance of fnac and fncc in thyroid lesions. methods: a total of 120 patients were included in this study conducted over a duration of 19 months. all thyroid swellings advised for cyto-diagnosis were sampled by both fine-needle aspiration (fnac) and non-aspiration (fncc) techniques. the slides were assessed according to the mair et al. scoring system. results: in the fncc group, 72 (60%) smears were diagnostically superior while 54 (45%) smears were diagnostically superior in the fnac group. blood contamination (p=0.003), cellular trauma (p=0.019), and degree of cellular degeneration (p=0.026) were less and cellular architecture (p=0.047) was preserved more in fncc in comparison to fnac groups. conclusion: this study showed the superiority of fncc for the interpretation and diagnosis of thyroid lesions. however, the combination of both fnac and fncc could maximize the diagnostic yield. keywords: fine needle aspiration cytology (fnac), fine needle capillary cytology (fncc), thyroid swelling original research articlehttps://doi.org/10.22502/jlmc.v8i2.385 archana tiwari,a,d prahar dahal,b,d sudeep regmi,b,d ramji rai,c,d fine needle aspiration versus fine needle capillary sampling technique in cyto-diagnosis of thyroid lesions how to cite this article:how to cite this article: tiwari a, dahal p, regmi s, rai r. fine needle aspiration versus fine needle capillary sampling technique in cyto-diagnosis of thyroid lesions. journal of lumbini medical college. 2020;8(2):195-200. doi: https://doi.org/10.22502/jlmc.v8i2.385 epub: 2020 august 23. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: fine needle aspiration cytology (fnac) is a routine, well-established, and widely accepted investigation modality in the evaluation of palpable and non-palpable lesions in the body. it is a minimally invasive technique with high sensitivity, specificity, and accuracy. thyroid nodules are the most common clinical problem encountered by surgeons in their out-patient department (opd).[1] about 1-10% of the thyroid nodules are malignant. the incidence of thyroid malignancy has multiplied over the years due to the increased incidence of papillary thyroid carcinoma.[2] therefore, a prompt diagnosis is necessary for its timely management. the quality of cellular material is a prerequisite for proper interpretation and diagnosis of thyroid specimens. the thyroid is a vascular organ and negative pressure exerted during aspiration techniques in fnac procedure frequently causes a compromise in cellular preservation due to bloody smears which may lead to unsatisfactory sampling and improper interpretation. the majority of diagnostic failures are due to non-diagnostic samples or pathologists j. lumbini. med. coll. vol 8, no 2, july-dec 2020 tiwari a, et al. fine needle aspiration versus fine needle capillary sampling technique in cyto-diagnosis of thyroid lesions. 196 jlmc.edu.np issuing diagnosis on samples with inadequate material. in an attempt to overcome this problem, a new method called fine needle capillary cytology (fncc), also known as fine needle capillary sampling (fncs), fine needle non-aspiration cytology (fnnac) and cyto-puncture was developed by briffod in france in 1982.[3] it was first described in diagnosing thyroid nodules by santos and leiman in 1988.[4] the main mechanism for fncc is capillary tension to suck the tissues; avoiding active aspiration. it was reported that, due to the absence of suction effect, fncc was less traumatic, producing less bloody and higher quality smears, easier to perform, and less painful. there are many conflicting studies regarding the superiority of fnac to fncc and vice versa. hence, this study aimed to compare the outcomes of fncc with that of fnac in thyroid lesions. methods: this prospective, observational study was conducted at the department of pathology, lumbini medical college and teaching hospital, nepal from 1st november 2019 to 31st may 2020. ethical clearance from the institutional review committee (irc-lmc 23-g/019) was obtained prior to starting the study. all the patients referred from clinical opds with a thyroid swelling for cyto-diagnosis were enrolled into the study. the patients with thyrotoxicosis were excluded because it is a highly vascular condition and irrespective of the technique used, there exists a high probability of bloody smear. thyroid swelling in every patient was sampled by both fine-needle aspiration (fna) and nonaspiration (fnc) techniques by a single operator and also further interpreted by a single pathologist. both the techniques were done using a 23 gauge needle. a 10 ml disposable plastic syringe was attached in the aspiration technique, while the non-aspiration technique was done without a syringe or holder. the needle held between the thumb and forefingers of aspirating hand was inserted into the nodule and moved in different directions within the nodule while performing fncc sampling. the material received in the hub of the needle by capillary action was then expressed onto clean glass slides. the pathologist was unaware of the sampling method employed (fnac/fncc). to reduce the bias and standardize the method non-aspirate was always performed before the aspirate technique and slides were marked as “a” and “b” randomly. the dry smears were stained by wright stain, and the wet smear was stained with papanicolaou stain. mair et al. scoring system was adopted for the interpretation of smears.[5] the two sampling techniques were compared by evaluating smears using five objective parameters: background clot/blood, cellularity, degree of cellular degeneration, degree of cellular trauma, and retention of appropriate architecture as shown in table 1. a cumulative score between 0 and 10 points was calculated for each specimen (smear) and categorized into one of the following three categories: category 1—(score 0–2) unsuitable for diagnosis. category 2—(score 3–6) adequate for cytological diagnosis. category 3—(score 7–10) diagnostically superior table 1. the mair et al. scoring system. background blood/clot large amount, great compromise of diagnosis 0 moderate amount, diagnosis possible 1 minimal amount, diagnosis easy 2 amount of cellular material minimal to absent, diagnosis not possible 0 sufficient for cytodiagnosis 1 abundant, diagnosis possible 2 degree of cellular degeneration marked, diagnosis impossible 0 moderate, diagnosis possible 1 minimal, diagnosis easy 2 degree of cellular trauma marked, diagnosis impossible 0 moderate, diagnosis possible 1 minimal, diagnosis obvious 2 retention of appropriate architecture minimal to absent non diagnostic 0 moderate, some preservation of, for example, follicle, papillae, and acini 1 excellent architectural display closely reflecting histology, diagnosis obvious 2 the cytological interpretation was made based on bethesda system for reporting thyroid j. lumbini. med. coll. vol 8, no 2, july-dec 2020 tiwari a, et al. fine needle aspiration versus fine needle capillary sampling technique in cyto-diagnosis of thyroid lesions. 197 jlmc.edu.np cytopathology (bsrtc). all the data thus collected were analyzed using the statistical package for social sciences (spsstm) software version 20. qualitative data were presented in frequency and percentages and quantitative data as mean with standard deviations. student’s t test was used to compare means. a p value < 0.05 was considered statistically significant. results: during the study period, a total of 1000 samples were processed at our department for cytodiagnosis, in which 150 cases were of the thyroid. out of them, 120 cases underwent both fnac and fncc for thyroid lesions. the distribution with regards to age, sex, and diagnosis of all cases was analyzed and compared for the five objective parameters in-between the two techniques. in this study, the age of the patients ranged from 16 to 89 years with the mean of 40.23±11.8 years. there were 88 (73.3 %) females and 32 males (26.6%) with a female-to-male ratio of 2.7:1. thyroid lesions were more common in the age group 35-40 (n=48, 40%) followed by 25-30 years (n=42, 35%) and 50-55 years (n=30, 25%) respectively. the frequency of thyroid lesions encountered during the study is tabulated in table 2. goiter was the most common lesion (n= 72, 60%) followed by thyroiditis (n=18, 15%). table 2. frequency of various thyroid lesions on cytology (n=120). diagnosis n (%) non-neoplastic lesions nodular goitre (single) 18 (15 %) colloid goitre 30 (25%) multi nodular goiter 24 (20%) hashimoto’s thyroiditis 12 (10%) lymphocytic thyroiditis 6 (5%) neoplastic lesions papillary carcinoma 12 (10%) follicular neoplasm 6 (5%) follicular lesion of undetermined significance (flus) 5 (4.16%) suspicious for malignancy 4 (3.33%) medullary carcinoma 2 (1.66%) undifferentiated/ anaplastic carcinoma 1 (0.83%) total 120 (100%) tables 3 and 4 show a comparison of both techniques. we found that the non-aspiration technique (fncc) yielded more diagnostically superior smears as compared to fnac. fncc yielded diagnostically superior samples in 72 (60%) out of 120 cases as compared to fnac method where diagnostically superior sample was seen in 54 (45%) cases as shown in table 3. fncc also showed fewer numbers of inadequate samples. out of 120 cases diagnostically inadequate smears were seen in 12 (10%) cases in fncc and in 24 (20%) cases in fnac group. fnac on the other hand, showed more diagnostically adequate samples (n=42, 35%) than fncc group (n=36, 30%). as per the individual criteria used in the mair et al. scoring system, blood contamination was more in fnac smears than in fncc smears and this difference was statistically significant (p=0.003). the degree of cellular trauma was less in fncc in comparison to fnac smears (p=0.019). the degree of cellular degeneration was less in fncc in comparison to fnac smears (p =0.026). the cellular architecture was preserved more in fncc smears than fnac samples (p=0.047). fnac performed well in case of amount of cellular material, it was retrieved more by fnac technique than fncc (p=0.019) table 3: diagnostic performance of fnac vs fncc techniques. fnac n(%) fncc n(%) diagnostically inadequate 24 (20) 12 (10) diagnostically adequate 42 (35) 36 (30) diagnostically superior 54 (45) 72 (60) total 120 (100) 120 (100) discussion: fnac is a useful diagnostic adjunct to the conventional method of diagnosis in cases of palpable thyroid lesions and impalpable lesions under image guidance. it is a less time consuming, simple, minimally invasive, cost-effective technique with a low complication rate which facilitates diagnosis and surgical planning. it is reported to have a high sensitivity, specificity, and overall accuracy. [6] however, it has well-recognized limitations of inadequate sampling, requiring repeated aspirations. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 tiwari a, et al. fine needle aspiration versus fine needle capillary sampling technique in cyto-diagnosis of thyroid lesions. 198 jlmc.edu.np as the thyroid gland is highly vascular, samples can contain significant quantities of blood resulting in inferior quality cellular material which makes cytological interpretation difficult and compromise diagnostic accuracy. the present study was undertaken to compare the efficacy of both fnac and fncc techniques about the method itself and those related to the quality and quantity of material obtained by each technique. in the present study, the non-aspiration technique (fncc) yielded more diagnostically superior smears as compared to fnac. fncc yielded diagnostically superior samples in 72 (60%) out of 120 cases as compared to the fnac method where the diagnostically superior sample was seen in 54 (45%) out of 120 cases. fncc also showed fewer numbers of diagnostically inadequate samples, out of 120 cases diagnostically inadequate smears were seen in 12 (10%) cases in fncc and in 24 (20%) cases in fnac group. fnac on the other hand, showed more diagnostically adequate samples, out of 120 cases diagnostically adequate smears were seen in 42 (35%) cases in fnac and in 36 (30%) cases in fncc group. similar results have been shown by various other studies. in a study conducted by rizvi et al. in 150 patients, they found more diagnostically superior samples (n=67, 44.66%) by fncc than (n=30, 20%) by fnac technique, and diagnostically inadequate samples were less in fncc (n=3, 2%) than fnac (n=10, 6.66%). whereas more diagnostically adequate samples were shown by fnac (n=110, 73.33%) in comparison to fncc (n=80, 53.33%).[7] in the study conducted by mainali et al., among 87 patients 19 (21.84%) samples showed diagnostic superiority in the fncc technique while 7 (8.06%) samples showed diagnostic superiority in fnac. twelve (13.79%) samples were unsuitable diagnostically in the fncc technique and 26 (29.89%) in the fnac technique. in contrast to our study, diagnostically adequate smears were seen more in the fncc group. fifty-six (64.37%) cases showed diagnostically adequate smears in the fncc technique while 54 (62.05%) cases showed diagnostic adequate smears in the fnac technique.[8] maurya et al. observed in a study of 50 cases that diagnostically superior samples were more in fncc (46%) than fnac (40%) group. similar to our study, diagnostically adequate samples were obtained more by fnac (24%) than fncc (18%) technique.[9] in contrast to our study the percentage of inadequate sampling was more with non-aspiration (38%) than with aspiration (34%) technique. the superiority of fncc in a vascular organ like the thyroid is shown in various studies. santos and leiman compared the two techniques in thyroid lesions.[4] in both benign and malignant lesions, their study has shown that diagnostically superior specimens were obtained more frequently by the fncc technique in thyroid lesions. diagnostic superiority of fncc was also supported by mair et al. and mahajan et al. who showed that fnac sampling was diagnostic in a greater number of cases, whereas diagnostically superior smears were obtained more frequently by the non-aspiration technique.[5,10] in our study, as per the individual criteria used in mair et al. scoring system, background blood/ clot, degree of cellular degeneration and degree of cellular trauma were less in samples taken by fncc as well as retention of appropriate architecture was more in fncc samples .whereas more amount of cellular material was obtained in samples taken by fnac. background blood/ clot was significantly less in the study done by mainali et al., pinki et al. and ramachandra et al. in fncc samples similar to our study.[8,11,12] but in contrast to our study, table 4. comparison of fnac and fncc for various parameters. parameters fnac (mean±sd) fncc (mean ± sd) statistics background blood or clot 1.37±0.549 1.58 ± 0.513 t = -3.037, df = 238 p = 0.003 amount of cellular material 1.29±0.492 1.13 ± 0.549 t = 2.353, df =238 p = 0.019 degree of cellular degeneration 1.36±0.786 1.56±0.577 t= -2.246, df=218.3 p=0.026 degree of cellular trauma 1.21±0.732 1.42±0.630 t= -2.363, df=238 0.019 retention of appropriate architecture 1.19±0.759 1.38±0.622 t=1.994, df=238 0.047 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 tiwari a, et al. fine needle aspiration versus fine needle capillary sampling technique in cyto-diagnosis of thyroid lesions. 199 jlmc.edu.np mainali et al. found the amount of cellular material was significantly more in fncc group and degree of cellular degeneration, degree of cellular trauma and retention of appropriate architecture did not show any statistical significance between fncc and fnac techniques. in a study by kamal et al. statistically significant difference in favor of fncc was observed only for the amount of cellular material. for the rest of the parameters i.e. background blood or clot, degree of cellular degeneration, degree of cellular trauma and retention of architecture, the average score favored fncc but was not statistically significant. although fncc sampling was diagnostic in a greater number of cases than fnac sampling, this study did not prove a clear superiority of fncc over fnac.[13] similar to our study kumar et al. also concluded fncc as a better technique than fnac in the cytological diagnosis of solitary thyroid nodules. [14] it showed more diagnostically superior smears by fncc, 19.44% in comparison to 13.88% by fnac and better cellular architecture preservation with less blood/colloid background in non-aspiration technique. romitelli et al. found retention of architecture to be better in the non-aspiration technique.[15] unlike our study, haddadi et al. concluded that fncc is not superior to fnac in the cytopathologic studies of thyroid nodules.[16] similarly, song et al. revealed that both techniques are equally useful in the assessment of thyroid nodules and opined the selection of technique depends on the personal preference of the operator.[17] conclusion: this study concluded that fncc yielded superior quality smears due to a significant improvement in the retention of cellular architecture, less cellular trauma, reduced cellular degeneration and less blood contamination in this technique. it found fnac to be superior in yielding a greater amount of cellular material. therefore, to increase the number and quality of results, both techniques (fncc and fnac) could be supplementary in lesions of vascular organs like thyroid. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available for the study. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 tiwari a, et al. fine needle aspiration versus fine needle capillary sampling technique in cyto-diagnosis of thyroid lesions. 200 jlmc.edu.np references: 1. ahmad t, naeem m, ahmad s, samad a, nasir a. fine needle aspiration cytology (fnac) and neck swellings in the surgical outpatient. j ayub med coll abbottabad. 2008;20(3):30-2. pmid: 19610510 2. pacini f, burroni l, ciuoli c, di cairano g, guarino e. management of thyroid nodules: a clinicopathological, evidence-based approach. european journal of nuclear medicine and molecular imaging. 2004;31(10):1443-9. available from: https://search.proquest.com/ openview/c371e476bbf059be8d05a94541246c18/ 1?pq-origsite=gscholar&cbl=42802 3. briffod m, gentile a, hebert h. cytopuncture in the follow-up of breast carcinoma. acta cytol. 1982;26(2):195-200. pmid: 6952722 4. santos je, leiman g. nonaspiration fine needle cytology. application of a new technique to nodular thyroid disease. acta cytol. 1988;32(3):353-6. pmid: 3376702 5. mair s, dunbar f, becker pj, du plessis w. fine needle cytology--is aspiration suction necessary? a study of 100 masses in various sites. acta cytol. 1989;33(6):809-13. pmid: 2488680 6. bista m, kc t, regmi d, maharjan m, kafle p, shrestha s. diagnostic accuracy of fine needle aspiration cytology in thyroid swellings. j nepal health res counc. 2011;9(18):14-6. doi: https://doi.org/10.33314/jnhrc.v0i0.246 7. rizvi saa, husain m, khan s, mohsin m. a comparative study of fine needle aspiration cytology versus non-aspiration technique in thyroid lesions. the surgeon. 2005;3(4):2736. doi: https://doi.org/10.1016/s1479666x(05)80091-5 8. mainali n, nepal n, choudhary pk, homagai n, khanal b. aspiration and non-aspiration technique in the study of thyroid gland lesion cytology. journal of pathology of nepal. 2018;8(1):1257-60. available from: https://www. nepjol.info/index.php/jpn/issue/view/1247 9. maurya ak, mehta a, mani ns, nijhawan vs, batra r. comparison of aspiration vs nonaspiration techniques in fine-needle cytology of thyroid lesions. j cytol. 2010;27(2):51-4. pmid: 21157549. doi: https://doi.org/10.4103/09709371.70737 10. mahajan p, sharma pr. fine-needle aspiration versus non aspiration technique of cytodiagnosis in thyroid lesions. jk sci. 2010;12(3):120-22. available from: https://www.jkscience.org/list_ articles.php?volume=12&issueno=3 11. pinki p, alok d, ranjan a, nanak chand m. fine needle aspiration cytology versus fine needle capillary sampling in cytological diagnosis of thyroid lesions. iran j pathol. 2015;10(1):47-53. pmid: 26516325. 12. ramachandra l, kudva r, rao bha, agrawal s. a comparative study of fine needle aspiration cytology (fnac) and fine needle non-aspiration cytology (fnnac) technique in lesions of thyroid gland. indian j surg. 2011;73(4):287-90. pmid: 22851843. doi: https:// doi.org/10.1007/s12262-011-0283-9 13. kamal mm, arjune dg, kulkarni hr. comparative study of fine needle aspiration and fine needle capillary sampling of thyroid lesions. acta cytol. 2002;46(1):30-4. pmid: 11843555. doi: https://doi.org/10.1159/000326712 14. c hk, c yk. comparative study of aspiration versus non-aspiration fine needle technique in thyroid nodule and its correlation with post-operative histopathological examination. international surgery journal. 2018;5(3):104651. doi: http://dx.doi.org/10.18203/2349-2902. isj20180828 15. romitelli f, di stasio e, santoro c, iozzino m, orsini a, cesareo r. a comparative study of fine needle aspiration and fine needle non-aspiration biopsy on suspected thyroid nodules. endocr pathol. 2009;20(2):108-13. pmid: 19377844. doi: https://doi.org/10.1007/s12022-009-9074-2 16. haddadi-nezhad s, larijani b, tavangar sm, nouraei sm. comparison of fine-needlenonaspiration with fine-needle-aspiration technique in the cytologic studies of thyroid nodules. endocrine pathology. 2003;14(4):36973. doi: https://doi.org/10.1385/ep:14:4:369 17. song h, wei c, li d, hua k, song j, maskey n, et al. comparison of fine needle aspiration and fine needle nonaspiration cytology of thyroid nodules: a meta-analysis. bio med res int. 2015;2015:796120. pmid: 26491689. doi: https://doi.org/10.1155/2015/796120 soft-tissue necrosis complicating bone-cement filling in a patient with proximal tibia giant cell tumour and co-morbid depressive illness sagar narang,a,c neeta narangb,d —–————————————————————————————————————————————— abstract: giant-cell tumors are common around the knee. proximal tibia is a challenging location for limb-salvage due to paucity of soft-tissue cover. bone cement has been used in treatment of giant-cell tumors after curettage. tissue irritant properties of its monomer and exothermic reaction involved in polymerization may compromise surgical outcome to varying degrees. preoperative planning and intra-operative positioning during cementing process are of importance to avoid complications. co-occurrence of psychiatric illness in tumor patients should be managed by psychiatric counselling and drug therapy. this case has been presented to suggest measures for preventing soft-tissue complications during cement filling in proximal tibia, and for dealing with concomitant psychiatric problems for a holistic improvement in tumor patients. keywords: bone cement • depression • giant cell tumor • proximal tibia • skin burn ——————————————————————————————————————————————— ___________________________________________________________________________________ a associate professor b lecturer c department of orthopedics and traumatology lumbini medical college teaching hospital, palpa, nepal d department of psychiatry lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. sagar narang e-mail: sagarnarang@jlmc.edu.np how to cite this article: narang s, narang n. soft-tissue necrosis complicating bonecement filling in a patient with proximal tibia giant cell tumour and comorbid depressive illness. journal of lumbini medical college. 2013;1(2):120-4. doi:10.22502/jlmc.v1i2.35. ___________________________________________________________________________________ j. lumbini. med. coll. vol 1, no 2, july-dec 2013 case report jlmc.edu.np https://doi.org/10.22502/jlmc.v1i2.35 introduction: giant-cell tumors of bone are benign tumors with aggressive potential. the most common site of occurrence is around the knee. proximal tibia giant cell tumors are fairly common, involving the medial or the lateral tibial plateau. intra-lesional resection by curettage has a higher recurrence rate, but a satisfactory knee function compared to wide resection, on a long-term follow up.1 curettage of tumor and filling the cavity with bone cement is an accepted procedure for the non-aggressive giant-cell tumor.2 bone cement usage in proximal tibia has its own set of complications because of proximity of neurovascular structures and sparse soft-tissue cover. we present a case, which made us modify our treatment approach in managing extensive lytic lesions with bone cement filling in proximal tibia. a second salvage surgery was required to manage the complication of full thickness skin necrosis. the presence of co-morbid psychiatric illness especially depression, in patients with bone tumors, needs to be evaluated and managed effectively for good overall outcome. case report: a 28 year male patient presented to our outpatient department complaining of pain and swelling around the right knee, gradually increasing over a three month period. he had sustained a trivial trauma to the affected area six months ago. he was prescribed medication for the pain (aceclofenac 100 mg twice daily for two weeks), by a local physician, without much improvement in the severity. he was 120 j. lumbini. med. coll. vol 1, no 2, july-dec 2013 jlmc.edu.np narang s. et al. soft-tissue necrosis complicating bone-cement filling in a patient with proximal tibia giant cell tumour quite anxious regarding the persistence of pain and appearance of swelling. the swelling had grown appreciably in size over a period of two weeks and he was finding difficulty in climbing stairs and squatting. due to the above symptoms he was worried about the possibility of it being a cancerous growth. he was sleeping poorly at night; his appetite had reduced considerably, and was gradually losing interest in his work. on examination a globular, bony hard mass was felt on the antero-medial aspect of right proximal tibia measuring 3 cm x 3 cm. it seemed to be arising from the bone. the overlying soft-tissue was non-adherent to the mass. there were no scars, sinus, venous prominence, overlying the involved area. there were no associated masses felt around the knee. knee flexion was terminally restricted. the right lower limb had no neurovascular deficit. radiographs were ordered, which revealed an extensive area of lucency, with bony septations within the proximal tibia, giving a "soap-bubble" appearance (figure 1). the lucency involved the whole of medial condyle and part of lateral condyle of right tibia. the tumor had not breached the cortex and there was no pathological fracture at presentation. based on these findings a diagnosis of giant-cell tumor of the proximal tibia was made. the patient was also referred to a psychiatrist for evaluation of his mental status and management of any co-morbid psychiatric illness. psychiatric evaluation resulted in the diagnosis of a depressive episode as per icd-10 guidelines. the instrument used for assessing the severity of the depressive episode was hamilton depression rating scale (ham-d scale). on the first psychiatric evaluation, a score of 16 was obtained indicating moderate depression. the patient was started on tablet escitalopram 10 mg once a day for treatment of the depressive episode. the limb was rested in a knee immobiliser. an urgent operative intervention was planned, to prevent a pathological fracture. curettage of giantcell tumor mass was done through an antero-medial approach to proximal tibia, elevating a full-thicknessskin soft-tissue flap. sterile water was used to lavage the cavity as an adjunct to curettage, for local control. the curetted bone cavity was packed with approximately 80 gm of polymethylmethacrylate (pmma) bone cement. the choice of pmma was made, to give immediate stability to the already weakened proximal tibia, and to utilize the tumoricidal (thermal necrosis) properties of pmma. post-operative radiographs showed good position of bone cement, supporting the tibial articular surface and the medial pillar (figure 2). on the first post-operative day, localized blistering of skin was noticed over the cement implanted area. patient was able to ambulate painfree, following the procedure. the skin blister was treated by local dressing change. it evolved to form an eschar at two weeks, the operative incision site healed without complications. on repeated dressings, there was no improvement, and no spontaneous epithelisation of the eschar area was noted. the patient on psychiatric follow up was seen to have improved with the prescribed medication. the ham-d score was 10 at four weeks follow-up. anti-depressant medication was continued at the fig 1: preoperative radiographs of right knee showing extensive lytic lesion of proximal tibia. note the "soap-bubble" appearance characteristoc of giant cell tumour. fig 2: postoperative antero-posterior radiograph of right knee showing good articular and medial pillar stability provided by bone cement. 121 j. lumbini. med. coll. vol 1, no 2, july-dec 2013 narang s. et al. soft-tissue necrosis complicating bone-cement filling in a patient with proximal tibia giant cell tumour jlmc.edu.np same dosage and follow up was advised. the eschar detached at four weeks, leaving a circular full-thickness skin and soft-tissue defect, measuring 5 cm x 5 cm. the base of this defect was formed by the implanted bone cement (figure 3). at this stage, radiographs showed good cement position in the cavity, no lucency and no detachment at cement-bone interface was noted. a decision was made to cover the bare implant surface by a second surgery. medial gastrocnemius rotation flap, with split-thickness skin graft was done to salvage the situation (figure 4). the defect area healed well over a one-month period (figure 5). psychiatric evaluation at this time showed that severity of the depressive episode had reduced considerably with a ham–d score of eight. tab escitalopram was continued at the same dose of 10 mg per day for another four months with regular opd follow-ups. at one year follow up, there was no recurrence of the tumor noted, there were no metastases, the bone cement was supporting the tibial articular surface well, and the patient was symptom free, with satisfactory knee function. the patent did not show any symptoms of a mood disorder at one year follow up. discussion: giant-cell tumor of bone has been classified as benign tumor with a potential of becoming aggressive. the most common site of occurrence is the knee area, involving the distal femur and the proximal tibia. various methods of management of this lesion have been reported in literature depending upon the amount of bone destruction, the location of tumor and the aggressiveness of the tumor. one of the modality of treatment is curettage of the tumor cavity and packing it with pmma bone cement. pmma is biologically compatible, provides immediate stability to the applied area, and in addition has tumoricidal effect due to the exothermic reaction involved in its polymerisation.2 there are complications reported in literature with the use of bone cement. thermal damage to adjacent soft-tissue structures including nerves and vessels, in various locations has been reported. cement burns following total hip replacement surgery involving obturator nerve, sciatic nerve, femoral nerve, ureter, and intrapelvic arteries can occur as serious unforeseen complications of a reconstructive surgery.3-7 skin and soft-tissue necrosis from discarded bone cement has been reported.8 embolism, allergic reactions, venous leakage, hypotension and rarely cardiac arrest have been encountered with usage of bone cement, both intraoperatively and after percutaneous injections. the systemic effects have been attributed to the absorbed methacrylate monomer.9 the local effects have been related to the heat of polymerisation causing coagulation of proteins, occlusion of metaphyseal arteries producing bone necrosis, and lipolytic and cytotoxic effects of unpolymerised monomer.10 bone cement has been used in skeletal metastases to relieve pain. the process of cementoplasty in such long bone and vertebral lesions, leads to local extrusion and soft-tissue damage. the extent of damage due to bone cement fig 3: the full thickness soft tissue defect over the anteromedial portion of proximal tibia. the base is formed by the implanted bone cement. the operative scar site has healed normally. fig 4: intraoperative photograph showing medial gastrocnemius rotation flap covering the soft tissue defect. fig 5: skin-soft tissue defect healed after medial gastrocnemius rotation flap and split-thickness skin graft application. 122 j. lumbini. med. coll. vol 1, no 2, july-dec 2013 jlmc.edu.np narang s. et al. soft-tissue necrosis complicating bone-cement filling in a patient with proximal tibia giant cell tumour has not been quantified and may have been considered insignificant in relation to the short life expectancy of such patients.11 but the scenario can be of immense importance in association with tumors with nearnormal life expectancy, such as giant-cell tumors. these situations are different from cementoplasty and vertebroplasty cases in which the amount of cement used is in small quantities, and the primary purpose is relief of bone pain. use of cement in arthroplasty for stabilization of components is also not to the amount used in filling extensive bone cavities, post-curettage. the bone cement is made of a white powder, consisting of polymethylmethacrylate, methyl methacrylate-styrenecopolymer and barium sulphate, with a flammable liquid monomer composed of methyl methacrylate, nn-dimethyl-ptoluidine, and hydroquinone.11 on mixing the white powder with the liquid monomer, dough is formed, as the monomer starts to polymerize. the setting time is usually 6-10 minutes depending upon the ambient temperature and the initial temperature of the bone cement components, cooling helps prolong the setting time. nearly 13 kcal (55 kj) of heat is evolved in polymerization of 100 gms of bone cement.5 the temperatures can reach 100 degree centigrade in a laboratory setting, although in vivo the temperatures range between 38 degrees to 56 degrees centigrade for arthroplasty patients with a 2-3 mm thick cement mantle.12-14 the surface temperature of setting cement varies with setting time and thickness of cement, with a 10 mm specimen reaching 107°c at room temperature (25°c).15 even when the dough is ready for insertion, there is 4% of unutilised monomer in the mixture.9 the percentage becomes significant if 80 grams or more of cement are used for the procedure, which increases the amount of unutilised monomer as well. in the past the thermal necrosis properties of bone cement have been studied and many soft tissue burns ascribed to it. there exists a co-component to the soft-tissue damage due to bone cement, which is the unutilised methylmethacrylate monomer, and causes chemical necrosis. as seen in our case, despite taking all precautions, regarding full thickness skin flap for the exposure of tumor, proper curettage and cement packing and cooling of the cement before suturing the flap back in place, full-thickness skin and soft-tissue necrosis did occur. this might have been due to contact thermal necrosis and chemical necrosis properties of pmma. in a report by arumilli brb, paul as, the full-thickness skin and soft-tissue necrosis occurred opposite to the incision site.16 this non-contact thermal necrosis was ascribed to extensive exothermic reaction and thermal conductivity of underlying bone. it was emphasized in this report, that if anterior approach is used for curettage and bone cement application, "there might be noncontact thermal necrosis of soft tissues posterior to the intact proximal tibia that might go undetected and could cause catastrophic neurovascular complicaions". this observation may be true, and as an addition to this we would like to emphasize modifications which might help avoid chemico-thermal necrosis of soft-tissue around proximal tibia. the first one would be regarding the position of the leg during cement application and setting. in the case report with non-contact thermal necrosis,the patient was positioned prone for a prolonged period, so this probably allowed the unutilised monomer to gravitate through the haversian system and damage tissues opposite (anterior) to the site of application of cement (posterior), causing noncontact necrosis.16 in the anterior approach, when the patient is in supine or lateral position, we believe that after the cement has been filled in the cavity of tibia, the knee should be bent to 90 degree, if possible, to let the neurovascular structures fall-back away from proximal tibia. the second one would be regarding the position of cortical window for tumor curettage. a pre-operative axial ct scan of the involved tibia can be of help. the window should be made in the thinnest cortex and should have the thickest cortex as its floor, to withstand the pressurizing of cement, invaginations in cancellous bone, and distribute (soak) the gravitating liquid monomer in many channels of haversian system, preventing focal accumulations, and soft-tissue burns. to achieve this, the patient should be positioned lateral, with the involved knee up, in case of predominant lateral condylar lytic tumor. for predominantly medial tibial condylar involvement; the patient should be positioned supine, and cementing done in a figureof-four position of the involved knee. the thinner the bone around the curetted cavity, higher is the chances of soft-tissue complications following bone cement application. the rate of depressive disorders in somatic illnesses varies between 10 – 40 percent. hence, it is important to diagnose this psychiatric co-morbidity at the earliest and start anti-depressant treatment in such patients.17 amongst the selective serotonin reuptake inhibitors (ssris), escitalopram has shown to be superior both in efficacy as well as safety 123 j. lumbini. med. coll. vol 1, no 2, july-dec 2013 narang s. et al. soft-tissue necrosis complicating bone-cement filling in a patient with proximal tibia giant cell tumour jlmc.edu.np 1. liu hs, wang jw. treatment of giant cell tumour of bone: a comparison of local curettage and wide resection. changgeng yi xue za zhi. 1998;21:37-43. 2. wada t, kaya m, nagoya s, et al. complications associated with bone cementing for the treatment of giant cell tumors of bone. j orthop sci. 2002; 7(2):194-8. 3. siliski j, scott r. obturator nerve palsy resulting from intrapelvic extrusion of cement during total hip replacement: report of four cases. j bone joint surg am. 1985;67:1225-8. 4. birch r, wilkinson m, vijayan k, et al. cement burn of the sciatic nerve. j bone joint surg br. 1992;74:731-3. 5. weber e, daube j, coventry j. peripheral neuropathies associated with total hip arthroplasty. j bone joint surg am. 1976;58:66-9. 6. waters e, bouchier hayes dm, hickey d. delayed presentation of ureteric injury after thermal insult at total hip replacement. br j urol. 1998;82:594. 7. nachbur b, meyer r, verkkala k, et al. the mechanisms of severe arterial injury in surgery of the hip joint. clin orthop. 1979;141:121–33. 8. burston b, yates p, bannister g. cement burn of the skin during hip replacement: ann r coll surg engl. 2007;89:151-2. 9. kirwan wo. systemic phenomena and bone cement. ir j med sci. 1973;142(6):342-5. 10. gupta a, majumdar p, amit j, et al. cell viability and growth on metallic surfaces: in vitro studies: trends biomater. artif organs. 2006;20(1):84-9. 11. hodge jc. cementoplasty and the oncogenic population. singapore med j. 2000;41(8):407-9. 12. toksvig-larsen s, franzen h, ryd l. cement interface temperature in hip arthroplasty. acta orthop scand. 1991;62:102–5. 13. li c, kotha s, huang c-h, et al. finite element thermal analysis of bone cement for joint replacements. j biomech engl. 2003;125:315-22. 14. reckling f, dillon w. the bone cement interface temperature during total joint replacement. j bone joint surg am. 1977;59:80-2. 15. meyer p, lautenschlager e, moore b. on the setting of acrylic bone cement. j bone joint surg am. 1973;55:14956. 16. arumilli brb, paul as. pretibial full thickness skin burn following indirect contact from bone-cement use in a giant cell tumour. sarcoma. 2007;2007:1-4. 17. zun s, kozumplik o, opic r, et al. depressive disorders and comorbidity: somatic illness vs. side effect. psychiatr danub. 2009;21(3):391-8. 18. ali mk, lam rw. comparative efficacy of escitalopram in the treatment of major depressive disorder. neuropsychiatr dis treat. 2011;7:39-49. 19. garnock-jones kp, mccormack pl. escitalopram: a review of its use in the management of major depressive disorder in adults. cns drugs. 2010;24(9):769-96. profile.18,19 it has also got minimal drug interactions and is well tolerated in the majority of patients. conclusion: giant-cell tumors in proximal tibia with extensive lysis at presentation can be a challenging situation in limb salvage surgery. the options for reconstruction are limited. autogenous bone graft is limited in quantity and there is uncertainty about its consolidation, with a risk of pathological fracture during the process of healing. pmma bone cement is required in large quantities, does not cause donor site morbidity, prevents pathological fracture from occurring, and results in satisfactory knee movement preservation. the amount of damage to soft-tissues following bone cement filling in large tumor cavities of proximal tibia, can be to a larger extent due to increased amount of cement used. this can cause more thermal necrosis and more chemical necrosis, in a confined space of proximal tibia with meagre muscle and fat cover to dissipate heat, and increased chances of damage to neurovascular structures around the knee. care is advised regarding planning of the position of patient, position of cortical window for curettage and position of knee during the polymerization phase of bone cementing, to avoid disastrous complications. the suspicion and hence the early diagnosis and treatment of depressive episode in this patient played a significant role in the favorable outcome of the surgical procedures. the improvement of mood and reduction in feelings of despair and pessimism with anti-depressant medication and supportive psychotherapy helped the patient to go through the second procedure with hope and confidence. references: 124 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 pandey t, et al. study of association between glycated hemoglobin and lipid profile in type 2 diabetes mellitus in tertiary care center 238 jlmc.edu.np ___________________________________________________________________________________ submitted: 29 june, 2020 accepted: 29 november, 2020 published: 2 december, 2020 alecturer, department of internal medicine, bassociate professor, department of internal medicine, cconsultant physician, dlumbini medical college and teaching hospital, palpa, nepal. ecrimson hospital, manigram, rupandehi, nepal. corresponding author: dr. tilchan pandey e-mail: tilchan_pandey@yahoo.com orcid: https://orcid.org/0000-0002-0682-4516_______________________________________________________ abstract: introduction: diabetes is one of the major burdens of non-communicable disease causing morbidity and mortality. glycated hemoglobin (hba1c) has been used as a tool to monitor glycemic control in patients with type 2 diabetes mellitus and elevated hba1c value is considered an independent risk factor for dyslipidemia. methods: a total of 120 patients with type 2 diabetes mellitus were enrolled in this cross-sectional study. means with standard deviation were used for age, height, weight and fasting blood sugar and pearson correlation test was applied to identify correlation between glycated hemoglobin (hba1c) and lipid profile. comparison of means was done by student 't' test in parametric data within the two groups. p value less than 0.05 was considered significant. results: the mean hba1c of male and female patients were 8.35±1.77 and 8.65±1.95 respectively. among patients with good glycemic control, mean total cholesterol and mean high density lipoprotein were higher than poor glycemic control patients. patients with poor glycemic control had higher mean triglyceride and low density lipoprotein than good glycemic control patients. correlation coefficient for various components of lipid profile and hba1c were: total cholesterol (r=0.189, p=0.038, n=120), triglyceride (r=0.418, p<0.01, n=120), low density lipoprotein (r=0.673,p<0.01,n=120) and high density lipoprotein ( r=-0.683,p<0.01, n=120). conclusion: there was a significant moderate correlation between hba1c and lipid profile. lipid profile values were significantly higher in poor glycemic control than good glycemic control patients. hence, hba1c can be considered as a surrogate marker for dyslipidemia in type 2 dm patients. key words: diabetes mellitus, glycated hemoglobin, lipid profile original research articlehttps://doi.org/10.22502/jlmc.v8i2.387 tilchan pandey,a,d jivan khanal,b,d krishna chandra godar c,e study of association between glycated hemoglobin and lipid profile in type 2 diabetes mellitus in tertiary care center how to cite this article:how to cite this article: pandey t, khanal j, godar kc. study of association between glycated hemoglobin and lipid profile in type 2 diabetes mellitus in tertiary care center. journal of lumbini medical college. 2020;8(2):238-243. doi: https://doi.org/10.22502/jlmc.v8i2.387 epub: 2020 december 2. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: diabetes mellitus (dm) is an endocrine disorder with high blood sugar level with disturbances of carbohydrate, lipid and protein metabolism resulting from variable degree of insulin resistance and deficiency or both.[1] abnormalities of lipid profiles in diabetic patients often termed “diabetic dyslipidemia”, is characterized by high total cholesterol (tc), high triglycerides (tg), low high-density lipoprotein cholesterol (hdl-c), increased levels of low density lipoprotein (ldl) particles and increased levels of very low density lipoprotein choleserol (vldl-c).[2] glycated hemoglobin (hba1c) shows the average plasma glucose over previous eight to twelve weeks and has been used as a tool to monitor glycemic control in patients with type 2 diabetes mellitus. an hba1c of ≥6.5% is recommended by american diabetic association as the cut-off point j. lumbini. med. coll. vol 8, no 2, july-dec 2020 pandey t, et al. study of association between glycated hemoglobin and lipid profile in type 2 diabetes mellitus in tertiary care center 239 jlmc.edu.np for diagnosis of diabetes mellitus.[3] elevated hba1c is an independent risk factor for dyslipidemia and coronary artery disease. it has also been seen that 18% cardiovascular disease (cvd) risk increase with every 1% increase in value of hba1c in diabetic.[4] it has been suggested that a reduction of 0.2% in the value of hba1c reduces mortality due to cardiovascular events by 10%. studies done in the past have shown significant positive correlation of hba1c with tc, ldl-c, and tg and significant negative correlation with hdl. the correlation between hba1c and ldl and hdl were found to be strong as suggested by higher values of correlation coefficients 0.785 and -0.897 respectively.[5] the aim of this study was to assess the relationship between hba1c and serum lipid profile in type 2 diabetic mellitus patients. methods: this was a cross sectional study conducted at lumbini medical college and teaching hospital, palpa in the department of internal medicine from may 2019 to november 2019. the study was approved by institutional review committee (irc) and written consent was obtained from all the patients. all patients aged > 30 years with a known diagnosis or newly diagnosed with type 2 diabetes mellitus as per american diabetic association (ada) criteria[3] were included in the study. necessary demographic, clinical and laboratory parameters like age, sex, diabetes, height, weight, blood sugar fasting and postprandial and various lipid profiles data were collected as in a preformed questionnaire through guided interview. following participants were excluded from this study: patients with known diagnosis of type1 diabetes mellitus, hypothyroidism, chronic renal failure, nephrotic syndrome, familial hypercholesteremia, cholestatic jaundice, alcohol consumption, patient on lipid lowering drugs for some other indications, beta blockers or thiazide diuretics, paraneoplastic syndrome, anemic patients and obese patients. samples were collected from patients attending outpatient department and stable indoor patients from department of internal medicine. cases were enrolled into study through purposive sampling. sample size calculation: from the previous study, correlation coefficient between hba1c and lipid profiles (tc) was found to be 0.257(r).[4,5] with the help of this r value sample size was calculated using standard sample size calculation formula where alpha value 0.05 and beta value 0.2 were taken. the standard normal deviate for α = zα = 1.960, the standard normal deviate for β = zβ = 0.842, c = 0.5 * ln[(1+r)/(1-r)] = 0.263 total sample size n= [(zα + zβ)/c] 2+3=117 technique of sample collection: venous blood was collected into two vials, three milliliter blood in plain vial and two milliliter blood in potassium-edta vial. fasting blood sugar was labeled as per fasting for eight hours and post prandial blood sugar was assessed two hours after food intake. glucose oxidase-peroxidase (godpod) method was applied to measure fasting blood sugar and nycocard reader was used to estimate the glycated hemoglobin (hba1c). venous blood sample was allowed to clot at room temperature in plain test tube and the serum was separated. serum lipids (triglyceride-tg, total cholesterol-tc, and high-density lipoprotein cholesterol-hdl-c) measured directly and the value of low-density lipoprotein cholesterol ldl-c was calculated using the friedewald’s formula.[6] all these parameters were analyzed using a fully automated chemistry analyzer (siemens adviacentuar 1800) and readyto-use reagent kits according to the manufacturer’s instructions (siemens diagnostics, germany). interpretation of lipid profile value was done as per national cholesterol education program-adult treatment panel iii (ncep-atpii). according to these guidelines’ recommendation normal, desirable, borderline and high-risk level of total cholesterol (tc) was defined as up to <200mg/dl, up to 200 mg/dl, 200-239mg/dl and >240mg/dl respectively. triglyceride (tg) value up to 149 mg/dl, 150-199 mg/dl, 200-499 mg/dl and >500 mg/dl was defined as optimal normal, borderline, high and very highrisk level tg respectively. low density lipoprotein (ldl) level was defined optimal risk when <100 mg/dl, near optimal 100-129 mg/dl, borderline high 130-159 mg/dl, high 160-189 mg/dl and very high >190 mg/dl respectively and low risk hdl as >60 mg/dl and high-risk level <40 mg/dl.[7] optimal glycemic target was considered when fbs≤130mg/ j. lumbini. med. coll. vol 8, no 2, july-dec 2020 pandey t, et al. study of association between glycated hemoglobin and lipid profile in type 2 diabetes mellitus in tertiary care center 240 jlmc.edu.np dl and ppbs≤180mg/dl and uncontrolled dm when it was greater than the optimal target value.glycemic status was divided into two groups; good glycemic control (ggc) if hba1c<7% and poor glycemic control (pgc) if hba1c ≥ 7% as per ada criteria. [3] for collecting the sample, this study used the structure questionnaires covering the age, gender, height, weight, body mass index (bmi), fasting blood sugar (fbs), postprandial (pp), and lipid profile of patients. with this evidence, we collected 120 samples for this study. data was analyzed with statistical package for social sciences (spsstm) software version 16. normally distributed data were presented as mean and standard deviation. pearson correlation test was done to identify the correlation between parametric data. comparison of means was done by student 't' test in parametric data with two groups. a p value less than 0.05 was considered significant. result: in our study, there were a total of 120 patients. age of the patients ranged from 30 to 90 years and more than half were older than 60 years. demographic parameters are shown in table 1. there was no statistically significant difference in age, height, weight, bmi, fbs, ppbs and hba1c between the two genders. table 1. demographic and clinical data in different genders. characteristics male patient (n=66) female patient (n=54) mean ± sd mean ± sd p-value age 57.77 ± 16.13 61.89 ±15.46 0.556 body mass index 22.32 ± 4.07 22.23 ± 5.45 0.910 fasting blood sugar 153.40 ± 36.78 161.16 ± 42.21 0.291 postprandial blood sugar 202.59 ± 54.49 218.66 ± 57.91 0.123 hba1c 8.35 ± 1.77 8.65 ± 1.95 0.374 a total of 96 (80%) patients had poor glycemic control (table 2). table 2. frequency and mean of poor glycemic control patients in different gender. n % mean ± sd hba1c ≥ 7% 96 80 9.05 ± 1.65 hba1c ≥ 7(male) 56 58.3 8.72 ± 1.66 hba1c ≥ 7(female) 40 41.7 9.50 ± 1.53 among patients with uncontrolled dm, uncontrolled fbs was in 84 (70%) and uncontrolled ppbs in 69 (57.5%) patients. their mean fasting and postprandial blood sugars were 170.87±39.42 and 229.98±54.36 mg% respectively. lipid profile levels in dm patients are described in table 3. table 3. lipid profile level in dm patients. cholesterol tg ldl hdl optimal 28 (23.3%) desirable 22 (18.3%) 13 (10.8%) 39 (32.5%) 1 (0.8%) borderline 8 (6.7%) 53 (44%) 17 (14.2%) 69 (57.5%) high 90 (75%) 54(45%) 36 (30%) 50 (41.7%) total 120 120 120 120 among poor glycemic control patients, mean serum value of tg, ldl were statistically significantly higher and mean hdl was statistically significantly lower (table 4). table 4. mean of lipid profiles among good and poor control dm patients. hba1c p value <7% ≥7% total cholesterol 281.21 ± 84.53 264.51 ± 70.74 0.322 tg 177.33 ± 12.25 215.26 ± 76.78 <0.01 ldl 103.04 ± 23.55 152.74 ± 56.02 <0.01 hdl 51.71 ± 3.91 44.36 ± 6.94 <0.01 among various lipid profile, ldl cholesterol had moderate positive correlation and hdl cholesterol had moderate negative correlation with hba1c values (table 5). j. lumbini. med. coll. vol 8, no 2, july-dec 2020 pandey t, et al. study of association between glycated hemoglobin and lipid profile in type 2 diabetes mellitus in tertiary care center 241 jlmc.edu.np among various lipid profile in males, ldl cholesterol had moderate positive correlation whereas hdl cholesterol had moderated negative correlation. among females, ldl had high positive correlation and hdl had high negative correlation (table 6). discussion: the percentage of diabetic patients has increased from 19.04% in 2002 to 25.9% in 2009 in nepal and is continuously growing ever since. a survey conducted in urban nepal between 2001 and 2002 showed that the ratio of male: female diabetics were 1.56:1.[8] our study with type 2 dm revealed male to female ratio of 1.22:1 the mean age of type 2 dm patients were 57.77±16.13 and 61.89±15.46 years for male and female respectively. a study done by hussain et al.[4] showed mean age of 51.71±11.70 years for male and 50.97±10.23 years for female. another study by baranwal et al.[5] had nearly equal number of participants as ours and depicted mean age of male and female patients to be 52.7±11.9 and 51.84±12.1 years respectively thus revealing that more elderly people with type 2 dm visited our hospital. presence of various risk factors, change in life style, poor dietary intake, low physical exercise may be an explanation for these observed differences.[9,10,11] with this realization an appropriate intervention to avoid or minimize these unhealthy behaviors is essential and warranted. most of our patients had poor glycemic control (n=96, 80%). majority of them were male patients and mean hba1c among poor glycemic control patients was 9.05±1.65 (table 2). this result was supported by various other studies but many of these studies showed disagreement with gender preponderance.[4,5,6] more than 80% patients had high tc, tg with low hdl. similarly, 44.2% had high ldl levels. these findings were also supported by some studies.[2,5] meanwhile, we also found that there was an increase mean tg, ldl and decrease in hdl levels in poor glycemic control than good glycemic control patients. the study by alzahrani et al. revealed partial agreement with our study where there was raised tg level in high hba1c group.[12] we also studied the relationship of hba1c with different lipid parameters. hba1c showed significant positive relationship with tg (r=0.418, p<0.01) and ldl (r=0.64, p<0.01) and significant negative correlation with hdl (r=-0.683, p<0.01). we observed a positive significant correlation between hba1c with tc, ldl, and tg and a significant negative correlation of hba1c with hdl. these findings are valid with regards to the metabolic effect of hyperglycemia and deficiency of insulin on various lipid parameters. various studies done by many authors have mixed results of hba1c with various lipids profile components.[2,4,5,6] these mixed findings were due to the differences in life style, genetic factors, behavioral and environmental factors.[14,15,16] thus, measures to change unhealthy life style, promoting good and healthy diet, reducing body weight and performing regular physical exercise to improve or control diabetic dyslipidemia is mandatory.[17,18,19] the present study is not without limitations. the study was done on a small sample size. impact table 5. correlations of hba1c to lipid profile level. total cholesterol tg ldl hdl hba1c correlation (r) 0.189 0.418 0.673 -0.683 p-value 0.038 <0.01 <0.01 <0.01 table 6. lipid profiles correlation between male and female. variables male p-value female p-value correlation correlation tg 0.36 0.003 0.49 <0.001 ldl 0.64 <0.001 0.70 <0.001 hdl -0.58 <0.001 -0.83 <0.001 tc 0.24 0.051 0.13 0.34 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 pandey t, et al. study of association between glycated hemoglobin and lipid profile in type 2 diabetes mellitus in tertiary care center 242 jlmc.edu.np of patients’ dietary habits, lifestyle, regular physical activity/exercise, time and duration since diagnosis of dm were not determined in this study. conclusion: there was a significant moderate correlation between hba1c and various components of lipid profile in type 2 dm patients. lipid profile values were significantly higher in poor glycemic control and uncontrolled dm patients. thus, hba1c can be considered as a surrogate marker of dyslipidemia control in type 2 dm patients. acknowledgement: dr. resham gautam mr. nirmal gautam conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available for the study. references: 1. rahimi hr, mohammadpour ah, dastani m, jaafari mr, abnous k, mobarhan mg, et al. the effect of nano-curcumin on hba1c, fasting blood glucose, and lipid profile in diabetic subjects: a randomized clinical trial. avicenna journal of phytomedicine. 2016;6(5):567. doi: http://dx.doi.org/10.22038/ajp.2016.6761 pmid: 27761427. 2. bhowmik b, siddiquee t, mujumder a, afsana f, ahmed t, mdala ia, et al. serum lipid profile and its association with diabetes and prediabetes in a rural bangladeshi population. int j environ res public health. 2018;15(9):1944. doi: https://doi.org/10.3390/ijerph15091944 3. american diabetes association. standards of medical care in diabetes--2014. diabetes care. 2014;37 suppl 1:s14-80. doi: https://doi. org/10.2337/dc14-s014. pmid: 24357209. 4. hussain a, ali i, ijaz m, rahim a. correlation between hemoglobin a1c and serum lipid profile in afghani patients with type 2diabetes: hemoglobin a1c prognosticates dyslipidemia. therapeutic advances in endocrinology and metabolism. 2017;8(4):51-7. doi: https:// doi.org/10.1177/2042018817692296 pmid: 28507727. 5. baranwal jk, maskey r, majhi s, lamsal m, baral n. association between level of hba1c and lipid profile in t2dm patients attending diabetic opd at bpkihs. health renaissance. 2015;13(3):16-23. doi: https://doi.org/10.3126/ hren.v13i3.17923 6. sapkota lb, thapa s. correlation between glycemic parameters and lipid profile in type 2 diabetic patients attending tertiary care centre in central region of nepal. j chitwan med coll. 2017;7(1):20-4. doi: 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cardiovascular diseases in type 2 diabetic patients. south east asia journal of public health. 2015; 5(2):30-4. doi: https://doi.org/10.3329/seajph. v5i2.28310 14. kautzky-willer a, harreiter j, pacini g. sex and gender differences in risk, pathophysiology and complications of type 2 diabetes mellitus. endocrine reviews. 2016; 37(3):278-316.doi: https://doi.org/10.1210/er.2015-1137 15. ogurtsova k, da rocha fernandes jd, huang y, linnenkamp u, guariguata l, cho nh, et al. idf diabetes atlas: global estimates for the prevalence of diabetes for 2015 and 2040. diabetes res clin pract. 2017;128:40-50. doi: https://doi.org/10.1016/j.diabres.2017.03.024 pmid: 28437734. 16. gale ea, gillespie km. diabetes and gender. diabetologia. 2001;44(1):3-15. doi: https://doi. org/10.1007/s001250051573 pmid: 11206408. 17. wu nq, li jj. clinical considerations of lipid target and goal in dyslipidemia control. chronic diseases and translational medicine. 2016;2(1):3. doi: https://doi.org/10.1016/j. cdtm.2016.05.002 18. hou q, yu c, li s, li y, zhang r, zheng t, et al. characteristics of lipid profiles and lipid control in patients with diabetes in a tertiary hospital in southwest china: an observational study based on electronic medical records. lipids in health and disease. 2019;18(1):13. doi: https://doi. org/10.1186/s12944-018-0945-8 19. guy j, ogden l, wadwa rp, hamman rf, mayer-davis ej, liese ad, d'agostino r jr, marcovina s, dabelea d. lipid and lipoprotein profiles in youth with and without type 1 diabetes: the search for diabetes in youth case-control study. diabetes care. 2009;32(3):416-20. doi: https://doi.org/10.2337/dc08-1775. pmid: 19092167; pmcid: pmc2646019. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 13 may, 2020 accepted: 31 may, 2020 published: 02 june, 2020 a assistant professor, department of forensic medicine, b lecturer, department of community medicine, c maharajgunj medical campus (tu-iom), kathmandu, nepal. dlumbini medical college teaching hospital, palpa, nepal. corresponding author: alok atreya e-mail: alokraj67@hotmail.com orcid: https://orcid.org/0000-0001-6657-7871_______________________________________________________ —–————————————————————————————————————————— abstract: the poor state of health care in nepal will be burdened further following the sars-cov-2 pandemic. the government failed in timely stockpiling of medical supplies and equipment, development of health infrastructure, including laboratories and quarantine centres, restriction and screening of international travel and information dissemination to the general public. while efforts have now been made to increase the capacity for diagnostic test for sars-cov-2, the government still needs to further increase the availability and accessibility throughout the country. this would be the first step in fighting the pandemic. however, it is also important to prepare for the worst case. similarly, advocacy programs should be developed to inform the general public and alleviate their fears about the disease. these measures would not only help nepal’s capability to respond to the covid-19 outbreak but could lay the foundations to improve the health of the citizens in general, even after this epidemic is controlled and could go a long way in developing trust of the government in the populace. keywords: covid-19, health policy, nepal, pandemic. brief reporthttps://doi.org/10.22502/jlmc.v8i1.341 rijen shrestha,a,c samata nepal,b,d alok atreya a,d need for prioritizing health: an old war-cry reiterated by covid-19 how to cite this article:how to cite this article: shrestha r, nepal s, atreya a. need for prioritizing health: an old shrestha r, nepal s, atreya a. need for prioritizing health: an old war-cry reiterated by covid-19. journal of lumbini medical war-cry reiterated by covid-19. journal of lumbini medical college. 2020;8(1):6 pages. doi: college. 2020;8(1):6 pages. doi: https://doi.org/10.22502/jlmc. v8i1.34141 epub: 2020 june 02. epub: 2020 june 02. introduction: the pandemic caused by the severe acute respiratory syndrome corona virus -2 (sarscov-2) has resulted in more than 250,000 deaths, with over 3.5 million cases confirmed globally. as of may 07, 2020, the total number of diagnosed cases in the country have risen to 99, with no reported deaths.[1] this has brought to the fore, the need to prioritize health globally, including in the developed countries. this is especially true for low income countries like nepal.[2] the government of nepal spending on health in the fiscal year 2018/19 was npr 65.3 billion, which accounted for 1.9% of gdp and 5% of the national budget. the per capita health expenditure of nepal for 2017/18 was npr 1,819. [3] this shows the poor state of health care in the country, which will be burdened further following the sars-cov-2 pandemic. the first case was confirmed on 24th january, with the second case being traced on 23rd march 2020. meanwhile, the world health organization (who) declared a public health emergency of international concern on the 30th of january following the second meeting of the emergency committee[4] and declared a pandemic on 11th march.[5] this provided ample time for the government to develop policies on managing the spread of the virus, and prepare for the impending crisis. however, the incompetence has been evident from the chaos among frontline health workers. this was further aggravated by the lack of equipment including real time polymerase chain reaction (rt j. lumbini. med. coll. vol 8, no 1, jan-june 2020 shrestha r, et al. need for prioritizing health: an old war-cry reiterated by covid-19. jlmc.edu.np pcr) machine for diagnosis and personal protective equipment (ppe). as of april 20, a 24-hour hotline had been established, 127 hospitals designated as covid-19 clinics, 12 hospitals for management of mild cases, 12 hospitals for management of moderate or severe cases, and 3 hospitals for specialized surgical and multi-speciality care across the country.[6] a total of 13 laboratories have been made functional for performing rt pcr tests, with 10 of these outside kathmandu. the government has disseminated guidelines, standard operating procedures (sops) and tools for covid management. in addition, the government has been providing daily virtual situation reports.[6] the major criticisms of the government relate to inadequate preparations undertaken following the outbreak of covid-19 in wuhan, china. this includes adequate and timely stockpiling of medical supplies and equipment, development of health infrastructure, including laboratories and quarantine centres, restriction and screening of international travel and information dissemination to the general public. supply of medical equipment: the supply of face masks saw a massive downturn following the shortage in china, the largest manufacturer in the world, which was compounded by the ban on export of indian manufactured masks on january 31.[7] this was despite the declaration from the chairman of federation of nepali cottage and small industries stating that two dozen industries would be able to cope with the country-wide demand for face masks within two days, if directed by the government.[8] in march, the authorities arrested 11 individuals and confiscated 1.2 million face masks from warehouses across kathmandu, including from rd suppliers’ warehouse in satungal, bishnudevi warehouse in kapan.[9] these masks were then sold to the general public through public health bodies. similarly, the lack of reagent extended to the capacity for testing. the first individual, a 32-year old student from wuhan was confirmed by who laboratory in hong kong.[10] there have been gross irregularities in the procurement of medical supplies, with reports confirming the grant of the procurement contract without following the government’s own procurement directives. reports further stated that the price of procurement of the medical supplies being multiple folds higher than the market price. [11] despite refuting the allegations, the contract awarded on march 26 was subsequently scrapped on april 02, following delivery of sub-standard equipment.[12] concerns have also been raised about the rapid diagnostic tests (rdt) being used, regarding their efficacy, reliability and usefulness in diagnosing new cases. a 65-year old woman who had tested negative following rdt was sent home but was found to be positive for coronavirus using pcr testing, after three days.[13] the who has always recommended against using rdt for diagnosing new cases.[14,15] rdt detects antibodies developed in the body and therefore, new cases of infection cannot be confirmed or excluded based on this test alone. the standard for diagnosing new infections requires the detection of the virus rna through real-time polymerase chain reaction (rt-pcr). [14] in addition, there have also been concerns regarding the reliability of the test kits procured for the government. on april 01, the government declared that the rdt kits procured did not meet who as well as government standards and should not be used.[15] development of health infrastructure: on february 4, the government stated that three hospitals, sukraraj tropical and infectious disease hospital, patan hospital and armed police force hospital were equipped with testing facilities and 43 beds to deal with coronavirus patients. it also informed that health desks were setup in chitwan, pokhara and bhairahawa. however, on february 26, nepal’s capacity for testing was limited to a single pcr machine available in the only biosafety laboratory ii (bsl-ii) at national public health laboratory, teku. the laboratory had reagents for testing 1500 samples. in addition, sukraraj tropical and infectious disease hospital at teku, the designated coronavirus hospital was short staffed and lacked infrastructure, with only three intensive care units, five isolation beds and 40 extra beds dedicated to fight the epidemic.[16] on march 21, the government made it mandatory for hospitals in the capital with more than 100 beds to setup fever clinics and free treatment to j. lumbini. med. coll. vol 8, no 1, jan-june 2020 shrestha r, et al. need for prioritizing health: an old war-cry reiterated by covid-19. jlmc.edu.np patients suspected of covid-19. the government provided 50 ppe kits to these hospitals from march 20. on march 23, it was reported that bir hospital, bp koirala institute of health sciences and dhulikhel hospital were capable of starting covid-19 testing, if reagents were provided.[17] testing was started at bpkihs on march 28,[18] at dhulikhel hospital from april 5,[19] and bir hospital from april 12[20]. equipment for pcr testing were received in all seven provinces on march 31. quarantine facilities were provided at nepal electricity authority training centre at kharipati, bhaktapur, for 175 nepalese students who were evacuated from wuhan on february 16.[21] while the facilities at the kharipati quarantine centre were found to be adequate, the state and condition of other quarantine facilities across the country have not. several medical experts have also expressed concern of these very quarantine centres developing into outbreak hotspots.[22] restriction and screening of travellers: on march 12, the government suspended all climbing permits and on-arrival visas.[23] on march 23, the government finally decided to close borders with china and india.[24] the government declared a partial lockdown on march 17th, temporarily halting all air travel, long distance transportation and all non-essential services.[25] this was enacted into a complete nationwide lockdown effective from march 24.[26] an estimated 2 million individuals left the capital fearing covid-19. on march 22 alone, over 2 lakhs population left kathmandu along all major highways.[27] this resulted in the first case outside kathmandu which was confirmed on march 27, in dhangadhi.[28] another major issue of criticism towards the government has been the screening of individuals travelling to nepal. the who recommended the practice of usual precautions to limit infection, including availability of trained staff, stockpiling of equipment, safe transportation to hospitals and developing policies on january 10.[29] in addition, on january 24, the who provided directives for screening of international passengers, including setting up of mandatory temperature screening, advocacy and information dissemination measures to detect infected individuals at points of entry.[30] however, tribhuvan international airport (tia) implemented an 'airport emergency plan' with selfdeclaration of travel history to wuhan and fever by the passengers. two thermal scanners purchased during the ebola outbreak were re-installed at tia on january 25. however, as of march 1st, only one scanner was functional, with reports of the second scanner having broken down within a week of the reinstallation.[31] tia was augmented with thermal guns for temperature screening on february 29.[32] other inadequacies reported in screening of travellers include the lack of manpower, lack of thermal scanners at land border points, inefficiency of the thermal scanner at tia due to lack of temperaturecontrolled room, and absence of appropriate transportation facilities, including ambulances and trained emergency medical technicians.[33] information dissemination: yet another criticism is the lack of effective information dissemination by the government and the distrust towards it. this was evident in the protests by residents of changunarayan municipality, ward 6 and ward 7 of bhaktapur, who were anxious and concerned with the lodging of the evacuated students. [34] the information dissemination was also faulty in informing medical professional as well as the general public on the usefulness of rdts. this has led to increased risks in the community by releasing individuals who tested negative using rdts but were found to be positive following rt-pcr. another aspect of information dissemination that is lacking is the differentiation of quarantine and isolation. all individuals tested required to be quarantined and their movements restricted, to prevent community spread. on the other hand, all confirmed cases needed to be isolated to prevent the spread of the disease to contacts. the government have however used the two interchangeably and this has led to confusion even among medical professionals on the preventive measures to be taken. diagnosis without treatment: while efforts have now been made to increase the capacity for diagnostic test for sars-cov-2, the government still needs to further increase the availability and accessibility throughout the country. this would be the first step in fighting the pandemic. however, it is also important to prepare for the worst case. a study published in 2015 states the intensive care unit (icu) capacity of nepal to be 16.7 beds per million population.[35] meanwhile, the number j. lumbini. med. coll. vol 8, no 1, jan-june 2020 shrestha r, et al. need for prioritizing health: an old war-cry reiterated by covid-19. jlmc.edu.np of ventilators in the country is estimated to range between the government stated 600 to estimates from experts of 360, with over 60% in the capital. estimates have found that 5% of cases require ventilator support, with an additional 15% requiring hospitalisation. the covid-19 nepal: preparedness and response plan estimates the expected cases based on extrapolations from figures of china (0.005%) to be 1,500.[36] however, based on the current global figures (0.05%), the caseload could be as high as 15,000. it is therefore important to strengthen the health infrastructure to cope with this additional burden. based on the conservative estimate, nepal would require 75 ventilators and 225 icu beds for treating the infected cases. while the numbers are not non-achievable, it is evident from the nature of the disease that covid-19 patients cannot be lodged in the same units as non-covid-19 patients. it should also be noted that during normal times, none of the available icu beds or ventilators were free and therefore, these estimates require the development of newer capacity to cope with the burden of covid-19. management of the dead: while numerous guidelines have been developed for diagnosis, tracing, and management of infected cases, it is also essential to note that guidelines have been developed for the management of dead bodies resulting from covid-19. numerous reports have established the overwhelming of mortuaries and funeral homes in developed countries.[37] with a fatality rate estimated at 3% of infections,[38] it should be noted that the expected toll on mortuary services and dead body management in nepal may not be overwhelmed by sheer numbers but by the fear surrounding the disease. conclusion: the pandemic resulting from sars-cov-2 infection has resulted in collapse of the medical system even in the most developed countries globally and has reiterated the need to prioritise investments in health policy and infrastructure development. while nepal has been relatively unaffected, the government needs to ensure that adequate and timely prevention measures are developed and the disease does not completely overwhelm the health system. it is also important to develop health infrastructure to deal with the pending catastrophe. local companies manufacturing medical supplies should be promoted and their capacity improved to counter the shortage of medical supplies internationally. similarly, advocacy programs should be developed to inform the general public and alleviate their fears about the disease. these measures would not only help nepal’s capability to respond to the covid-19 outbreak but could lay the foundations to improve the health of the citizens in general, even after this pandemic is controlled and could go a long way in developing trust of the government in the populace. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 shrestha r, et al. need for prioritizing health: an old war-cry reiterated by covid-19. jlmc.edu.np references: 1. world health organization. coronavirus disease (covid-2019) situation report -108. who: geneva; 7 may 2020. https://www. who.int/docs/default-source/coronaviruse/ situation-reports/20200507covid-19-sitrep-108. pdf?sfvrsn=44cc8ed8_2 2. the world bank. gdp per capita (current us$) nepal. https://tinyurl.com/yd5vbb4l 3. fmohp and nhssp (2018). budget analysis of ministry of health and population fy 2018/19. federal ministry of health and population and nepal health sector support programme. https://www.nhssp.org.np/resources/ppfm/ budget_analysis_of_nepal_federal_mohp_ fy2018_19_sep2018.pdf 4. statement on the second meeting of the international health regulations (2005) emergency committee regarding the outbreak of novel coronavirus (2019-ncov). world health organization: geneva; 30 jan 2020. https://www.who.int/news-room/detail/30-012020-statement-on-the-second-meeting-ofthe-international-health-regulations-(2005)emergency-committee-regarding-the-outbreakof-novel-coronavirus-(2019-ncov) 5. who director-general’s opening remarks at the media briefing on covid-19. world health organization: geneva; 11 mar 2020. https:// www.who.int/dg/speeches/detail/who-directorg e n e r a l s o p e n i n g r e m a r k s a t t h e m e d i a briefing-on-covid-19---11-march-2020 6. situation updatecoronavirus disease 2019 (covid-19). world health organization: nepal (country office); 20 apr 2020. https:// w w w. w h o . i n t / d o c s / d e f a u l t s o u r c e / n e p a l documents/novel-coronavirus/who-nepalsitrep/who-nepal--sitrep-covid-19-20apr2020. pdf?sfvrsn=c788bf96_2 7. poudel a. nepalis rush to buy face masks amidst coronavirus outbreak but there are none available. the kathmandu post: 3 feb 2020. https://tkpo.st/2oo2c4x 8. poudel kr. nepali markets face shortage of mask after coronavirus outbreak in china. rising nepal: 6 feb 2020. https://tinyurl.com/ y8a6emaq 9. govt to sell 1.2 million confiscated masks. the himalayan times; 17 mar 2020. https:// thehimalayantimes.com/nepal/govt-to-sell-1-2million-confiscated-masks/ 10. bastola a, sah r, rodriguez-morales aj et al. the first 2019 novel coronavirus case in nepal. lancet infect dis. 2020;20(3):279–280. doi: https://doi.org/10.1016/s1473-3099(20)30067-0 pmcid: pmc7130048 11. sapkota s. financial irregularities suspected in procurement of medical equipment from china. republica nepal; 29 mar 2020. http://tiny.cc/ uueqoz 12. nepal scraps medical supply deal of chinese company. deccan herald; 2 apr 2020. http:// tiny.cc/i0eqoz 13. sapkota r. why rapid tests are doing more harm than good. nepali times; 17 apr 2020. http://tiny. cc/f5eqoz 14. efficacy of rapid corona tests questioned as 16 test positive after negative rdt. himalayan times; 25 april 2020. https://wp.me/p6ic0n2lzp 15. sapkota r. nepal to test covid-19 test kits from china. nepali times; 1 apr 2020. https://www. nepalitimes.com/latest/nepal-to-test-covid-19test-kits-from-china/ 16. dhakal s. nepal ill-prepared for coronavirus outbreak. himalayan times; 26 feb 2020. https://wp.me/p6ic0n-2ibv 17. editorial-inadequate testing. himalayan times; 23 mar 2020. https://thehimalayantimes.com/ opinion/editorial-inadequate-testing/ 18. covid-19 sample test also begins from dharan today. rising nepal; 28 mar 2020. https:// shorturl.at/dgdu8 19. covid-19 test to begin in dhulikhel today. rising nepal; 5 apr 2020. https://shorturl.at/ gmnw2 20. covid-19 testing starts at bir hospital. republica nepal: 12 apr 2020. http://tiny.cc/ l6eqoz 21. what after they land in nepal? republica nepal: 16 feb 2020. https://myrepublica. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 shrestha r, et al. need for prioritizing health: an old war-cry reiterated by covid-19. jlmc.edu.np nagariknetwork.com/news/what-after-they-landin-nepal/ 22. poudel a. poor quarantine facilities could themselves become outbreak hotspots, doctors warn. the kathmandu post: 6 apr 2020. https:// tkpo.st/34byh7k 23. prasain s, shrestha pm. suspension of climbing permits and on-arrival visas entails losses of thousands of jobs and millions of dollars. the kathmandu post: 14 mar 2020. http://bit. ly/38vedpc 24. pradhan tr. government to close down border with india and china for a week. the kathmandu post: 22 mar 2020. https://tkpo.st/33cv1lz 25. pradhan tr. oli announces suspension of all flights, all long-haul transport and all nonessential services. the kathmandu post: 20 mar 2020. https://tkpo.st/2u8o7qp 26. pradhan tr. nepal goes under lockdown for a week starting 6am tuesday. the kathmandu post: 23 mar 2020. https://tkpo.st/2wcfohw 27. sedhai r. mass exodus amid corona fears. the record: 23 mar 2020. https://www.recordnepal. com/wire/features/mass-exodus-amid-coronafears/ 28. poudel a. fourth nepali tests positive for covid-19. the kathmandu post: 27 mar 2020. https://tkpo.st/2ue7im9 29. world health organization. who advice for international travel and trade in relation to the outbreak of pneumonia caused by a new coronavirus in china. who: 10 jan 2020. https:// www.who.int/news-room/articles-detail/whoadvice-for-international-travel-and-trade-inrelation-to-the-outbreak-of-pneumonia-causedby-a-new-coronavirus-in-china 30. world health organization. updated who advice for international traffic in relation to the outbreak of the novel coronavirus 2019-ncov. who: 24 jan 2020. https://www.who.int/newsroom/articles-detail/updated-who-advice-forinternational-traffic-in-relation-to-the-outbreakof-the-novel-coronavirus-2019-ncov-24-jan/ 31. lamsal r. inadequate preparations put nepal at high risk from coronavirus. khabarhub: 1 mar 2020. https://english.khabarhub. com/2020/01/78762 32. tia enhances health screening for covid-19. the himalayan times: 2 mar 2020. https:// wp.me/p6ic0n-2isy 33. dhakal s. nepal lacks preparation as who declares global emergency. the himalayan times: 1 feb 2020. https://wp.me/p6ic0n-2hfu 34. poudel a. concerns over quarantine centre in bhaktapur stem from lack of trust in government. the kathmandu post: 14 feb 2020. https://tkpo. st/31spyef 35. murthy s, leligdowicz a, adhikari nk. intensive care unit capacity in low-income countries: a systematic review. plos one. 2015;10(1):e0116949. pmid: 25617837 pmcid: pmc4305307 doi: https://doi. org/10.1371/journal.pone.0116949 36. covid-19 nepal: preparedness and response plan (nprp). united nations nepal: april 2020. https://www.who.int/docs/default-source/ nepal-documents/novel-coronavirus/covid-19nepal-preparedness-and-response-plan-(nprp)draft-april-9.pdf 37. kestler-d’amours j. coronavirus: overwhelmed us funeral homes turn families away. aljazeera: 7 apr 2020. https://aje.io/yr2sh 38. wang c, horby pw, hayden fg, gao gf. a novel coronavirus outbreak of global health concern. lancet. 2020;395(10223):470-473. pmcid: pmc7135038 doi: https://doi. org/10.1016/s0140-6736(20)30185-9 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 1 may, 2020 accepted: 31 may, 2020 published: 02 june, 2020 a lecturer, bassistant professor, cprofessor, ddepartment of surgery, lumbini medical college teaching hospital, palpa, nepal. corresponding author: suman baral e-mail: brylsuman.sur@gmail.com orcid: https://orcid.org/0000-0003-0906-138x_______________________________________________________ –————————————————————————————————————————— abstract: introduction: preoperative prediction of the factors leading to difficulty or conversion in cholecystectomy could help plan the surgical strategies and possible outcomes beforehand. the present study aimed to predict and analyze risk factors using a scoring system deemed responsible for surgical difficulties in patients undergoing cholecystectomy for symptomatic cholelithiasis. methods: this hospital based prospective study was conducted at department of surgery, lumbini medical college and teaching hospital, nepal. various factors considered preoperatively were gender, age, previous history of hospitalization, impacted stone, obesity, gall bladder wall thickness, pericholecystic collection, previous abdominal scar and palpable gall bladder. results: among 177 cases operated, the mean age ±sd of the patients was 47.72±17.54 years. conversion rate was 7.9 %. at preoperative score of 5; sensitivity, specificity, positive predictive value and negative predictive value were 89.40% (ci: 83.36%-93.82%), 69.23% (ci: 48.21 %-85.67%), 94.41%(ci: 90.44%-96.79%) and 52.94% (ci: 39.85%-65.64%) respectively{area under curve– 0.74, p=0.0001, ci (0.637-0.846)}. multivariate analysis showed abdominal scar {p=0.02, or (ci): 5.2 (1.2-21.8)}, previous hospitalization {p=0.001, or(ci): 6.8(2.2-20.8)} and thickened gall bladder wall {p= 0.03, or(ci): 3.6(1.111.5)} to be statistically significant risk factors. conclusion: with possible prediction beforehand, high risk group of patients can be identified and dealt accordingly to generate good surgical outcome avoiding complications. key words: conversion, laparoscopic cholecystectomy, preoperative prediction original research articlehttps://doi.org/10.22502/jlmc.v8i1.297 suman baral,a,d neeraj thapa,b,d raj kumar chhetri c,d validation of a preoperative scoring system to predict difficult laparoscopic cholecystectomy: a nepalese perspective how to cite this article:how to cite this article: baral s, thapa n, chhetri rk. validation of a preoperative scoring system to predict difficult laparoscopic cholecystectomy: a nepalese perspective. journal of lumbini medical college. 2020;8(1):7 pages journal of lumbini medical college. 2020;8(1):7 pages doi: doi: https://doi.org/10.22502/jlmc.v8i1.323. epub: 2020 june 02.. epub: 2020 june 02. introduction: laparoscopic cholecystectomy(lc) is one of the most common surgical procedures performed worldwide and is the procedure of choice for the management of symptomatic gall stones.[1] though this has been considered one of the safest surgeries to begin with laparoscopy, it requires meticulous dissection and good exposure of calot’s triangle in order to prevent bile duct injuries.[2] dense adhesions at calot’s triangle and patients presenting with chronic cholecystitis with fibrotic and contracted gall bladder sometimes make surgery difficult and chances of conversion remains.[3] various preoperative risk factors include male sex, old age, features of acute cholecystitis with fever and leukocytosis, obesity, previous surgery leading to abdominal scar, ultrasonographic findings like thickened gall bladder wall more than 4 mm, distended gall bladder, pericholecystic collection, impacted stone etc. which make laparoscopic surgery difficult.[4] preoperative prediction of difficulty in laparoscopic surgery and grading scales have widely been studied.[3,5,6] they have an advantage for the j. lumbini. med. coll. vol 8, no 1, jan-june 2020 baral s, et al. validation of a preoperative scoring system to predict difficult laparoscopic cholecystectomy: a nepalese perspective jlmc.edu.np operating surgeon regarding quantifying the highrisk cases, managing operation room schedules, and counselling the relatives before the surgery about the potential complications. also, the surgeons can prepare themselves for the adverse outcomes like arranging logistics and facilities, seeking help from seniors and colleagues. the present study aimed to utilize a preoperative scoring system and validate its applicability in a tertiary hospital of a developing country. methods: this was a prospective cross-sectional study conducted in the department of surgery, lumbini medical college teaching hospital after the approval from institutional review committee (irc-lmc 02-e/019). the study commenced from 15th july 2019 to 14th march 2020 for a period of eight months. proper history and physical examination were carried out along with abdominal ultrasonography (usg). laboratory parameters like complete blood count (cbc), liver function test (lft) and preoperative laboratory assessment were carried out regarding fitness for surgery. all the patients with symptomatic gall stone disease including acute calculus cholecystitis were included in the study. those patients who were unfit for general anesthesia, acute calculus cholecystitis managed conservatively, and those with chronic liver disease, choledocholithiasis and features of obstructive jaundice were excluded. a preoperative difficulty scoring system developed by randhawa et al. was used in the present study. [7] the patients were assigned their difficulty level according to history, clinical parameters and usg findings ( table 1). history included variables like age, sex and past history of hospital admission for acute cholecystitis. clinical parameters included body mass index (bmi) which was designated 18.5-24.9 kg/m2 being normal weight as per who classification[8] and more than 25 kg/m2 was taken as risk factors which was splitted to 25-27.5 kg/m2 and more than 27.5 kg/m2 to corroborate with the scoring system, abdominal scar following previous abdominal surgery, and presence of clinically palpable gall bladder. a performa was filled up by the operating surgeons before attending surgery. the patients were admitted a day before the procedure, evaluated for the surgical fitness and posted for surgery the next day as electives which applies for acute calculus cholecystitis cases too. all the surgeries were performed by experienced surgeons. table 1. scoring factors used for grading the patient parameters patient characteristics (n= 177) score age (years) <50 0 ≥50 1 sex male 1 female 0 history of hospitalization for acute cholecystitis yes 4 no 0 bmi <25 0 25-27.5 1 >27.5 2 abdominal scar infraumbilical 1 supraumbilical 2 no 0 palpable gall bladder yes 1 no 0 thick gall bladder wall ≥4 mm 2 <4mm 1 pericholecystic collection yes 1 no 0 impacted stone yes 1 no 0 score: 0-5: easy 6-10: difficult 11-15: very difficult surgery was conducted creating co2 pneumoperitoneum through open hasson method. the 4-port technique was used with umbilical as camera port, epigastric as working port, and two 5mm ports on mid clavicular and anterior axillary line. attaining a critical view of safety was the major goal, starting the dissection posteriorly and artery first clipping followed by cystic duct was the method we follow. however, intraoperative cholangiogram (ioc) was not done because of lack of feasibility and assets. open conversion was done if critical view of safety was not attainable along with reconstituting subtotal cholecystectomy in cases of frozen calot’s triangle where complete removal of gall bladder was deemed impossible. total duration of surgery was the time after the commencement of skin incision and layer by layer closure after the procedure. all intraoperative events like bile spillage, bile duct injury or open conversion were recorded. the preoperative scores were compared with the j. lumbini. med. coll. vol 8, no 1, jan-june 2020 baral s, et al. validation of a preoperative scoring system to predict difficult laparoscopic cholecystectomy: a nepalese perspective jlmc.edu.np intraoperative assessment (table 2). table 2. showing the parameters and scoring/ grading on the basis of intraoperative assessment. parameters score grading time taken <60 minutes and no bile spillage and no injury to duct 0-5 easy time taken 60-120 minutes and/or bile or stone spillage and/or injury to duct 6-10 difficult time taken > 120 minutes or conversion 11-15 very difficult statistical analysis was performed with statistical package for social sciences (spsstm) software version 20. chi-square test/ fisher exact test was used to find significance of association between preoperative and intraoperative findings for categorical variables whilst student-t test was used for continuous variables. univariate and multivariate analysis were done to predict the risk factors for difficulty in surgery using binary logistic regression on the basis of intraoperative outcome as easy or difficult. area under the receiver operating characteristic (roc) curve was used to find the diagnostic and predictive value of preoperative score for predicting the intraoperative outcome. similarly, sensitivity and specificity of the proposed preoperative scoring system at our setting were also determined. p value <0.05 was considered statistically significant. results: there were 190 patients with symptomatic cholelithiasis during the study period. however, 13 of them did not fulfill the inclusion criteria. one hundred and seventy-seven patients under went laparoscopic cholecystectomy which included 36 males and 141 females. the mean age±sd of the patient was 47.72 ± 17.54 years. twenty-four patients had past history of hospitalization for acute calculus cholecystitis while 12 had prior history of surgery with abdominal scar mostly midline. gall bladder was palpable clinically in 27 patients. seventeen patients had thickened gall bladder wall more than 4 mm. pericholecystic collection was seen in 15 patients while impacted stone was observed in 16 cases. fourteen patients needed conversion to open cholecystectomy with conversion rate of 7.9% (table 3). conversion occurred due to difficulty in dissection owing to dense adhesions rather than biliary spillage or uncontrolled intraoperative bleeding. mean operative time was 51.16 ± 15.27 minutes for easy cases and 62.79 ± 16.66 minutes for difficult cases. table 3: distribution of parameters. patient characteristics (n= 177) frequency age (years) <50 96 >50 81 sex male 36 female 141 history of hospitalization for acute cholecystitis yes 24 no 153 bmi <25 108 25-27.5 42 >27.5 27 abdominal scar yes 12 no 165 palpable gall bladder yes 27 no 150 thick gall bladder wall yes 17 no 160 pericholecystic collection yes 15 no 162 impacted stone yes 16 no 161 conversion 14 table 4: preoperative score and the outcome preoperative score easy difficult very difficult total 0-5 135 14 2 151 6-10 8 6 12 26 11-15 total 143 20 14 177 most of the patients had preoperative score of 0-5 and most were easy. none of the patients had score above 10 pre-operatively (table 4). however, 14 patients were labelled very difficult according to intraoperative assessment. considering preoperative score of 5; sensitivity, specificity, j. lumbini. med. coll. vol 8, no 1, jan-june 2020 baral s, et al. validation of a preoperative scoring system to predict difficult laparoscopic cholecystectomy: a nepalese perspective jlmc.edu.np positive predictivevalue (ppv) and negative predictive value (npv) were 89.40% (ci: 83.36%93.82%), 69.23%(ci: 48.21 %-85.67%), 94.41%(ci: 90.44%-96.79%) and 52.94% (ci: 39.85%-65.64%) respectively.area under the receiver operating characteristic (roc) curve was 0.74{p value – 0.0001, ci: (0.637-0.846} (figure 1). univariate analysis of intraoperative outcome with risk factors showed abdominal scar due to previous surgery, previous hospitalization for acute calculus cholecystitis managed conservatively during previous episode, thickened gall bladder wall more than 4 mm and impacted gall bladder stone to be statistically significant ( p value <0.05). multivariate analysis depicted abdominal scar {p=0.02, or(ci) 5.2 ( 1.2-21.8)}, previous hospitalization {p=0.001, or(ci):6.8(2.2-20.8)} and thickened gall bladder wall {p= 0.03, or(ci):3.6(1.1-11.5)} to be statistically significant risk factors (table 5). fig. 1. receiver operating characteristic (roc) curve and area under the curve (auc) for prediction of intra-operative outcome based on preoperative scores. table 5: predictive association of risk factors with intraoperative outcome risk factors level intra-operative outcome univariate (or-ci) multivariate (or-ci) easy difficult age <50 70 14 ≥50 59 20 p=0.177 or=1.7(0.78-3.6) sex female 108 24 male 21 10 p=0.08 or=2.1(0.89-5.1) bmi <25 92 19 25-27.5 25 11 p=0.08 or=2.1(0.89-5.0) >27.5 12 4 p=0.44 or=1.6(0.47-5.5) abdominal scar no 124 29 yes 5 5 p=0.02 or=4.2 (1.1-15.7) p=0.02 or= 5.2 (1.221.8) previous hospitalization for acute calculus cholecystitis no 121 22 yes 8 12 p=0.0001 or=8.2 (3.0-22.5) p=0.001 or= 6.8 (2.220.8) palpable gall bladder no 116 27 yes 13 7 p= 0.104 or=2.3 (0.84-6.3) thick wall ≥ 4mm no 120 26 yes 9 8 p=0.008 or= 4.1 (1.4-11.6) p=0.03 or= 3.6 (1.111.5) pericholecystic collection no 119 32 yes 10 2 p=0.711 or= 10.7(0.15-3.5) impacted stone no 124 26 yes 5 8 p=0.001 or=7.6 (2.3-25.2) j. lumbini. med. coll. vol 8, no 1, jan-june 2020 baral s, et al. validation of a preoperative scoring system to predict difficult laparoscopic cholecystectomy: a nepalese perspective jlmc.edu.np discussion: laparoscopic cholecystectomy (lc) is one of the most commonly performed surgeries worldwide and has been considered gold standard for the treatment of symptomatic gall stones. because of the propensity of lesser post-operative pain, cosmesis, shorter hospital stay and disability from work, this has been the choice of procedure for maximum patients worldwide.[9,10] however, post-operative complication rates have been found higher in minimal invasive procedures like lc in comparison to open surgeries.[11] safe laparoscopic surgery has become one of the most important topics discussed and various studies are ongoing regarding well-being of the patient and surgeon himself. intraoperative findings may not be similar in every case and these greatly vary upon clinical presentation and surgical challenges might arise for the operating surgeon. if the prediction of safety of surgery could be made beforehand, surgeon will have a range of benefits like planning for surgery, patient counselling, operating room preparation and scheduling, and prepare for help from seniors and colleagues if needed.[12] increasing age or elderly population tend to be an important risk factor for difficulty in surgery as they are likely to have more longstanding disease with higher likelihood of complicated biliary tract disease which gets superimposed by various comorbidities.[13] various studies have concluded that older age is one of the significant risk factors.[7, 14] however, our study could not corroborate with their findings which other studies did too (p=0.177). [3,15] this could be due to cut off of age group as more than 50 years as some studies predicted using the cut off of 40 years.[12] the role of gender has also been mentioned in literatures as male population showed trends of high risk of conversion and surgical difficulty.[7,12,16,17] however, in our study, gender was not related to high risk of conversion. there was not any significant association between gender as male patients showing difficult surgeries or conversion rates (p= 0.08) which was also seen in study by gupta et al.[3] this could be due to less sample population of males who were operated in comparison to female groups. previous history of hospitalization for acute cholecystitis managed conservatively is one of the risk factors for difficulty in surgery which has been clarified by our study too (p=0.001, or=6.8). this can be explained as the chances of difficulty that may lead to conversion are about six times higher than those groups of people who have not been previously admitted or treated conservatively for acute cholecystitis. the absence of previous repeated attacks of cholecystitis and hospitalizations has been clarified to determine safe surgery in a study from montenegro.[18] pathogenesis could be repeated scarring and fibrosis of gall bladder due to multiple colic. obesity or high bmi also has been considered the risk factor for conversion in another study.[19] however, this was not statistically significant in our study. abdominal scar due to previous surgery may develop adhesions of viscera to the anterior abdominal wall and chances of conversion remains as risk of injury to bowel or other visceral structures are prudent during insertion of trocars.[20] our study concluded the same ( p= 0.02, or = 5.2). this suggests the chances of difficulty are five times in patients with past history of surgery leading to abdominal scar. thickened gall bladder wall more than 4 mm is one of the sonological criteria for diagnosis of acute cholecystitis and this has been attributed to difficulty in surgery or chances of conversion in various studies. [21,22] palpable gall bladder due to development of mucocele or cholecystitis leading to empyema could render surgery difficult due to inability to grasp the fundus of the gall bladder leading to perforation and spillage of bile or pus along with gall stones in the peritoneal cavity. a study by randhawa et al.[7] has correlated the significant association of palpable gall bladder with intraoperative difficulty which is also supported by gupta et al.[3] pericholecystic collection was seen in 12 patients in our study. however, no significant association was seen with difficulty in laparoscopy (p= 0.71) which was consistent with that observed in studies from delhi and banglore, india.[3,7] impacted stone was significantly associated with difficulty in laparoscopic cholecystectomy which has been concluded in other studies too.[3,5] preoperative difficulty scores seem not coordinating with intraoperative scoring at score level of 6-10 in difficult surgeries. difficult numbers are small however we could see increased very difficult cases that corroborates the preoperative level of difficulty. this could be due to selection bias; a smaller number of sample size and the intraoperative scoring system could be merged as very difficult level to difficult considering only two intraoperative variables modifying the scoring system. also, none of the samples attained very difficult score j. lumbini. med. coll. vol 8, no 1, jan-june 2020 baral s, et al. validation of a preoperative scoring system to predict difficult laparoscopic cholecystectomy: a nepalese perspective jlmc.edu.np preoperatively which could be removed. our study could conclude sensitivity of around 90% and specificity of around 70% which can be correlated with findings from gupta et al. who mentioned sensitivity of 95% and specificity of around 74% in his validation study.[3]similarly, conversion rate in our case was 7.9% which is comparable to a national conversion rate in united states which was 5-10% in a nationwide study conducted on 2004 collecting sample operated from 1998 to 2001.[23]ghnnam et al. showed the conversion of 5% at khamis general hospital, saudi arabia where he analyzed retrospectively 340 patients.[24] however, males constituted about 20%( n=36) of total operated cases and conversion rate was as high as 25 % which could be due to less sample size . females had conversion of 3.5% in our study. conclusion: the scoring system can be used clinically to predict and guide the surgeons regarding safe surgical practice and anticipate the outcomes beforehand. however, larger sample sizes and multi center studies may be required in order to validate statistically and purposeful wide spread applicability in daily schedules. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. acar t, kamer e, acar n, atahan k, bağ h, hacıyanlı m, et al. laparoscopic cholecystectomy in the treatment of acute cholecystitis: comparison of results between early and late cholecystectomy. pan afr med j. 2017;26:49.pmid: 28451027doi: 10.11604/pamj.2017.26.49.8359 2. suliman e, palade rș, suliman e. importance of cystic pedicle dissection in laparoscopic cholecystectomy in order to avoid the common bile duct injuries. j med life. 2016;9(1):44-48. pmid: 27974912 3. gupta n, ranjan g, arora mp, goswami b, chaudhary p, kapur a, et al. validation of a scoring system to predict difficult laparoscopic cholecystectomy. int j surg. 2013;11(9):10021006. pmid: 23751733 doi: 10.1016/j. ijsu.2013.05.037 4. abdel baki na, motawei ma, soliman ke, farouk am.pre-operative prediction of difficult laparoscopic cholecystectomy using clinical and ultrasonographic parameters. jmri. 2006;27(3):102-107. 5. agrawal n, singh s, khichy s. preoperative prediction of difficult laparoscopic cholecystectomy: a scoring method. niger j surg. 2015;21(2):130-133. pmid: 26425067 doi: 10.4103/1117-6806.162567. 6. hayama s, ohtaka k, shoji y, ichimura t, fujita m, senmaru n, et al. risk factors for difficult laparoscopic cholecystectomy in acute cholecystitis. jsls. 2016;20(4):e2016.00065. pmid: 27807397 doi: 10.4293/jsls.2016.00065. 7. randhawa js, pujahari ak. preoperative prediction of difficult lap chole: a scoring method. indian j surg. 2009;71(4):198-201. pmid: 23133154 doi: 10.1007/s12262-009-0055-y 8. lim ju, lee jh, kim js, hwang yi, kim th, lim sy. comparison of world health organization and asia-pacific body mass index classifications in copd patients. int j chron obstruct pulmon dis. 2017;12:2465-2475. pmid: 28860741 doi: 10.2147/copd.s141295. 9. chesney t, acuna sa. do elderly patients have the most to gain from laparoscopic surgery? ann med surg (lond). 2015;4(3):321-323. pmid: 26557989 doi: 10.1016/j.amsu.2015.09.007. 10. yamashita y, takada t, kawarada y, nimura y, j. lumbini. med. coll. vol 8, no 1, jan-june 2020 baral s, et al. validation of a preoperative scoring system to predict difficult laparoscopic cholecystectomy: a nepalese perspective jlmc.edu.np hirota m, miura f, et al. surgical treatment of patients with acute cholecystitis: tokyo guidelines. j hepatobiliary pancreat surg. 2007;14(1):9197.pmid: 17252302 doi: 10.1007/s00534-0061161-x 11. radunovic m, lazovic r, popovic n, magdelinic m, bulajic m, radunovic l, et al. complications of laparoscopic cholecystectomy: our experience from a retrospective analysis. open access maced j med sci. 2016;4(4):641-646. pmid: 28028405 doi: 10.3889/oamjms.2016.128 12. nassar ahm, hodson j, ng hj, vohra rs, katbeh t, zino s, et al. choles study group, west midlands research collaborative. predicting the difficult laparoscopic cholecystectomy: development and validation of a pre-operative risk score using an objective operative difficulty grading system. surg endosc. 2019; [epub ahead of print]. pmid: 31732855 doi: 10.1007/s00464019-07244-5. 13. amin a, haider mi, aamir is, khan ms, choudry ku, amir m,et al. preoperative and operative risk factors for conversion of laparoscopic cholecystectomy to open cholecystectomy in pakistan. cureus. 2019;11(8):e5446.pmid: 31637145 doi: 10.7759/cureus.5446. 14. terho pm, leppäniemi ak, mentula pj. laparoscopic cholecystectomy for acute calculous cholecystitis: a retrospective study assessing risk factors for conversion and complications. world j emerg surg. 2016 ;11:54. pmid: 27891173 doi: 10.1186/s13017-016-0111-4 15. ashfaq a, ahmadieh k, shah aa, chapital ab, harold kl, johnson dj. the difficult gall bladder: outcomes following laparoscopic cholecystectomy and the need for open conversion. am j surg. 2016 ;212(6):1261-1264. pmid: 28340928 doi: 10.1016/j.amjsurg.2016.09.024 16. bourgouin s, mancini j, monchal t, calvary r, bordes j, balandraud p. how to predict difficult laparoscopic cholecystectomy? proposal for a simple preoperative scoring system. am j surg. 2016 ;212(5):873-881. pmid: 27329073 doi: 10.1016/j.amjsurg.2016.04.003 17. kanakala v, borowski dw, pellen mg, dronamraju ss, woodcock sa, seymour k, et al. risk factors in laparoscopic cholecystectomy: a multivariate analysis. int j surg. 2011;9(4):318323. pmid: 21333763 doi: 10.1016/j. ijsu.2011.02.003 18. stanisic v, milicevic m, kocev n, stojanovic m, vlaovic d, babic i, et al. prediction of difficulties in laparoscopic cholecystectomy on the base of routinely available parameters in a smaller regional hospital. eur rev med pharmacol sci. 2014;18(8):1204-1211. pmid: 24817296 19. tiong l, oh j. safety and efficacy of a laparoscopic cholecystectomy in the morbid and super obese patients. hpb (oxford). 2015;17(7):600604. pmid: 25906816 doi: 10.1111/hpb.12415 20. geraci g, d’orazio b, rizzuto s, cajozzo m, modica g. videolaparoscopic cholecystectomy in patients with previous abdominal surgery. personal experience and literature review. clin ter. 2017;168(6):e357-e360.pmid: 29209684 doi: 10.7417/t.2017.2034 21. chand p, singh r, singh b, singla rl, yadav m. preoperative ultrasonography as a predictor of difficult laparoscopic cholecystectomy that requires conversion to open procedure. niger j surg. 2015;21(2):102-105. pmid: 26425061 doi: 10.4103/1117-6806.162573 22. hu asy, menon r, gunnarsson r, de costa a. risk factors for conversion of laparoscopic cholecystectomy to open surgery a systematic literature review of 30 studies. am j surg. 2017;214(5):920-930. pmid: 28739121 doi: 10.1016/j.amjsurg.2017.07.029 23. livingston eh, rege rv.a nationwide study of conversion from laparoscopic to open cholecystectomy. am j surg. 2004;188(3):205-211. 24. ghnnam w, malek j, shebl e, elbeshry t, ibrahim a. rate of conversion and complications of laparoscopic cholecystectomy in a tertiary care center in saudi arabia. ann saudi med. 2010;30(2):145-148. pmid: 20220265 doi: 10.4103/0256-4947.60521 j. lumbini. med. coll. vol 9, no 2, july-dec 2021 chhetri pk, et al. anatomical variations of renal artery in patients undergoing computed tomography of abdomen jlmc.edu.np ___________________________________________________________________________________ submitted: 18 april, 2021 accepted: 14 june, 2021 published: 29 august, 2021 aassociate professor, department of radiology blecturer, department of radiology cresident, department of radiology dcollege of medical sciences teaching hospital, bharatpur, nepal. corresponding author: pramod kumar chhetri e-mail: dr.chhetripramod@gmail.com orcid: https://orcid.org/0000-0001-5779-2633_______________________________________________________ abstract: introduction: renal vasculature is known for presenting a wide range of variations. knowledge of different anatomical variations helps the surgeon prevent possible intraoperative complications. computed tomography (ct) is an excellent imaging modality providing detailed anatomy of the renal artery. this study aimed to evaluate renal arterial variations in individuals undergoing abdominal ct examination. methods: this was a hospital based cross-sectional study on 400 consecutive patients who underwent abdominal ct examination in a medical college in nepal. the number of patients with normal and any arterial variations was noted. accessory renal artery (hilar and polar artery) and any pre-hilar branching were evaluated. results: among 400 patients, 271 (67.75%) individuals had normal renal artery supply and 129 (32.25%) had variations. among 129 individuals (79 males and 50 females) with artery variations, 93 (72.09%) had unilateral and 36 (27.91%) had bilateral variations.the most common unilateral variation was a single polar artery in 66 (70.97%) cases, pre-hilar branching in 18 (19.35%), accessory hilar artery in 7 (7.53%) and dual polar arteries in 2 (2.15%). in those with bilateral arterial variations, the right and left kidneys showed polar artery in 25 (69%) and 30 (83%), pre-hilar branching in 6 (17%) and 2 (6%), and accessory hilar in 5 (14%) and 4 (11%) cases respectively. conclusion: renal artery variation was observed in approximately one-third of individuals. unilateral variation was more common than bilateral and polar artery was the most common arterial variant. keywords: anatomical variations; computed tomography; renal artery original research articlehttps://doi.org/10.22502/jlmc.v9i2.434 pramod kumar chhetri,a,d prabhat basnet,b,d aarati adhikari c,d anatomical variations of renal artery in patients undergoing computed tomography of abdomen: a hospital-based cross-sectional study how to cite this article:how to cite this article: chhetri pk, basnet p, adhikari a. anatomical variations of renal artery in patients undergoing computed tomography of abdomen: a hospital-based cross-sectional study. journal of lumbini medical college. 2021;9(2):7 pages. doi: https://doi.org/10.22502/jlmc. v9i2.434. epub: august 29, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: each kidney is normally supplied by a single renal artery which divides into segmental arteries near the hilum. anatomical variations in the number and origin of the renal arteries were first reported by bartholin (1665-1738).[1] in approximately 25-30% of individuals, more than one renal artery is present.[2] different origin and variations of renal artery are explained by the development of the mesonephric arteries. during embryogenesis, the kidneys ascend from the pelvis to lumbar region. during their ascent, they are supplied by several mesonephric arteries. overtime, the preceding caudal vessels usually regress and disappear, leaving only one mesonephric artery. however, failure of regression leads to anomalous renal arteries.[3] clinically, the identification of renal vascular variants is important especially for transplant surgeons, vascular surgeons and for intervention radiologists.[4,5] when a kidney has two or more arteries with separate aortic ostium, the vessel with the greatest diameter is considered the main renal artery and others, accessory arteries.[6] accessory arteries are categorized as either hilar or polar. hilar artery enters j. lumbini. med. coll. vol 9, no 2, july-dec 2021 chhetri pk, et al. anatomical variations of renal artery in patients undergoing computed tomography of abdomen jlmc.edu.np the kidney through the hilum while polar artery enters the kidney through the capsule outside the hilum. polar arteries perfuse the superior or inferior renal poles.[7] pre-hilar or early branching arise less than 1.5-2 cm from the origin of the main renal ostium in the left kidney or in retrocaval segment at the right kidney.[8] although digital subtraction angiography (dsa), an accepted gold standard in assessing the renal vascular anatomy, is an invasive procedure and hence not used routinely.[9] currently, multidetector-row computed tomographic (mdct) angiography has become a key imaging modality. [6] the sensitivity of ct angiography (cta) for the demonstration and location of the main renal arteries approaches 100%.[10] the disadvantages of cta include reactions to iodinated contrast material, nephrotoxicity and exposure to ionizing radiation. typically detection of vessels smaller than 2 mm is limited in cta.[10,11] this study aimed to determine the prevalence of renal arterial variations in patients advised for mdct for various indications. methods: this was a hospital based cross-sectional study on 400 consecutive patients who underwent abdominal ct for various indications between november 2018 and october 2019 in the department of radiology, college of medical sciences-teaching hospital, bharatpur. patients with history of contrast reactions, impaired renal function, images with artifacts or suboptimal post-contrast arterial opacification and presence of renal pathology (e.g., large renal mass or gross hydronephrosis) that distorted or interfered with optimum evaluation of the renal vessels were excluded from the study. patients were advised 4-6 hours of fasting prior to ct. they were placed in supine position and advised quiet breathing. an 18-gauze peripheral line was inserted into the antecubital vein. 2 ml/kg of non-ionic iodinated contrast agent (iohexol) with a concentration of 300 mg/ml was injected using the bolus tracking technique with an automatic injector at a flow rate of 4-5 ml/sec. the scan area was taken from the diaphragm to the mid-sacrum as per routine ct abdominal protocol. a voltage of 120 kvp, current of 220 ma, slice thickness of 0.5 and pitch ratio of one was taken. patients were advised breath-hold technique during the scan. the arterial phase scanning was done with the bolus tracking method. scanning commenced following peak enhancement of 150 hu at the region of interest placed within the abdominal aorta at the level of the diaphragm. after scanning, images were analyzed via vitrea® advanced visualisation software. image reconstruction and interpretation were done using multi-planar reconstruction (mpr), maximum intensity projection (mip) and volume rendering (vr) technique. data were analyzed using statistical package for social sciences (spss) version 20. the descriptive results were presented in terms of mean, standard deviation, frequency and percentage. ethical clearance was obtained from the ethical review committee of the institute (ref. no. 2018-038). results: a total of 400 consecutive patients (219 males and 181 females) undergoing abdominal ct examination were included in this study. the mean age (+sd) of the patients were 48.51 (+/-20.47) years (range: 3-92 years). normal renal arterial supply to both the kidneys was noted in 271 (67.75%) individuals (figure 1). remaining 129 (32.25%) individuals had variations in either kidney or both the kidneys. among those with renal arterial variations, 79 (61%) were males and 50 (39%) were females. however no statistically significant association was found between the existence of renal arterial variations and gender (p=0.4). fig. 1: coronal mip image showing normal single renal artery supplying each kidney. we found unilateral renal artery anomaly (n=93) was more common than bilateral renal artery j. lumbini. med. coll. vol 9, no 2, july-dec 2021 chhetri pk, et al. anatomical variations of renal artery in patients undergoing computed tomography of abdomen jlmc.edu.np anomaly (n=36). ninety-one (70.54%) patients had arterial variation limited to one kidney, two (1.55%) had double renal artery involving the left kidney and 36 (27.91%) had variations involving both the kidneys. in unilateral variations, the most common anomaly noted was polar artery (n=66) (figure 2) followed by pre-hilar branching (n=18) (figure 3). the right kidney was affected in 51 (54.84 %) and left kidney in 42 (45.16 %) individuals (table 1). fig. 2: coronal volume rendering image showing a polar artery (arrow) supplying inferior pole of the right kidney. fig. 3: coronal volume rendering image showing pre-hilar branching of the left renal artery (arrow) near the origin from the aorta. in 36 patients, both kidneys showed variation in the arterial supply. table 2 shows the various frequencies and the combinations affecting each kidney. the most common combination was an inferior polar artery supplying both kidneys (n=12) followed by superior polar artery supplying both kidneys (n=6). pre-hilar branching in both kidneys was seen in two and hilar artery in both kidneys was reported in one individual. the rest of the patients showed various combinations as shown in table 2. table 1. frequency of unilateral renal arterial variants (n=93). renal artery variant right kidney left kidney total superior renal polar artery 26 10 36 (38.71%) inferior renal polar artery 13 17 30 (32.26%) pre-hilar branching 8 10 18 (19.35%) hilar artery 4 3 7 (7.53%) both superior and inferior polar artery 0 2 2 (%) total 51 (54.84%) 42 (45.16%) 93 (100%) table 2. frequency of combination of bilateral renal artery variations (n=36). right kidney left kidney n (%) inferior polar artery, and inferior polar artery 12 (33.3%) superior polar artery 1 (2.8%) superior polar artery, and superior polar artery 6 (16.7%) accessory hilar artery 3 (8.3%) inferior polar artery 3 (8.3%) pre-hilar branching, and inferior polar artery 4 (11.1%) pre-hilar branching 2 (5.6%) accessory hilar artery, and inferior polar artery 3 (8.3%) accessory hilar artery 1 (2.8%) superior polar artery 1 (2.8%) also among the 36 individuals with bilateral renal anomalies, the right kidney showed polar artery in 25 (inferior polar artery in 13 and superior polar artery in 12), pre-hilar branching in six, hilar in five and the left kidney showed polar artery in 30 (inferior polar artery in 22 and superior polar artery in 8), hilar artery in four and pre-hilar branching in two. thus polar artery was the most common anomaly seen in 55 kidneys (inferior polar artery in 35 and superior polar artery in 20 kidneys), followed by accessory hilar artery in nine kidneys (figure 4) and pre-hilar branching in eight kidneys. j. lumbini. med. coll. vol 9, no 2, july-dec 2021 chhetri pk, et al. anatomical variations of renal artery in patients undergoing computed tomography of abdomen jlmc.edu.np fig.4: coronal mip image showing accessory hilar renal artery (arrow) supplying the right kidney. as shown in table 3, among 400 patients studied, the most common variation was inferior polar artery seen in 65 kidneys (16.25%) followed by superior polar artery in 56 kidneys (14%), prehilar branching in 24 kidneys (6%), hilar artery in 16 kidneys (4%) and combined superior and inferior renal arterial supply in two kidneys (0.5%). table 3. frequency of renal artery variant affecting each kidney (n=400). renal artery variant right left total inferior polar artery 26 39 65 (16.25%) superior polar artery 38 18 56 (14%) pre-hilar branching 14 10 24 (6%) hilar artery 9 7 16 (4%) both superior & inferior polar artery 2 2 (0.5%) discussion: awareness of the presence of renal artery variations is important if surgical procedures are indicated in this region. mdct being a reliable, easily applicable and non-invasive tool for visualization of abdominal organs and vascular structures [12], proves to be a supportive pre-operative investigation. in this study, 271 (67.75%) had a normal renal arterial supply. similar findings were reported by reginelli a et al. (69%), ugurel m et al. (58%) and ozkan u et al. (76%).[13,14,15] however, tardo et al. (87.8%) and raman ss et al. (81%) reported higher prevalence of normal variants. this might be because the sample frame of their study consisted of kidney donors only and naturally people with grossly abnormal vasculature were not included. [16,17] on the other hand, studies by munnusamy k et al. (49%) and toro jcs et al. (48%) found comparatively lower prevalence.[18,19] this shows that the prevalence of normal renal artery varies widely among different population. our study found no statistically significant association between the existence of renal arterial variation and gender (p=0.4). similarly, no statistically significant association was found in the studies by toro jcs et al. (p = 0.16).[19] and palmieri bj et al. (p = 0.31).[20] however, in a study by famurewa oc et al. vascular variants were present in 37 (36.3 %) females and 63 (64.3%) males and were noted to be significantly commoner in males (p<0.001).[21] among 129 patients with renal artery variations in this study, unilateral arterial anomaly was more common than bilateral arterial anomaly. similarly, in a study by toro jcs et al. 117 (77%) patients had unilateral variations and 35 (33%) had bilateral variations.[19] sampaio and passos found bilateral renal arterial variations in only 12 cases (4.5%).[22] in our study, among 93 individuals with unilateral renal arterial variations, right kidney was involved in 51 (54.84 %) and left kidney in 42 (45.16 %) individuals. similarly, toro jcs et al. noted variation to be significantly more frequent in the right kidney than the left (58% vs 42%, p = 0.002).[19] however, palmieri bj et al. noted that the relationship of the presence of multiple arteries between sex and laterality was no different in right and left kidneys of males (p = 0.29) and between left and right kidneys in females (p = 0.22).[20] similar to our study, toro jcs et al. noted that among those with unilateral variations, the most commonly observed was polar artery in 66 patients (55%) but the second most common was hilar artery in 39 patients (33%).[19] the present study found a very low prevalence (0.5%) of the presence of both the superior and inferior polar arteries involving the left kidney. similarly, prevalence of 0.3% individuals with both superior and inferior renal polar artery was noted by kornafel o et al.[23] in this study, 36 (9%) patients had renal artery variations affecting both the kidneys. in the literature, the prevalence of bilateral renal arterial variations ranged between 3.1% and 12%.[23,24] also, among 36 individuals (72 kidneys), polar artery was the most common anomaly seen in 55 kidneys (inferior polar artery in 35 and superior j. lumbini. med. coll. vol 9, no 2, july-dec 2021 chhetri pk, et al. anatomical variations of renal artery in patients undergoing computed tomography of abdomen jlmc.edu.np polar artery in 20 kidneys) followed by hilar artery in 9 kidneys. similarly, the presence of a polar artery was the most common variation found in 61% of the 35 patients with bilateral renal artery variations by toro jcs et at.[19] when both unilateral and bilateral variations were considered together, inferior polar artery (16.25%) was noted more frequently than superior polar artery (14%) and hilar artery (4%) in this study. in a study by bordei p et al., the most common variation observed was also an inferior renal polar artery (29.63%) followed by superior renal polar artery (9.26%).[24] similarly, kornafel o et al. found inferior renal polar artery (8.7%) to be the most common variant.[23] it is important for the surgeons to know if the accessory artery is supplying the upper or lower pole because their accidental injury during surgery can lead to necrosis. hence any disease confined to the upper or lower poles of the kidney will need special care in case of accessory vessels supplying these regions. moreover, inferior polar renal arteries are more important clinically because they can lead to obstruction of the pelviureteric junction.[25] however, swarna et al., noted that among patients with right renal accessory arteries on mdct angiography, 72 (58.5%) were hilar and 51 (41.5%) were polar arteries and on the left, 94 (61.8%) were hilar and 58 (38.2%) were polar arteries. thus hilar accessory was more common than polar artery in their study.[26] likewise, among 24% of kidneys with accessory renal artery, uflacker noted that 12% had two hilar arteries and 12% had one hilar and one polar artery.[27] presence of accessory renal arteries is a relative contraindication to transplant surgery.since these are end-arteries, these must be re-implanted and require several anastomoses with a prolonged ischemic time leading to a theoretically higher incidence of renal failure, graft rejection and reduced graft function.[28] in our study, pre-hilar branching was seen in 24 (6%) individuals. similarly, reginelli a et al. and ozkan u et al. reported pre-hilar branching in 6% and 8% patients respectively.[13,15] however, pre-hilar branching was not observed in a study by bordei p et al.[24] although an infrequent anomaly, it is important to detect any pre-hilar branching because most transplant surgeons require at least 2 cm length of renal artery before hilar branching in order to clamp and properly anastomose the artery in the recipient.[8] in a study to determine the site of anomaly, raman ss et al. noted that pre-hilar branching was more common on the left (21%) than on the right side (15%).[17] in a renal mdct angiographic study by clnar c and turkavatan a, the rate of prehilar branching was 2.6% on the right, 3.7% on the left and 0.2% bilateral.[29] these findings were quite similar to our study where 14 (3.5%) of prehilar branching was on right, 10 (2.5%) on the left and 2 (0.5%) on both sides. one limitation of this study was that images from cect of the abdomen with optimal enhancement of the aorta and renal vessels were evaluated rather than cta of the aorta and its branches which is potentially more suitable. another limitation is that a larger study is needed to further explore the prevalence of renal arterial variations in our population. conclusion: this study aimed to evaluate renal arterial variations in patients undergoing ct abdomen. renal arterial variations were not uncommon. they were observed in approximately one-third of the patients; unilateral renal arterial variation being more common than bilateral variations. polar arterial supply was the most common arterial variant in this study. however, larger multicentric studies are needed to verify and generalize the results of this study. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. j. lumbini. med. coll. vol 9, no 2, july-dec 2021 chhetri pk, et al. anatomical variations of renal artery in patients undergoing computed tomography of abdomen jlmc.edu.np references: 1. beregi jp, mauroy b, willoteaux s, mouniervehier c, rémy-jardin m, francke jp. anatomic variation in the origin of the main renal arteries: spiral cta evaluation. eur radiol. 999;9(7):1330-4. pmid: 10460369 doi: https://doi.org/10.1007/s003300050843 2. hazirolan t, öz m, türkbey b, karaosmanoǧlu ad, oǧuz bs, canyiǧit m. ct angiography of the renal arteries and veins: normal anatomy and variants. diagn interv radiol. 2011;17(1):6773. pmid: 20151356 doi: https://doi. org/10.4261/1305-3825.dir.2902-09.1 3. moore kl, persaud tvn torchia mg. the developing humanclinically oriented embryology. 9 th ed. philadelphia, usa: elsevier saunders, 2013. 4. rao tr, r. aberrant renal arteries and its clinical significance: a case report. international journal of 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pmid: 15026593 doi: https://doi.org/10.1148/rg.242035104 9. hänninen el, denecke t, stelter l, pech m, podrabsky p, pratschke j, et al. preoperative evaluation of living kidney donors using multirow detector computed tomography: comparison with digital subtraction angiography and intraoperative findings. transpl int. 2005;18(10):1134-41. pmid: 16162099 doi: https://doi.org/10.1111/j.14322277.2005.00196.x 10. urban ba, ratner le, fishman ek. threedimensional volume-rendered ct angiography of the renal arteries and veins: normal anatomy, variants, and clinical applications. radiographics. 2001;21(1):373-86. pmid: 11259702 doi: https://doi.org/10.1148/ radiographics.21.2.g01mr19373 11. platt jf, ellis jh, korobkin m, reige k. helical ct evaluation of potential kidney donors: findings in 154 subjects. ajr am j roentgenol. 1997;169(5):1325-30. pmid: 9353451 doi: https://doi.org/10.2214/ajr.169.5.9353451 12. hyare h, desigan s, nicholl h, guiney mj, brookes ja, lees wr. multi-section ct angiography compared with digital subtraction angiography in diagnosing major arterial hemorrhage in inflammatory pancreatic disease. eur j radiol. 2006;59(2):295-300. pmid: 16542810 doi: https://doi.org/10.1016/j. ejrad.2006.02.006 13. reginelli a, somma f, izzo a, urraro f, d’andrea a, grassi r, et al. renovascular anatomic variants at ct angiography. int angiol. 2015;34(6 suppl 1):36-42. pmid: 26498890 14. ugurel ms, battal b, bozlar u, nural ms, tasar m, ors f, et al. anatomical variations of hepatic arterial system, coeliac trunk and renal arteries: an analysis with multidetector ct angiography. br j radiol. 2010;83(992):661-7. pmid: 20551256 doi: https://doi.org/10.1259/ bjr/21236482 15. ozkan u, oǧuzkurt l, tercan f, kizilkiliç o, koç z, koca n. renal artery origins and variations: angiographic evaluation of 855 consecutive patients. diagn interv radiol. 2006;12(4):183-6. pmid: 17160802 16. tardo dt, briggs c, ahern g, pitman a, sinha s. anatomical variations of the renal arterial vasculature: an australian perspective. j med imaging radiat oncol. 2017;61(5):643-9. pmid: 28466967 doi: https://doi.org/10.1111/17549485.12618 17. raman ss, pojchamarnwiputh s, muangsomboon k, schulam pg, gritsch ha, lu dsk. surgically relevant normal and variant renal parenchymal j. lumbini. med. coll. vol 9, no 2, july-dec 2021 chhetri pk, et al. anatomical variations of renal artery in patients undergoing computed tomography of abdomen jlmc.edu.np and vascular anatomy in preoperative 16-mdct evaluation of potential laparoscopic renal donors. ajr am j roentgenol. 2007;188(1):105-14. pmid: 17179352 doi: https://doi.org/10.2214/ ajr.05.1002 18. munnusamy k, kasirajan sp, gurusamy k, raghunath g, bolshetty sl, chakrabarti s, et al. variations in branching pattern of renal artery in kidney donors using ct angiography. j clin diagn res. 2016;10(3):ac01-3. pmid: 27134847 doi: https://doi.org/10.7860/ jcdr/2016/16690.7342 19. toro jsc, prada g, takeuchi syr, pachecho r, baena g, granados am. anatomic variations of the renal arteries from a local study population using 3d computed tomography angiography reconstruction images from a reference hospital in cali, colombia. artery research. 2016;14(c):22-6. doi: https://dx.doi. org/10.1016/j.artres.2016.02.004 20. palmieri bj, petroianu a, silva lc, andrade lm, alberti lr. study of arterial pattern of 200 renal pedicle through angiotomography. rev col bras cir. 2011;38(2):116-121. pmid: 21710050 doi: https://doi.org/10.1590/s010069912011000200009 21. famurewa oc, asaleye cm, ibitoye bo, ayoola oo, aderibigbe as, badmus ta. variations of renal vascular anatomy in a nigerian population: a computerized tomography studys. niger j clin pract. 2018;21(7):840-6. pmid: 29984713 doi: https://doi.org/10.4103/njcp.njcp_237_17 22. sampaio fj, passos ma. renal arteries: anatomic study for surgical and radiological practice. surg radiol anat. 1992;14(2):113-7. pmid: 1641734 doi: https://doi.org/10.1007/ bf01794885 23. kornafel o, baran b, pawlikowska i, laszczyński p, guziński m, sasiadek m. analysis of anatomical variations of the main arteries branching from the abdominal aorta, with 64-detector computed tomography. pol j radiol. 2010;75(2):38-45. pmid: 22802775 pmcid: http://www.ncbi.nlm.nih.gov/pmc/ articles/pmc3389861/ 24. bordei p, sapte e, iliescu d. double renal arteries originating from the aorta. surg radiol anat. 2004;26(6):474-9. pmid: 15378279 doi: https://doi.org/10.1007/s00276-004-0272-9 25. shoja mm, tubbs rs, shakeri a, loukas m, ardalan mr, khosroshahi ht, et al. peri-hilar branching patterns and morphologies of the renal artery: a review and anatomical study. surg radiol anat. 2008;30(5):375-82. pmid: 18368282 doi: https://doi.org/10.1007/s00276008-0342-5 26. swarna, agarwal y, jain s, chawla as. renal vasculature: spectrum of anatomical variations and the significance from a surgeon’s standpoint. astrocyte. 2018;4:233-9. 27. uflacker r. abdominal aorta and branches. in: uflacker r, editor. atlas of vascular anatomy: an angiographic approach. 2nd ed. philadelphia, pa: lippincott williams and wilkins, 2006; 111222. 28. falesch la, foley wd. computed tomograpy angiography of the renal circulation. radiol clin of north am. 2016;51(1):71-86. pmid: 26654392 doi: https://doi.org/10.1016/j. rcl.2015.08.003 29. çlnar c, türkvatan a. prevalence of renal vascular variations: evaluation with mdct angiography. diagnostic and interventional imaging. 2016;97(9):891-7. doi: https://doi. org/10.1016/j.diii.2016.04.001 j. lumbini. med. coll. vol 9, no 1, jan-june 2021 nepal p, et al. clinical nurses’ knowledge and attitude on palliative care: a cross-sectional study. 38 jlmc.edu.np ___________________________________________________________________________________ submitted: 1 may, 2021 accepted: 18 june, 2021 published: 30 june, 2021 aassistant professor, blumbini medical college teaching hospital, palpa, nepal. cpatan academy of health sciences, school of nursing and midwifery, latitpur nursing campus, lalitpur, nepal corresponding author: parbati nepal e-mail: kirparu@gmail.com orcid: https://orcid.org/0000-0001-9879-5486_______________________________________________________ abstract: introduction: palliative care is a multidisciplinary approach for enhancing the quality of life of terminally ill patients. for nurses, being the core members of the palliative care team, adequate knowledge and a positive attitude are crucial. this study aimed to assess clinical nurses' knowledge and attitude on palliative care. method: a cross-sectional descriptive study was conducted among 122 nurses. a simple random sampling technique was applied to select the sample. internationally validated questionnaires-“the palliative care quiz for nursing” and “frommelt attitudes toward care of the dying scale” were used to assess knowledge and attitude. data were analyzed using descriptive statistics and inferential statistics. results: the mean age of participants was 25±5.42 years and a majority (70.5%) were staff nurses. none of the participants had ever received training or in-service education related to palliative care. only 29.5% had a fair level of knowledge and, 28.7% had a good level of attitude towards palliative care. pearson correlation test revealed a negligible correlation between the level of knowledge and attitude (r= 0.135, p=0.887). ethnicity (p=0.02) and religion (p=0.02) were statistically significant with the level of knowledge and care for dying relatives (p=0.03) was statistically significant with the level of attitude. conclusion: the study revealed that nurses’ have poor knowledge of palliative care but had a fair attitude. as nurses are core members, regular training and in-service education can enhance their knowledge level. positive reinforcement, appreciation, and reward for desirable behavior can help them develop a good attitude towards palliative care. keywords: attitude; knowledge; nurse; palliative care original research articlehttps://doi.org/10.22502/jlmc.v9i1.435 parbati nepal,a,b chandra kumari garbuja,a,b manju nepal a,c clinical nurses’ knowledge and attitude on palliative care: a cross-sectional study how to cite this article:how to cite this article: nepal p, garbuja ck, nepal m. clinical nurses’ knowledge and attitude on palliative care: a cross-sectional study. journal of lumbini medical college. 2021;9(1):38-44. doi: https://doi. org/10.22502/jlmc.v9i1.435. epub: june 30, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: dying and death is an inevitable universal phenomenon that brings a very bitter experience for both patients and their families, and palliative care could bring a ray of hope to soothe them at their end-of-life care.[1,2] palliative care, as described by who, is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of sufferings by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.[2] it can be started at any point after diagnosis of any chronic and/or terminal diseases along with other therapies to maintain quality of life, prolong life, and distress-related complications at centers like the hospital, daycare centers, or even at the patient’s own home.[3,4] the global need for palliative care is on an increasing trend due to the rising aged population, chronic non-communicable and terminal staged diseases.[3] end-of-life care or care for the dying is the care provided in the final days or weeks before the death of patients so hospice care is a final phase of palliative care.[2,5] for the successful delivery of palliative health care, sound knowledge and positive attitude of health care professionals especially of nurses, who are the main interventionist, is very fundamental.[6,7,8] studies conducted in different countries have shown relatively poor knowledge j. lumbini. med. coll. vol 9, no 1, jan-june 2021 nepal p, et al. clinical nurses’ knowledge and attitude on palliative care: a cross-sectional study. 39 jlmc.edu.np but a positive attitude towards palliative care among nurses.[6,8] though assessment of knowledge and attitude of nurses towards palliative care has received considerable global attention from the researchers, very limited studies are available in the nepalese context. therefore, this study was aimed to find out the knowledge and attitude of clinical nurses on palliative care. methods: a cross-sectional descriptive study design was adopted to assess the nurses’ knowledge and attitude towards palliative care. ethical approval was taken from the institutional research committee of lumbini medical college and teaching hospital (irc-lmc 05-g/020). the sample size was estimated using solvin’s formula, n= n/(1+ne2) were, total population(n)=175 and allowable error (e)=0.05 and calculated sample size(n) was 122. the desired sample was taken from computer-generated simple random numbers. nurses who were absent or in long leave during data collection were replaced by other randomly generated numbers. those registered nurses (auxillary nurse midwives, proficiency certificate level and bachelor graduates) working in critical areasintensive care unit, pediatric intensive care unit, neonatal intensive care unit, emergency department and post-operative ward; non-critical areasgeneral medical ward, surgical ward, gynecological ward, pediatric ward, and orthopedic ward of lumbini medical college and teaching hospital (lmcth) and who gave voluntary consent for the participation in the study were included. whereas, nurses who are working in outpatient departments, and operation theatre were excluded. the data was collected over march 2021. questionnaires were filled in the presence of the researcher and around 20 minutes were taken by each participant. confidentiality and anonymity were strictly maintained. the self-administered questionnaire used in this study consisted of three parts: part i: sociodemographic variables. part ii: knowledge related questions were assessed by “palliative care quiz for nursing (pcqn)” and part iii: “frommelt attitude toward the care of the dying scale (fatcod)” to assess the attitude. pcqn and fatcod are validated questionnaires in which the former had high content validity, and reasonable reliability (the internal consistency = 0.78 and test-retest = the correlation coefficient=0.56) and the latter had cronbach’s alpha coefficient 0.83.[9,10] pcqn consisted of 20 items as (a) philosophy and principles of palliative care (14), (b) management of pain and other symptoms (517), and (c) psychosocial aspects of care (18-20). the response options were true, false, and i don’t know. the right answer was graded as ‘1’ and for incorrect and don’t know were graded as ‘0’. the total score was 20 which was converted into a percentage score and classified into three categories based on the study conducted in egypt as poor knowledge (<50%), fair knowledge (50 <75%), and good knowledge (≥75%).[11] fatcod is a five-point likert scale ranged from 1= strongly disagree to 5=strongly agree which has 30 items divided into three domains: (a)cognitive domain (12 items): 1,2,6,1 0,11,17,19,21,23,25,27,30 (b) affective domain (9 items):3,5,7,8,9,13,14,15,26 and (c) patient’s family (9 items): 4,12,16,18,20,22,24,28,29.[10]there were 15 items (3, 5, 6, 7, 8, 9, 11, 13, 14, 15, 17, 19, 26, 28, and 29) that needed reverse scoring. the scores ranged from 30 to 150. the total attitude scores were further classified into poor (<50%), fair (50 <75%), and good (≥75%).[11] the questionnaire was translated in nepali version and pretested among 12 nurses working in the operation theatre and cronbach’s alpha coefficient value was 0.71 for pcqn and 0.81 for fatcod. the collected data were checked for completeness, coded and entered in microsoft excel 2007, and transformed in statistical package for the social sciences (spss) version 16. descriptive statisticsfrequency, percentage, mean, standard deviation, and range; and inferential statistics (chisquare test) were used for the analysis of data. the p-value was set at <0.05 for statistical significance. results: a majority (65.5%) of participants were from the age group <25 years with a mean ± sd of 25±5.42 years (range:18 to 45 years). more than half (53.3%) of the participants were janajati followed by 41.8% brahmin/ chhetri and 4.9% dalit. a majority (94.3%) of the participants were hindus. a majority (70.5%) were staff nurses, 19.7% were auxiliary nurse midwives (anm) and 9.8% were bachelor graduates. the mean job experience of participants was 3.43±3 years ranging from 0.3 to 15 years. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 nepal p, et al. clinical nurses’ knowledge and attitude on palliative care: a cross-sectional study. 40 jlmc.edu.np most (88.5%) of the participants had an experience of caring for dying patients whereas, 38.5% had an experience of caring for their dying relatives. onethird (33.6%) of them were working in critical areas. none of the participants had received any pieces of training or in-service education related to palliative care. two-thirds (64.8%) of participants stated palliative care was appropriate only in situations where there is evidence of a downhill trajectory or deterioration. less than half (40.2%) of participants agreed that the provision of palliative care requires emotional detachment. a majority (86.1%) answered that the extent of the disease determines the method of pain management. likewise, 87.7% assumed that drug addiction becomes the major problem when morphine is used for prolonged table 1. knowledge on palliative care of participants measured by pcqn (n=122). s. n. characteristics true n (%) false n (%) don’t know n (%) 1 palliative care is appropriate only in situations where there is evidence of a downhill trajectory or deterioration. 79(64.8) 37(30.3)* 6(4.9) 2 the provision of palliative care requires emotional detachment 68(55.7) 49(40.2)* 5(4.1) 3 the philosophy of palliative care is compatible with that of aggressive treatment. 28(23)* 64(52.5) 30(24.6) 4 the accumulation of losses renders burnout inevitable for those who seek work in palliative care. 43(35.2) 56(45.9)* 23(18.9) 5 morphine is the standard used to compare the analgesic effect of other opioids. 102(83.6)* 8(6.6) 12(9.8) 6 the extent of the disease determines the method of pain treatment. 105(86.1) 14(11.5)* 3(2.5) 7 adjuvant therapies are important in managing pain. 110(90.2)* 7(5.7) 5(4.1) 8 during the last days of life, the drowsiness associated with electrolyte imbalance may decrease the need for sedation. 70(57.4)* 30(24.6) 22(18.0) 9 drug addiction is a major problem when morphine is used on a long-term basis for the management of pain. 107(87.7) 10(8.2)* 5(4.1) 10 individuals who are taking opioids should also follow a bowel regime. 80(65.5)* 14(11.5) 28(23.0) 11 during the terminal stages of an illness, drugs that can cause respiratory depression are appropriate for the treatment of severe dyspnea. 66(54.1)* 35(28.7) 21(70.2) 12 the use of placebos is appropriate in the treatment of some types of pain. 68(55.7) 37(30.3)* 17(13.9) 13 in high doses, codeine causes more nausea and vomiting than morphine. 79(60.8)* 21(17.2) 22(18.0) 14 suffering and physical pain are synonymous. 41(33.6) 75(61.5)* 6(4.9) 15 demerol is not an effective analgesic in the control of chronic pain. 48(39.3)* 56(45.9) 18(14.8) 16 manifestations of chronic pain are different from those of acute pain. 90(73.8)* 25(20.5) 7(5.7) 17 the pain threshold is lowered by anxiety or fatigue. 92(75.4)* 19(15.6) 11(9.0) 18 it is crucial for family members to remain at the bedside until death occurs. 93(76.2) 21(17.2)* 8(6.6) 19 the loss of a distant or contentious relationship is easier to resolve than the loss of one that is close or intimate. 106(86.9) 8(6.6)* 8(6.6) 20 men generally reconcile their grief more quickly than women. 109(89.3) 10(8.2)* 3(2.5) * right answers j. lumbini. med. coll. vol 9, no 1, jan-june 2021 nepal p, et al. clinical nurses’ knowledge and attitude on palliative care: a cross-sectional study. 41 jlmc.edu.np periods for pain management. a majority (90.2%) of participants stated that adjuvant therapies are important in managing pain. three quarters (76.2%) of participants expressed about it is crucial for family members to remain at the bedside until death occurs. details are depicted in table 1. regarding the domains of pcqn, philosophy, and principles of pcqn had mean±sd of 1.38±0.98 (range=0-4), management of pain / other symptoms domain had mean±sd of 7.18±1.66 (range=3-11) and in psychological aspects of care mean ±sd was 1.25±0.50 (range=0-2). as regard to attitude as measured by “frommelt attitude toward the care of the dying scale (fatcod)”, three quarters (76.2%) of participants affirmed that giving care to the dying person was worthwhile to experience. nearly twothirds (68.9%) of participants agreed that they would be uncomfortable talking about impending death with the dying person. most (92.6%) of participants accepted that caring for the patient’s family should continue throughout grief and bereavement. more than half (60.7%) of participants strongly disagreed that they would not want to care for a dying person. two-thirds (69.6%) of the participants disagreed that the length of time required to care for a dying person frustrated them. one-third (32.8%) of participants agreed that it was difficult to form a close relationship with the dying person. a majority (80.3%) of participants affirmed that there were times when death was welcomed by the dying person. two-thirds (66.4%) of participants thought that it is best to change the subject to something cheerful when a patient asked about their dying. the majority (86%) of the participants acknowledged that families need emotional support accepting the behavioral changes in the dying person. when participants were inquired if the dying person should be allowed to decide on their physical care, 55.7% of them agreed. most (90%) of the participants accepted that families should maintain a normal environment for their dying members. a majority (82.6%) of the participants agreed that dying persons need to be provided with flexible visiting schedules by the caregivers. there was an agreement seen in 68.1% of participants that they felt uncomfortable entering the room of a terminally ill person who was crying. the mean score of different domains is depicted in table 2. a majority (70.5%) of participants had a poor level of knowledge whereas, 71.3% had a fair attitude which is presented in table 3. table 2. mean score of participants’ atitude based on fatcod questionnaire (n=122). characteristics items score range mean ± sd cognitive domain 12 27 52 42.01 ± 4.23 affective domain 9 18 42 29.95 ± 4.31 family-related domain 9 22 42 30.67 ± 3.56 table 3. level of knowledge and attitude of participants (n=122). characteristics n (%) range mean ± sd knowledge poor 86 (70.5) 4-14 8.82 ± 1.95fair 36 (29.5) attitude fair 87 (71.3) 88-142 107.36 ± 9.17good 35 (28.7) on analysis with pearson correlation test, there was a negligible correlation between the level of knowledge and attitude which was not statistically significant (r = 0.135, p = 0.887). ethnicity and religion was statistically significant with level of knowledge(χ2=5.736, df=1, p=0.03). whereas, cared for dying relatives was found statistically significant with the level of attitude (χ2=5.146, df=1, p=0.03). discussion: the study aimed to find out the nurses’ knowledge and attitude on palliative care. the present study revealed that the majority of nurses had a poor level of knowledge which is similar to the studies conducted in congo and egypt.[6,11] but it contrasted with other studies which showed a comparatively good level of knowledge.[4,12,13] the possible reason for variation may be that those participants had received palliative care training, had exposure in palliative care unit as well as higher working experience. the overall mean score of knowledge of pcqn in this study was 8.82 which is consistent with other studies.[3,11,13] the present study reported a lower mean score (1.25±0.50) in the psychological aspects of care. the possible reason may be, in our context, we are not giving much j. lumbini. med. coll. vol 9, no 1, jan-june 2021 nepal p, et al. clinical nurses’ knowledge and attitude on palliative care: a cross-sectional study. 42 jlmc.edu.np importance to mental health as compared to physical health. the study revealed that 64.8% of participants think palliative care is appropriate for terminally ill patients or at end-of-life care. this is similar to the studies conducted in ethiopia.[4,8] from this inference can be drawn that, palliative care is still viewed as care offered only for dying patient or patient who have no chances of improvement. likewise, many (86.1%) participants believed that the extent of the disease determines the method of pain management which is similar to the studies conducted in ethiopia and congo.[4,6] but the fact is that the severity of the pain determines the method of pain management not by the extent of disease. as none of the participants had ever attended training related to palliative care might be the possible reason for giving such an answer. in the present study, most of the participants expressed that drug addiction is the major problem when morphine is used for a prolonged period of pain management which is similar to other studies’ findings.[4,8] drug addiction is not a major problem in dying patients other than pain management. the possible reason for this might be a lack of exposure and training on palliative care for nurses. a maximum (90.2%) number of participants also reported that adjuvant therapies are important in managing pain. this finding is comparable with other studies as well. [3,4,6,8] in the present study, 76.2% of participants acknowledged that family members must remain at the bedside until the death of the patient. similarly, 89.3% of participants reported that men generally reconcile their grief more quickly than women but the contradictory finding was reported by another study.[3] the possible reason may be the cultural and value system differences in both countries. this study revealed that 71.3% of the participants had a fair attitude towards care of the dying patient and these consistent results have also been found in other studies.[3,4,6,8,11,13,14] the mean score of attitude was 107.36 in this study which is consistent with the findings of other studies. [3,13,15] this study stated that 76.1% of nurses agreed that giving care to the dying person is a worthwhile experience. a similar opinion has been reported in other studies as well.[3,4,6,8,11] likewise, 68.9% of the participants expressed that they would be uncomfortable talking about impending death with the dying person and a similar opinion has been told by the nurses in some other studies.[6,11] but the contradictory finding was found in other studies. [4,8,13] possible reason for differences in opinion may be the disparity in cultural values and norms. the study documented that, 92.6% of participants agreed about extending care to the patient’s family throughout grief and bereavement and similar opinions were also expressed in other studies. [3,8,12,11] present study reported that 66.4% of the nurses agreed to change the topic to something cheerful when the dying person asked if he/she was dying. similar expressions were found in other studies as well.[3,6,8,11] expressing or talking about negative outcomes to the patient himself could be a bitter experience which nurses may be tended to remain aloof. the majority of nurses opined that the dying person and his or her family should be the in-charge decision-makers which is akin to other studies.[3,6,8,11] this will indicate that nurses respect patient’s bill of rights. the present study revealed that there is a statistically significant relationship between religion and ethnicity with the level of knowledge. the culture molds the behavior and the belief systems of an individual which could be a possible reason for the relationship. similarly, the experience of care for dying family and close relatives have found statistically significant with attitude towards the care of dying which is concurrent with the findings of another study.[13] but the findings of other studies showed that working area, working in the palliative care unit, training in palliative care, education level, and experience were found statistically significant with knowledge and attitude level.[3,4,8,12,13] possible reason for differences in findings might be that the participants of this study were aloof from formal training and had no or minimal experience of working in a palliative care unit. the study prevailed correlation between knowledge and attitude which is similar to the finding of a study conducted in india. [15] the study is not exclusive of limitations. limited clinical experience of nurses’, lack of exposure to separate palliative care units, no provision of formal training, and in-service education regarding palliative care so far might be the possible reason for lack of knowledge. thus, the result cannot be generalized. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 nepal p, et al. clinical nurses’ knowledge and attitude on palliative care: a cross-sectional study. 43 jlmc.edu.np conclusion: nurses’ knowledge regarding palliative care was found poor, but they had a fair attitude in dealing with the patient who requires palliative care. the psychological aspect of care knowledge seems very poor. in the attitude aspect, nurses were feeling very reluctant to deal with or discuss negative outcomes with the patient themselves. training and regular in-service education for nurses can enhance their knowledge level. provision of positive reinforcement, appreciation, and rewards for desirable behavior could help nurses to develop a positive attitude towards palliative care. acknowledgment: ms. bandana pokharel, nursing program coordinator, lmcth. all the nursing faculties and administrative staffs, nursing programme lmcth. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available for the study. references: 1. rome rb, luminais hh, bourgeois da, blais cm. the role of palliative care at the end of life. ochsner j. 2011;11(4):348-52. pmid: 22190887 pmcid: pmc3241069 2. berman a, synder sj, kozier b, erb g. fundamental of nursing. 8th ed. dorling kindersely: india; 2011. 3. etafa w, wakuma b, fetensa g, tsegaye r, abdisa e, oluma a, et al. nurses’ knowledge about palliative care and attitude towards endof-life care in public hospitals in wollega zones: a multicenter cross-sectional study. plos one. 2020; 15(10):e0238357. pmid: 33027265 doi: https://doi.org/10.1371/journal. pone.0238357 4. zeru t, berihu h, gerensea h, teklay g, teklu t, gebrehiwot h, et al. assessment of knowledge and attitude towards palliative care and associated factors among nurses working in selected tigray hospitals, northern ethiopia: a cross-sectional study. pan afr med j. 2020;35:121. doi: https:// dx.doi.org/10.11604/pamj.2020.35.121.17820 pmid: 32637019 pmcid: pmc7320791 5. potter pa, perry ag. fundamental of nursing. 7th ed. elsevier : india; 2009 6. mukemo ak, kasongo nm, nzaji mk, tshamba hm, mukengeshayi an, nikulu ji, et al. assessment of nurses’ knowledge, attitude and associated factors towards palliative care in lubumbashi’s hospitals. international journal of science and research. 2017;6(10):922-928. https://www.ijsr.net/search_index_results_ paperid.php?id=art20177206 7. singer ae, goebel jr, kim ys, dy sm, ahluwalia sc, clifford m, et al. populations and interventions for palliative and end-oflife care: a systematic review. j palliat med. 2016;19(9):995-1008. pmid: 27533892 doi: https://doi.org/10.1089/jpm.2015.0367 8. kassa h, murugan r, zewdu f, hailu m, woldeyohannes d. assessment of knowledge, attitude and practice and associated factors towards palliative care among nurses working in selected hospitals, addis ababa, ethiopia. bmc palliat care. 2014;13(1):6. pmid: 24593779 doi: https://doi.org/10.1186/1472-684x-13-6 j. lumbini. med. coll. vol 9, no 1, jan-june 2021 nepal p, et al. clinical nurses’ knowledge and attitude on palliative care: a cross-sectional study. 44 jlmc.edu.np 9. ross mm, mcdonald b, mcguinness j. the palliative care quiz for nursing (pcqn): the development of an instrument to measure nurses’ knowledge of palliative care. j adv nurs. 1996;23(1):126-37. pmid: 8708208 doi: https://doi.org/10.1111/j.1365-2648.1996. tb03106.x 10. mastroianni c, piredda m, taboga c, mirabella f, marfoli e, casale g, et al. frommelt attitudes toward care of the dying scale form b: psychometric testing of the italian version for students. omega (westport). 2015;70(3) 227-50. pmid: 26036054 doi: https://doi. org/10.1177/0030222815568944 11. elsaman se. undergraduate critical care nursing students’ knowledge and attitudes toward caring of dying patients. iosr journal of nursing and health science. 2017;6(1):3140. available from: http://www.iosrjournals. org/iosr-jnhs/papers/vol6-issue1/version-1/ e0601013140.pdf 12. ayed ma, sayej s, harazneh l, fashafsheh i, eqtait f. the nurses’ knowledge and attitudes towards the palliative care. journal of education and practice. 2015;6(4):91-99. available from: https://www.iiste.org/journals/index.php/jep/ article/view/19799/20363 13. abate at, amdie fz, bayu nh, gebeyehu d, g/ mariam t. knowledge, attitude and associated factors towards end of life care among nurses’ working in amhara referral hospitals, northwest ethiopia: a cross-sectional study. bmc res notes. 2019;12(1):521. doi: https:// doi.org/10.1186/s13104-019-4567-7 pmid: 31426854 pmcid: pmc6700991 14. gurung m, timalsina r. attitudes of nepalese hospital nurses towards care of dying people. j aging stud ther. 20181(1):10.16966/jast.101. available from: https://sciforschenonline.org/ journals/aging-studies-therapies/jast-1-101. php 15. vakkachan r, varghese a, bivin j b, nagarajaiah. knowledge and attitude towards end of life care among student nurses and staff nurses. indian j psy nsg. 2013;5:18-21. available from: https:// www.ijpn.in/text.asp?2013/5/1/18/261767 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 24 may, 2020 accepted: 03 june, 2020 published: 06 june, 2020 a lecturer, department of physiology, b lumbini medical college and teaching hospital, palpa, nepal. corresponding author: lok raj joshi e-mail: lokraaj.joshi@gmail.com orcid: https://orcid.org/0000-0002-0734-9876_______________________________________________________ —–—————————————————————————————————————————abstract pulse oximetry is an essential component of the standard care of covid-19 patients. in the context of the spreading covid-19 pandemic for which no targeted therapy or vaccines are yet available, early identification of the severe cases or cases with high risk of severe disease and appropriate supportive treatment are of paramount importance to save lives. pulse oximetry is a cheap, fast, easy to use, noninvasive, painless and accurate tool that allows real-time monitoring of hypoxemia. as the primary target of the disease is the respiratory system pulse oximetry provides an unparalleled way to assess the severity of the disease, guide supportive therapies and monitor the clinical status and response to treatment with greater benefits in the low-resource settings. all settings from the quarantine facilities at the ground level to the icus in the highest level hospitals can utilize it to achieve their goals. to get the best of this tool, it needs to be used properly and the findings interpreted carefully. role of basic understanding of the physiological principles and technology behind its use and awareness of its limitations cannot be overemphasized. the pulse oximetry readings are interpreted in the context of blood hemoglobin concentration, tissue perfusion, arterial blood carbon dioxide concentration and oxygen supplementation status. keywords: covid-19, limitations, nepal, pulse oximetry, utility brief reporthttps://doi.org/10.22502/jlmc.v8i1.356 lok raj joshi a,b principles, utility and limitations of pulse oximetry in management of covid-19 how to cite this article:how to cite this article: joshi lr. principles, utility and limitations of pulse oximetry in management of covid-19. journal of lumbini medical college. 2020;8(1):6 pages. doi: https://doi.org/10.22502/jlmc.v8i1.356 epub: 2020 june 06. background the world health organization (who) recommends that pulse oximetry be available in all settings caring for patients with severe acute respiratory infections including covid-19 (coronavirus disease 2019).[1] in the context of spreading pandemic of covid-19, the present article attempts to summarize the principles, utility and limitations of pulse oximetry to optimize clinical outcomes. physiology behind pulse oximetry pulse oximetry is one of the tools used to assess respiratory functions. it gives an estimate of the level of oxygen saturation of hemoglobin in the arterial blood (sao2). sao2 provides an important information about the oxygen content of the arterial blood that has been oxygenated in the lungs. reversible binding of hemoglobin with oxygen allows hemoglobin to carry oxygen from the lungs and release it in other tissues for their functioning and survival. while breathing room air, most of the oxygen in the arterial blood is in the form bound to hemoglobin and remaining three percent is carried in the dissolved form.[2] however, the dissolved form is responsible for partial pressure of oxygen in blood and determines how much oxygen binds with hemoglobin to form oxyhemoglobin. hemoglobin not bound to oxygen is called deoxyhemoglobin. the ratio of the actual amount of oxygen that has bound with hemoglobin relative to the maximum amount of oxygen that the total amount of hemoglobin could bind with is called oxygen saturation of hemoglobin and is expressed as percentage. the graphical relationship between oxygen saturation of j. lumbini. med. coll. vol 8, no 1, jan-june 2020 joshi lr. principles, utility and limitations of pulse oximetry in management of covid-19.joshi lr. principles, utility and limitations of pulse oximetry in management of covid-19. jlmc.edu.np hemoglobin and partial pressure of oxygen in blood is depicted by oxygen-hemoglobin dissociation curve (fig. 1) and its sigmoid shape has major physiological and clinical significance.[3] normally oxygen saturation of the arterial blood (sao2) is about 97%. as partial pressure of oxygen is less in the peripheral tissues, oxygen dissociates from the hemoglobin and is used by the tissues. on the same basis, if oxygenation of blood is impaired in the lungs, oxygen saturation of arterial blood (sao2) falls which can be detected by pulse oximetry. fig. 1. oxygen hemoglobin dissociation curve (solid curve); total oxygen content of blood (top dotted curve) and amount of oxygen in the dissolved form (bottom dotted line) assuming normal hemoglobin (hb) concentration (15 g/dl). po2: partial pressure of oxygen in blood. [reproduced from collins j-a et al. european respiratory society 2015 (cc by-nc 4.0)] besides oxygenation of blood, respiratory system is also responsible for removal of carbon dioxide. of note, carbon dioxide concentration in the blood or extracellular fluid has a major influence on another important parameter that is ph. gas exchange in the lungs is affected by alveolar ventilation, diffusion of the gases across the respiratory membrane, perfusion of the lungs and level of match between ventilation and perfusion.[2] diffusing capacity of the respiratory membrane for carbon dioxide is about 20 times that for oxygen and hence carbon dioxide elimination is relatively less affected in conditions that impair diffusion.[2] furthermore, oxygen transport from the lungs to the tissues and carbon dioxide transport back from the tissues to the lungs depends on rate of blood flow or cardiac output. therefore, respiratory functions need to be assessed along with the cardiovascular status. pathophysiology of respiratory insufficiency in covid-19 though the knowledge about the details of pathophysiology of covid-19 is still evolving, primary involvement of the respiratory system is now well known. severe acute respiratory syndrome coronavirus 2 (sars-cov-2), a virus from the coronaviridae family is responsible for the disease. [4] sars-cov-2 initially enters the respiratory epithelial cells after binding with the angiotensin converting enzyme type 2 (ace2) receptors initially in the nasal cavity and then the lower respiratory tract as well.[5, 6] direct attack to the alveolar epithelial cells by the virus causes cellular injury and initiates immune response including leukocyte infiltration, local vasodilation, increased capillary permeability, edema and exudation. peripheral lung areas have been found to be involved in the initial stage and in more severe cases, bilateral multifocal widespread involvement has been documented.[7] initial interstitial edema is later complicated by alveolar edema and local abnormal blood coagulation in the pulmonary vessels worsens the scenario. pulmonary embolism has also been observed in some cases. [5, 6] these all pathological changes compromise respiratory functions by affecting gas exchange between the alveoli and the pulmonary capillary blood and also causing ventilation-perfusion mismatch.[8] primarily, hypoxemic respiratory failure does occur in severe cases. regarding the effect on lung compliance, there are conflicting findings.[8, 9] though it is possible to have normal lung compliance at least during some stage of the disease progression or recovery, low compliance that is not uncommon increases the work of breathing and dyspnea. the overwhelming immune response also known as cytokine storm has been pointed to complicate the pathogenesis and to cause widespread involvement including other systems for instance cardiovascular and renal systems. due to widespread expression of ace2 receptors in many organs in the body, direct injury by the virus is also possible. [5, 6] direct viral or indirect immunological injury to the heart and blood vessels compromises blood circulation and further reduces oxygen delivery to the tissues. resulting compromised coronary circulation can initiate vicious positive feedback cycle of low cardiac output, lower coronary blood flow and so on culminating into death.[5] depending on the degree of damage to the respiratory system, clinical presentation of covid-19 is variable. asymptomatic infection or j. lumbini. med. coll. vol 8, no 1, jan-june 2020 joshi lr. principles, utility and limitations of pulse oximetry in management of covid-19.joshi lr. principles, utility and limitations of pulse oximetry in management of covid-19. jlmc.edu.np mild disease occurs in about 80-90% of the cases. fever, cough, difficulty breathing are the common initial presenting complaints. serious complications occur in about 10% of the cases and critical ones in about 5% which include rapid progression to severe pneumonia, acute respiratory distress syndrome (ards), respiratory failure, septic shock and multiorgan failure. case fatality rate varies from 2-5%. [4] co-morbid conditions like diabetes mellitus, hypertension, renal diseases, chronic obstructive pulmonary diseases, cancers etc. increase the risk of severity and death. unlike other respiratory illnesses, covid-19 might present with mild clinical symptoms and signs but severe fall in oxygen saturation.[4,10] strategies for management of covid-19 considering the unavailability of targeted drugs or vaccines with proven efficacy against covid-19 till date, public health measures to prevent transmission are the mainstay of the strategies to combat covid-19 at present. almost the entire globe is under lockdown of variable degree with the hope to minimize transmission while buying time for better preparation to uphold the capacity of the health facilities and develop specific drugs and vaccines. for now, early detection of the cases and identification of severe cases or cases with high risk of severe disease; their isolation and treatment; tracing the contacts; quality quarantine and monitoring of the suspected contacts are the available strategies stressed by the who.[11] in the context of the lowresource settings like nepal, rapid spread of the disease, limited capacity of the health care facilities and risk of infection to the frontline healthcare and support staff who are already limited in number make the abovementioned strategies invaluable both from the public health and the clinical viewpoints. despite the enforced public health measures, it has not been possible to control transmission. new cases are on rise and so is mortality. in the absence of the specific therapy, appropriate symptomatic and supportive treatment are the only available modalities of treatment.[4] understandably, oxygen therapy and ventilator support are among the major life-saving interventions as the disease primarily targets the lungs. role of pulse oximetry in management of covid-19 pulse oximetry is an invaluable tool for assessing respiratory functions. in contrast to arterial blood gas analysis that is the gold standard technique to evaluate respiratory insufficiency and acid-base status, pulse oximetry is a cheap, fast and easy to use technique. pulse oximetry is reasonably accurate and allows non-invasive real time monitoring of hypoxemia.[1] these all qualities of pulse oximetry make it the best available tool for detection and continuous real time monitoring of hypoxemia. [12] these remarkable features can be utilized in management of covid-19 from the ground levels i.e. quarantine facilities to the icus in the highest levels of the hospitals caring for covid-19. its value is even greater in low resource settings like nepal. pulse oximetry can detect respiratory insufficiency that in some covid-19 patients may not be detected on clinical examination in the early stage.[10] as evident from the discussion above, early detection and referral of the severe cases is an important step toward saving lives. well managed quarantine facilities can help achieve this goal and pulse oximetry can be an easy to use cost-effective valuable tool and more so for people with risk factors for severe diseases. basic orientation to pulse oximetry of all health care workers caring for people under quarantine and provision of communication with the clinicians on duty or on call may improve the outcomes. population-wide use of pulse oximetry was not recommended in the pre-covid-19 period. [13] however, this pandemic has raised the question if it can be used for monitoring mild cases being cared for in home isolation under guidance of telehealth facility when in-hospital care is not feasible.[6] use of pulse oximetry to monitor patients being transported in the ambulance is a well-known one. similarly, it can be used for spot examination of the patients in the fever clinics, outpatient departments and monitoring in the emergency departments, isolation wards and icus. pulse oximetry aids in diagnosis of severe pneumonia. furthermore, it can be reliably used to diagnose ards in resource-limited settings.[1,14] it also guides therapies like oxygen supplementation or ventilator support, the lifesaving supportive therapies for severe covd-19. it also minimizes the use of arterial blood gas analysis.[13] technology behind pulse oximetry and its implications a transmittance pulse oximeter uses a probe with a light emitter and a sensor facing each other between which a perfused tissue (finger or earlobe) is placed.[13] a modification of beer-lambert law is exploited to assess oxygen saturation of j. lumbini. med. coll. vol 8, no 1, jan-june 2020 joshi lr. principles, utility and limitations of pulse oximetry in management of covid-19.joshi lr. principles, utility and limitations of pulse oximetry in management of covid-19. jlmc.edu.np hemoglobin in the arterial blood flowing through the tissues. beer-lambert law enables determination of concentration of a light absorbing substance in a solution when intensity and wavelength of the incident light, transmission path length and absorbance characteristics of the substance are known.[15] the fact that absorbance characteristics of oxyhemoglobin and deoxyhemoglobin are different for red and near infrared light is utilized to make a differentiation between the two forms of hemoglobin. however, as significant scattering of light does occur with the current model of the pulse oximeter, some modifications to calculations from the beer-lambert law are introduced to minimize the error in the measurements.[16] in addition, the ability of the oximeter to analyze the pulsatile component separating it from the background absorbance of the tissues and venous blood makes it possible to estimate the oxygen saturation of hemoglobin in the arterial blood.[16] it is called spo2 (in contrast with sao2) for oxygen saturation being measured by the pulse oximeter. however, carboxyhemoglobin and methemoglobin (normally present in very low concentrations) cannot be distinguished by the usual pulse oximetry. pulse oximetry thus overestimates oxygen saturation in carbon monoxide poisoning making the findings invalid. multi-wavelength or laboratory co-oximetry on the blood sample is useful in such cases as it is the gold standard.[15,16] pulse oximeters using lights of multiple wavelengths are also available from some manufacturers with variable results.[17] designs that do not require empirical calibration are also under consideration. [17] fig. 2. valid pulse oximeter reading with normal pulse trace; spo2: oxygen saturation of hemoglobin in the arterial blood as estimated by the pulse oximeter. [reproduced from who 2020. (https:// www.who.int/publications-detail/clinical-care-ofsevere-acute-respiratory-infections-tool-kit) (cc by-nc-sa 3.0 igo)] nail polish and excessive ambient light are also the sources of error. besides this, motion of the probes while recording and low perfusion status add errors to the estimates.[13] also, abnormal shape of the pulse wave displayed on the screen should question the validity of the record. the health care worker can apply the oximeter to his/her own finger to make sure that the tool is functioning well.[18] normal reading and pulse wave is shown in fig 2.[18] reflectance pulse oximeters also work on a similar principle but both the emitter and the sensor are placed on the same surface e.g. forehead.[16] they are more useful than the transmittance pulse oximeters in the conditions when the fingers are poorly perfused due to local vasoconstriction.[17] the accuracy of pulse oximetry clinical studies have shown that spo2 readings differ from the sao2 readings obtained from the gold standard multi-wavelength co-oximetry by 2-4%.[17] as it is a significant difference, cut off level of spo2 to diagnose hypoxemia is set at 93% to make it parallel with the sao2 of 90%. regarding the use for continuous monitoring, pulse oximetry can detect sudden drop of spo2 by 3-4%. [17] the manufacturers use findings from healthy volunteers subjected to induced hypoxemia (but not less than spo2 of 70% due to ethical considerations) to validate their recordings. therefore, findings in the critically ill patients at the extremes of age with oxygen saturation below 70% may not be so accurate. [15,16,17] from clinical viewpoint, however, it does not limit its use as the target spo2 is above 90%.[3] when these aspects are analysed together with its other benefits that are already mentioned, pulse oximetry is considered as an essential part of the standard critical care.[17,18] interpretation of the readings and limitations of pulse oximetry normally spo2 reading is 96% or greater while breathing room air at rest. a patient with spo2 of 94% or higher on room air is considered stable if the patient is otherwise stable. spo2 values of 93% or less (90% or less for patients with chronic hypoxic conditions) are considered to have high risk of developing severe illness though other risk factors also need to be considered.[14] spo2 less than 90% in an acutely ill patient is a clinical emergency.[18] the target spo2 values with oxygen therapy are 9396%. for patients with chronic type ii respiratory failure the target levels are 88-92%.[14] despite the remarkable utility of pulse oximetry as explained above, the best possible j. lumbini. med. coll. vol 8, no 1, jan-june 2020 joshi lr. principles, utility and limitations of pulse oximetry in management of covid-19.joshi lr. principles, utility and limitations of pulse oximetry in management of covid-19. jlmc.edu.np outcomes are achieved only when it is used properly and the findings are interpreted carefully being aware of its limitations.[13,15] basic understanding of the technology behind the tool and the physiology of the parameter that it intends to measure and evaluate are essential. when oxygenation of blood in the lungs is impaired, partial pressure of oxygen in arterial blood (pao2) decreases and oxygen saturation of arterial blood (sao2) also decreases but not as much as pao2 in mild to moderate cases (as shown by the flat top portion of the curve in figure 2).[3] it means that even a small fall in sao2 reading indicates a greater fall in pao2 in this portion of the curve. for example, sao2 of 90% (normal about 98%) corresponds to pao2 of 60 mmhg (normal about 95 mmhg). further decrease in pao2 (below 60 mmhg) due to pulmonary lesions reduces sao2 more rapidly as shown by the slippery slope of the curve. on the positive side, oxygen supplementation can raise pao2 and sao2 to a greater extent in such cases. moreover, sao2 gives an important but not the complete information about oxygen delivery to the tissues. oxygen delivery to the tissues depends on oxygen content of the arterial blood and rate of blood flow to the tissues or cardiac output.[1,3] besides sao2 and pao2, oxygen content of blood also depends on concentration of normal hemoglobin in blood. hence, normal sao2 in severely anemic patients does not meet the oxygen demands of the tissues. lack of validity of the pulse oximetry reading in elevated levels of carbon monoxide and methemoglobin have already been discussed. another important factor to be considered to evaluate oxygen delivery to the tissues is the rate of blood flow to the tissues. hence, spo2 value can falsely reassure one of the adequate oxygen delivery to the tissues. fortunately, patients suffering from severe anemia or poor perfusion as in septic shock, benefit from oxygen supplementation as it increases oxygen delivery to the tissues by increasing the amount of oxygen dissolved in the arterial blood. though quantitatively small, this additional dissolved oxygen may be life-saving in critically ill patients.[2] moreover, pulse oximetry alone does not reflect the overall ventilation status particularly in patients on oxygen supplementation. carbon dioxide status and ph need to be determined by other techniques e.g. end tidal co2 or arterial blood gas analysis. other scenarios that decrease the reliability of pulse oximetry are extremes of oxygen saturation as already mentioned. the pulse oximetry readings also need to be interpreted in the context of the altitude of the place from the sea level. the reference values mentioned in the literature are generally for measurements on people breathing room air at sea level at rest unless mentioned otherwise. with increase in altitude, the spo2 values decrease even in healthy people. for example, at an altitude of 1400 m (altitude of kathmandu), spo2 values are 1.5% less than those at sea level.[13] moreover, spo2 values should be interpreted in the context of oxygen supplementation to evaluate the severity of the disease. the status of a patient with spo2 of 90% with oxygen supplementation at 10l/min is obviously more critical than the status of another patient with the same value on room air.[1] as covid-19 is a highly infectious disease, hand hygiene and dedicated use of pulse oximeter or if not possible, gentle cleaning and disinfection of the probe with soap water or alcohol swab after each use are integral components of infection prevention and control measures.[18] in sum, pulse oximetry is an essential component of the standard care of covid-19 patients in all settings. its value is even greater in low-resource settings. and for best clinical outcomes, the pulse oximetry readings need to be interpreted in the context of hemoglobin status, tissue perfusion, arterial blood carbon dioxide concentration and oxygen supplementation status. conflict of interest: author declares that no competing interest exists. funding: no funds were available for the study. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 joshi lr. principles, utility and limitations of pulse oximetry in management of covid-19.joshi lr. principles, utility and limitations of pulse oximetry in management of covid-19. jlmc.edu.np references: 1. openwho. geneva: world health organisation; c2016-2020. who clinical care severe acute respiratory infection training. openwho. available from: https://openwho.org/courses/ severe-acute-respiratory-infection accessed on 2020 may 14. 2. hall je. guyton and hall textbook of medical physiology. 13th ed. new delhi: reed elsiever india; 2015. 3. 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g, cai xp, et al. an overview of covid-19. j zhejiang univ sci b. 2020;21(5):343‐360. pmid: 32425000 pmcid: pmc7205601 doi: https://dx.doi.org/10.1631/ jzus.b2000083 8. wilcox sr. management of respiratory failure due to covid-19. bmj. 2020;369. doi: https:// doi.org/10.1136/bmj.m1786 9. gattinoni l, coppola s, cressoni m, busana m, rossi s, chiumello d. covid-19 does not lead to a “typical” acute respiratory distress syndrome. am j respir crit care med. 2020;201(10):1299–300. doi: https//doi. org/10.1164/rccm.202003-0817le 10. dondorp am, hayat m, aryal d, beane a, schultz mj. respiratory support in novel coronavirus disease (covid-19) patients, with a focus on resource-limited settings. am j trop med hyg. 2020; [epub ahead of print]. pmid: 32319424 doi: https://doi.org/10.4269/ ajtmh.20-0283 11. world health organisation. critical preparedness, readiness and response actions for covid-19. available from: https://www.who. int/publications-detail/critical-preparednessreadiness-and-response-actions-for-covid-19. accessed 2020 may 31. 12. world health organisation. clinical care for severe acute respiratory infection: toolkit. covid-19 adaptation. geneva: world health organization; 2020 (who/2019ncov/sari_ toolkit/2020.1). available from: https://apps. who.int/iris/handle/10665/331736 accessed 2020 may 14. 13. pretto jj, roebuck t, beckert l, et al. clinical use of pulse oximetry: official guidelines from the thoracic society of australia and new zealand. respirology. 2014;19(1):38–46. pmid: 24251722 doi: https//doi.org/10.1111/ resp.12204 14. nepal medical council, covid-19 treatment guidance committe. interim clinical guidance for care of patients with covid-19 in health care settings. kathmandu: nepal medical council; 2020 april 3. 30p. available from: https:// nmc.org.np/files/4/nmc%20covid-19%20 interim%20clinical%20guideline%20for%20 care%203%20april.pdf accessed 2020 may 9. 15. sinex je. pulse oximetry: principles and limitations. am j emerg med. 1999;17(1):59– 67. doi: https://doi.org/10.1016/s07356757(99)90019-0 16. mannheimer pd. the light-tissue interaction of pulse oximetry. anesth analg. 2007;105(6 suppl):s10-17. doi: https//doi.org/10.1213/01. ane.0000269522.84942.54 17. nitzan m, romem a, koppel r. pulse oximetry: fundamentals and technology update. med devices auckl nz. 2014;7:231–9. doi: http:// dx.doi.org/10.2147/mder.s47319 18. world health organisation. pulse oximetry training manual. geneva: world health organisation; 2011. available from: https:// www.who.int/patientsafety/safesurgery/pulse_ oximetry/who_ps_pulse_oxymetry_training_ manual_en.pdf accessed 2020 may 12. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1 jan-june 2020 ___________________________________________________________________________________ submitted: 5 may, 2020 accepted: 21 may, 2020 published: 22 may, 2020 a clinical professor of surgeryuniversity of kansas school of medicine, kansas city, united states. b secretary, american college of surgeons. corresponding author: tyler g. hughes e-mail: rsurgeon1@gmail.com how to cite this article: hughes tg. perspectives on the covid-19 pandemic: truth and trust. journal of lumbini medical college. 2020;8(1):2 pages. 2020;8(1):2 pages. doi: https://doi: https://doi.org/10.22502/jlmc.v8i1.336doi.org/10.22502/jlmc.v8i1.336 epub: 2020 may epub: 2020 may 22._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.336 tyler g. hughesa,b perspectives on the covid-19 pandemic: truth and trust when one examines life in various countries of the world regardless of type of government, health system, or even culture, one sees the great diversity of the world but also large areas of commonality among all people and all places. the twentieth century’s history is one of almost constant war, two of those wars having affected the majority of the global population, but only one event parallels today’s pandemic in impact on almost every individual on planet earth: the great pandemic of 1918, which by various accounts took between 20 to 100 million lives over a three-year period. when word began to spread of an epidemic in china in late 2019, most of us worldwide were only mildly concerned. threats from swine flu, h1n1, and ebola had all been temporary scares, and the effect on most individuals was mild. so, the world went on with its important activities assuming that soon we would hear the epidemic was contained and yet another catastrophe of epic proportions had, like an errant asteroid, passed without tragedy to most. of course, we all know now that events took a far different course. nepal’s course so far in this troubled time resembles that of new zealand and other countries that have generally been spared the medical tsunami filling hospitals beyond capacity as has been seen in new york city, italy, and china. large parts of the united states similarly have been bracing for an enormous blow that has not come. the price paid for avoidance of medical catastrophe was economic collapse. now every nation, every individual, is facing an ongoing challenge of choosing medical risk versus economic reward. great minds and institutions as well as government leaders are being forced to make decisions based on insufficient knowledge. the american college of surgeons (acs) has walked with all of the world, experiencing much of the same emotions and sharing an enormous amount of medical and technical information. because the acs has been a world leader in trauma response, it also has rather naturally developed expertise in disaster response. though this was a disaster like no other, we found that what we knew from other such smaller events gave us a path for leading through this universal event. here are the technical lessons we learned: as always, the first phase of a disaster is that of confusion and non-recognition that a disaster is not just imminent but is actually happening. the second phase is marked by preparation. the third phase is appropriate triage and utilization of resources. finally, after-event review is essential for preparation for the next disaster. in all these phases, communication, transparency, and pragmatic optimism are the essential ingredients to procure the best outcome. perhaps the best success the acs achieved was through communication. covid-19, while a new disease in humans, still could be addressed through knowledge we already possessed. also, as events unfolded, new information and some misinformation was traveling at the speed of light around the world. without a communication strategy, all of this would become just noise, unintelligible to those in need. as the college began to recognize the nature of the disaster, our first steps hughes tg. perspectives on the covid-19 pandemic: truth and trust. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-june 2020 were to develop clear communications among our fellows, the government, and the public. this is the mark of true leadership. the smartest person on the planet cannot be of service if that person has no way of getting a coherent message out. while we had dozens of leaders across the globe working with us, the college funneled all output through a newsletter published twice a week using input from three main sources: our own membership, medical literature, and government data. managing crisis, though, is not just information transmission. human beings are emotional creatures. fear, stress, anger, and sorrow play a central role in any crisis. emotions, like the virus we fight, are contagious. those emotions that sap energy and create despair can make matters far worse. certainly, we see this in our still-developing economic crisis as well as the purely medical one we face. so, it is crucial at this time that we in the medical profession seek to be the calm voice of reason as is always necessary. this does not mean telling the world that we know all the answers and that all will be well. truth and trust go together. our patients and our government leaders will not trust us if we do not tell the truth. however, projecting messages of doom do not inspire others to endure the hardships being faced. we know from history that all pandemics pass. our common goals as physicians remain to save as many lives as we can, to be present for our patients, and to help them understand that despite the fears of covid infection they will need medical care for other reasons. we know how to do all these things. we just have to do them on a larger scale than before but with the same basic mission, to serve all with skill and fidelity. conflict of interest: the author declares that no competing interest exists. funding: no funds were available for the study. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 23 may, 2020 accepted: 29 may, 2020 published: 06 june, 2020 a assistant professor, department of obstetrics and gynaecology, b lumbini medical college teaching hospital, palpa, nepal. corresponding author: deepak shrestha email: thecups814@gmail.com orcid: https://orcid.org/0000-0002-9006-3640 how to cite this article: shrestha d. limitations of covid-19 fever clinic as the first point of contact: are we relying too much? an experience from a tertiary center. journal of lumbini medical college.2020;8(1):2 pages. doi: https://doi.org/10.22502/jlmc.v8i1.352 epub: 2020 june 06._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.352 deepak shrestha a,b limitations of covid-19 fever clinic as the first point of contact: are we relying too much? an experience from a tertiary center in nepal, after the first case was diagnosed with corona virus disease -19 (covid -19) in a 32-year-old returnee from wuhan, china on 13 january 2020,[1] it took more than four months to reach a figure of 500 infected cases.[2] seventy of them have already recovered and returned home.[2] however, the curve has been taking a steeper slope after the first 50 cases were documented. with the first mortality from covid-19 confirmed on 16th may, 2020, the fact that this pandemic is tightening its grip in the country is more evident now. and with each passing day, more cases are being diagnosed. in such a situation, strategies of screening the infected/ suspects are of paramount importance and those already in place should be strengthened. on march 19, the nepal medical council asked all hospitals, both private and public, with over 100 beds to operate a separate fever clinics and postpone elective surgeries to conserve resources for an outbreak.[3] such fever clinics aim at separating and filtering out the suspected/ diagnosed covid-19 patients. arguably started first in kathmandu medical college, fever clinics now have been established and run in almost every large health care centers. united nations international children’s emergency fund (unicef) has been pivotal in supporting some of these centers.[4] rising up to the task, lumbini medical college and teaching hospital started its fever clinic from 22 march 2020 in a separate make shift place which later moved to a more organized structure. the fever clinic is set up at a separate area in order to keep off suspected patients from the main hospital. each day, an average of 200 patients are being screened in the fever clinic. a consultant-supervised resident doctor teamed up by an intern and a nurse run the fever clinic. they assess the symptoms of the patients e.g. fever paired with cough, sore throat, shortness of breath, diarrhea, assess their travel history and takes a temperature reading to determine further actions. despite such elaborate investment in terms of human and materialistic resources, fever clinics have clearly been not able to detect all the suspicious cases. reports of cases being transferred to isolation ward after being attended in emergency department and some after being treated in the ward for days are few evidences. the key problem is the asymptomatic status of many positive cases. people with no symptoms and history of travelling, who might have acquired infection from contact to other unconfirmed cases easily escape detection at fever clinics. formulation and implementation of stringent protocols, dedicated contact tracing and testing might minimize this to some extent. owing to the fear of being denied admission or treatments in the hospitals, many patients resort to concealing their true history at fever clinics. many fever-patients are found to have self-medicated with over the counter anti-pyretic prior visiting to the hospital. amidst disturbing news of patients being turned away from hospitals floating on the media, such way-outs on part of the patients are only but expected.[5] this actually is leading to assimilation of suspicious cases with the non-exposed ones. shrestha d. limitations of covid-19 fever clinic as the first point of contact: are we relying too much? jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 as it is an entirely new disease, no country was adequately prepared for the pandemic. as such, many fever clinics which are newly constructed or converted from old unused set-ups are not ideally separated from the main hospital buildings or isolation wards. suspected/confirmed cases, while being transported from fever clinics, thus not only face challenge during the transit but equally confer the high probability of exposing the hospital premises themselves. with inadequate and substandard personal protective equipment, health care workers who dedicated themselves round the clock in fever clinics are at high risk of being infected themselves. furthermore, the immense mental pressure they are withstanding just adds on to their plight. the flip side of this whole re-direction of the resources, attention and focus to fever patients is; unfortunate incidents of serious cases being missed or delayed of their care. patients dying on the way while being bounced from one hospital to another are not unheard of. having said so, currently there is no other ideal alternative to fever clinics as screening mechanism at first point of contact in the current scenario. the solution lies in continuing to strengthen the effectiveness of fever clinics complemented with strategies of accurate tracing and testing, quarantine management, expanding isolation capacity and raising awareness. conflict of interest: the author declares that no competing interest exists. funding: no funds were available for the study. references: 1. bastola a, sah r, rodriguez-morales aj, lal bk, jha r, ojha hc, et al. the first 2019 novel coronavirus case in nepal. the lancet. 2020;20(3):279-80. pmid: 32057299 doi: https://doi.org/10.1016/s1473-3099(20)30067-0 2. corona info-daily census. government of nepal, ministry of health and population. 2020 may 22. available from: https://covid19.mohp. gov.np/#/ 3. the covid-19 outbreak so far and how nepal can prepare for the worst. the kathmandu post. 2020 mar 21. available from: https://tkpo. st/2qcgtsg 4. first point of contact: covid-19 fever clinics. unicef, nepal. 2020 apr 5. available from: https://www.unicef.org/nepal/stories/first-pointcontact-covid-19-fever-clinics 5. gautam l. hospital turns away patients with fever. the himalayan times. 2020 mar 1. available from: https://thehimalayantimes.com/ nepal/hospitals-turn-away-patients-with-fever/ lmc journal vol. 2.indd 111 penetra ng brain injury sharma ap department of surgery, lumbini medical college and teaching hospital, tansen-11, pravas, palpa, lumbini zone, nepal corresponding author: prof. achyut prasad sharma, frcs(ed), neurosurgeon and head department of surgery, lumbini medical college and teaching hospital, tansen-11, pravas, lumbini zone, nepal; e-mail: achyut-s@hotmail.com abstract in the past 20 years, there has been an increase in the incidence of head injuries caused by gunshot wounds. penetra ng brain injury is a trauma c brain injury caused by high-velocity projec les or low-velocity sharp objects. a wound in which the projec le breaches the cranium but does not exit is referred as a penetra ng wound, and an injury in which the projec le passes en rely through the head, leaving both entrance and exit wounds, is referred to as a perfora ng wound. a large number of these pa ents who survive their ini al wounding will nevertheless expire shortly a er admission to the hospital. un l the introduc on of asep c surgery in the last quarter of the nineteenth century, penetra ng missile injuries of the brain were almost universally fatal. we have learned a great deal about gunshot wounds and their management from military experience gained during mes of war, when a large number of fi rearm-related casual es are treated in a short period of me.1 newly designed protec ve body armor has reduced the incidence of penetra ng brain injuries signifi cantly. many of the vic ms in the vicinity of a cased explosive or an improvised explosive device will incur injuries by fragments. blast injury is a common mechanism of trauma c brain injury among soldiers serving in war zone. each war has had diff erent lessons to teach. world war i for example, proved the effi cacy of vigorous surgical interven on. during world war ii, the importance of ini al dural repair and an bio c medica on was fi rst, debated, then acknowledged, and fi nally, universally accepted. the incidence of blast-induced trauma c brain injury has increased substan ally in recent military confl icts. blast-induced neurotrauma is the term given to describe an injury to the brain that occurs a er exposure to a blast. resent confl ict has exposed military personnel to sophis cated explosive devices genera ng blast overpressure that results in secondary cellular and molecular insults to the brain parenchyma akin to diff use brain injury. in soldiers with varying amounts of body armor, the pa ern is quite diff erent. what had previously been fatal penetra ng brain injuries now become treatable brain injuries as a consequence of secondary damping of energy by the helmet. trauma c brain injury is not prevented by a protec ve helmet. highand low-frequency blast waves disrupt the blood-brain barrier and produce massive brain swelling in a very short me, thereby necessita ng urgent decompressive craniectomy, and when low in energy, such blast waves may result in cytoskeletal and diff use axonal injury that leads to neurodegenera on. penetra ng trauma c brain injury is typically iden fi ed and treated immediately mild trauma c brain injury may be missed, par cularly in the presence of other more obvious injuries. in recent years there has been an apparent paradigm shi of scien fi c interest in long-term eff ects of mild trauma c brain injury and its contribu on to pos rauma c stress disorder.1,¹4 the introduc on of guidelines for the management of penetra ng brain injury has revolu onized the medical and surgical management of penetra ng brain injury during the last decade¹. there has been a paradigm shi toward a less aggressive debridement of deep seated fragments and a more aggressive an bio cs prophylaxis in an eff ort to improve outcomes. keywords: penetra ng brain injury, debridement, less aggressive surgical management. introduction gunshot wounds are a major health problem. many deaths are due to gunshot wounds to the head, which are the most lethal. in the spring of 1998, the interna onal brain injury associa on, the brain injury associa on, usa, the american associa on of neurological surgeons, and the congress of neurological surgeons began work on the formula on of standard medical and surgical management for penetra ng brain injury pa ents. thus, guidelines for the management of penetra ng brain injury was published in 2001, which a empted to standardize both the medical and surgical management of penetra ng craniocerebral trauma. op mum management of penetra ng brain injury requires a good understanding of ballis c characteris cs of the wounding agents and the mechanism of wounding and the ssue damage and adherence to basic surgical principles are prerequisites to a carefully executed and defi ni ve surgical management, when indicated¹. ballistics and pathology a fi rearm is any weapon that uses an explosive powder to propel a projec le. firearms are classifi ed based on their size, their muzzle velocity and type of projec le fi red. the ability of bullets, shrapnel, and low velocity reveiw article l m coll j 2013; 1(2): 111-116 112 journal of lumbini medical college objects such as knives and arrow to penetrate the brain is dependent on their energy, shape, the angle of approach, and characteris cs of intervening ssues. primary injury to the brain is determined by the ballis c proper es. there are three components to ballis cs: interior, exterior and terminal. the behavior of a projec le on impac ng its target is terminal ballis cs. interior ballis cs is defi ned as the science of mo on of a projec le through a gun barrel as a result of combus on and expansion of a powder charge. exterior ballis cs is the projec le’s behavior in a medium such as air and is dependent on the projec le’s shape, caliber, weight, ini al velocity, and ballis c coeffi cient. most handguns and revolvers use heavy bullets and have muzzle veloci es ranging from 550 to 900 /sec. these are referred to as low velocity missiles. in contrast, most of today’s rifl es use very light bullets and have muzzle veloci es averaging 3000 /sec, with a range of 2300 to 6000 /sec. the wounding energy (e) of a projec le depends mainly on its weight and velocity; hence, e= ½m (vi²vr²), where m is the projec le’s weight, vi is the impact velocity, and vr is the residual velocity if the projec le has a perfora ng mode. transla on of kine c energy into tissue damage is brought about by the tremendous amount of crushing pressure exerted on the brain parenchyma. juxtamissile pressure aff ects the brain ssue immediately in the path of a projec le and may be in the thousands of atmospheres. longitudinal strong shock waves start immediately a er impact of the projec le with brain ssue and travel in spheres ahead of the projec le with veloci es in excess of 1460m/sec. shock waves last up to 10 μsec and measure up to 80 atm. ordinary pressure waves measuring up to 20 to 30 atm are generated as the projec le transfers its kine c energy to the surrounding brain tissue and produces a temporary cavity. the nega ve pressure generated by the temporary cavity can suck contaminated material into the cavity. every cycle of temporary expansion and collapse creates signifi cant surrounding ssue injury to the brain.6,11 this can result in shear-like injury of the neurons or can result in epidural hematomas, subdural hematomas, or parenchymal contusions. the low-velocity sharp objects, which lack any defi nable ballis cs, penetrate the scalp, skull, and dura and lacerate the brain parenchyma, including the cortex, subcor cal white ma er, basal ganglia, and diencephalon or brain stem and any blood vessels in their path. similarly, low-velocity projec les from ar llery shells, improvised explosive devices, and spent bullets cut into the brain just like sharp objects do. fragments of high-explosive devices are of various shapes and sizes and can weigh as much as 100 g. these should be regarded as high-velocity missiles, because ini ally they travel at speed of over 3000 /sec, although they rapidly lose speed because of their volume, irregular shape, and aerodynamic instability and become low-velocity missiles at distances as near as 10 meters. the extent of ssue damage depends on the amount of energy expended by the missile at the point of ssue penetra on. as the projec le travels through the brain parenchyma, it is preceded by transient sonic wave (2μs) which appears to have minimal infl uence on surrounding ssue. the projec le itself, however, crushes the so brain ssue in its path, crea ng a permanent track of injury. this is in addi on to the secondary missiles such as bone and metal fragments created from the impact of projec le on the skull. addi onally, a penetra ng injury is expected to be much more severe in case of a close range fi rearm injury as maximum amount of ini al kine c energy is transferred to the brain ssue. clinical findings most patients involved in civilian gunshot wounds to head are male (87%) in the third to fourth decade of life and are nearly equally divided between homicides (50%) and suicides (46%), with a small percentage being due to accidents (4%). military vic ms of penetra ng brain injury tend to be younger. in civilian penetra ng brain injury an altered level of consciousness is the rule. glasgow coma scale score of the pa ents is used to assess the level of consciousness.7 when sharp objects, low-velocity and spent bullets penetrate the brain, they may cause focal deficits; however, if they do not disrupt the neuronal circuitry in the brainstem tegmentum or ascending re cular ac va ng system, they may not cause a depressed level of consciousness. management the guidelines for the management of penetrating brain injury was adopted and published in the journal of trauma in august 2001, which has standardized both the medical and surgical management of these unique and challenging injuries.¹ the pre-hospital rescue, intuba on, oxygenation, ventilation, volume resuscitation, and medical management of pa ents with penetra ng brain injury must clearly be adopted from diff erent pre-hospital emergency department, cri cal care, and surgical guidelines. immediately a er arrival of the pa ent in the emergency department, a primary survey and stabilization of the pa ent with regard to the airway, breathing, cervical spine, and circula on including external hemorrhage should be achieved. a er resuscita on, an inspec on of superfi cial wound should be done. the skin, especially the scalp, must be examined me culously for wounds as it may be covered by blood-ma ed hair. an entrance wound should be iden fi ed and its loca on recorded as well as any exit wounds when they exist. the superfi cial scalp should also be observed for powder burn, which would imply a close range fi rearm injury. any cerebrospinal fl uid, bleeding, or brain parenchyma oozing from the wound should be noted, the size of the defi cit should also be documented. all orifi ces 113 ap sharma must be checked for retained foreign bodies, the missile, teeth, and bone. a detailed neurological examina on should be performed, and post-resuscita ve glasgow coma scale of the pa ents should be documented. a complete head to toe examina on is recommended as penetra ng brain injury pa ents may have mul ple organ injuries. a detailed medical history from family or friends and a chronology of the incidence from a witness is warranted. ini al laboratory investigation must include a complete blood count, electrolytes, coagula on profi le, blood grouping and crossmatching and blood gas analysis. once the ini al evalua on is done, the pa ent should have imaging studies. the u lity of various neuroimaging methods used in pa ents with penetra ng brain injury lies on the poten al management and prognostic implications of these modalities. plain radiographs of the skull can be considerable value in identifying the cranial wounds, the location of missile and bone fragments, and the presence of intracranial air. computed tomography scanning of the head is now the primary modality used in the neuroradiologic evalua on of patients with penetrating brain injury.2 computed tomography, including three-dimensional reconstruc on of the head, defi nes the entry site and trajectory of the fragment into the brain, perforating, penetrating, or tangential terminal ballistics, and involvement of the paranasal sinuses, orbits, skull base, and mastoids. it defi nes the missile track, number of tracks and ricochet, whether the penetra on is across the midsagi al or midcoronal planes, and the presence or absence of intracranial hematomas such as acute epidural, subdural, intracerebral, or intraventricular hematomas. the extent of brain edema and ischemia and brainstem involvement is defi ned by computed tomography. if a vascular injury is suspected, then cerebral angiography is recommended. the sensi vity to diagnose vascular injury such as trauma c dissec on of the caro d or vertebral arteries with computed tomography angiography has been reported to be similar or even superior to that of magnetic resonance imaging angiography. in terms of other vascular pathology, the incidence of vasospasm in the se ng of blast-related penetra ng trauma c brain injury is high, approaching 50%. thus, it is recommended that pa ents with acute penetra ng trauma c brain injury from explosives undergo regular noninvasive vascular assessment via transcranial doppler, with follow-up invasive digital subtrac on angiography for defi ni ve diagnosis and endovascular interven on. magne c resonance imaging is generally not recommended but can be useful in penetra ng brain injury caused by a wooden object. when stabiliza on and imaging are complete, decisions concerning further therapy o en take into account the pa ent’s neurologic status as determined by the glasgow coma scale score. poor survival and outcome are reported in pa ents with gcs scores between 3 and 5 points. most neurosurgeons agree that a pa ent with a postresuscita on gcs score of 3 points with two dilated nonreac ve pupils but without a mass lesion on ct should not receive surgical interven on. it has long been known that bihemispheric and transventricular injuries have poor prognosis. surgical management the general guidelines of surgical treatment include: adequate debridement of devitalized ssue, removal of the mass lesions, removal of the accessible in-driven bone fragments and foreign bodies, adequate haemostasis, dural reconstruc on and complete closure of the scalp. the “infec on in neurosurgery” working party of bri sh society for antimicrobial therapy recommended the following regimen for penetra ng brain injury: intravenous co-amoxiclav 1.2g q 8h, or intravenous cefuroxime 1.5g, then 750mg q 8h, with intravenous metronidazole 500mg q 8h. it is recommended that this regimen should be started as soon as possible a er injury and con nued for 5 days postopera vely. scalp lacera ons from missile head wounds are usually contaminated, have devitalized edges, and may be hard to repair. treatment of small entrance wounds with local wound care and closure in pa ents whose scalp has not been devitalized and have no signifi cant intracranial pathological fi ndings on ct scan is not only adequate but recommended according to guidelines. when scalp is penetrated by a projec le, it is shredded, torn, or burned with devitalized edges of up to few millimeters, if feasible, it is strongly recommended that a plas c surgeon be consulted for primary closure of the skin over a torn dura, especially if the dural tear is at the base in the vicinity of the basal cisterns, near the air sinuses or mastoid air cells, to prevent csf fi stulas. once a pa ent has been classifi ed as a surgical candidate, a empts should be made to operate within 12 hours of injury to prevent infec on and resul ng abscesses.7 in the presence of signifi cant mass eff ect, debridement of necro c brain ssue along with safely accessible bone fragments is recommended. brandvold and colleagues, taha and associates, and more recently amirjamshidi and coworkers, based on their experience in israel, lebanon, and iran, respec vely, have reported on minimal debridement of missile head wounds in special circumstances.² similarly, during arm-confl ict in nepal, the penetra ng brain injuries were managed by less aggressive surgical debridement of devitalized brain ssue, removal of easily accessible metal and in-driven bone fragments with water ght closure of the dura mater at birendra hospital.¹0 it should be noted that any deeply seated bone fragments especially those in eloquent brain areas should not be retrieved because this has been shown to correlate with worse outcomes. this has marked a signifi cant trend since vietnam era to proceed with a more conservative, minimally invasive approach toward cerebral debridement as this has been shown to improve outcomes and lower morbidity. as with bone fragments, only accessible missile fragments in non114 journal of lumbini medical college eloquent brain should be retrieved although there has been some sugges on that removal of all missile fragments may decrease the risk of seizures. intracranial haematomas with signifi cant mass eff ects should be evacuated. although craniectomies around the entrance site of a projec le have been the favored technique in previous military confl icts, the present recommenda on is craniotomy and debridement of the skull with replacement of the bone to avoid the future need for cranioplasty. recent war me explosive injuries from a transfrontal or transtemporal direc on may disrupt the anterior and lateral skull base. such injuries are associated with signifi cant risk for csf leaks and loss of anatomic con nuity between the anterior cranial fossa, orbits, maxilla, and infratemporal fossa. during the recent confl ict this has led to an aggressive strategy of early skull base repair with tanium mesh, local pericranium, fat, temporalis fascia, and muscle. complications pa ents who survive penetra ng craniocerebral injuries are at risk of experiencing mul ple complica ons, including persistence neurological defi cits, infec ons, epilepsy, csf leak, cranial nerve defi cits, pseudoaneurysms, arteriovenous fi stulas, and hydrocephalus. the principal objec ves when trea ng pa ents with craniocerebral missile wounds are to lower morbidity and mortality and begin rehabilita on. extensive studies have evaluated long-term survival and cogni ve, behavioral, and func onal outcome a er pbi, especially in war injuries sustained in world war ii and korean and vietnam confl icts.5,13 for pa ents who survive a pbi, the size and loca on of the parenchymal injury may have a long-las ng eff ect on intelligence test scores. the focal motor defi cits with or without sensory defi cit can be hemiparesis, monoparesis, triparesis, paraparesis, pseudobulbar palsy, ataxia or spas c ataxia, quadriparesis, visual fi eld defi cit, cranial nerve defi cit, speech diffi culty etc. depending on the entrance site, a persistent focal neurological defi cit is quite common in the survivors. the incidence of motor defi cits, visual fi eld cuts, and speech diffi cul es in the casual es from the iran-iraq war was 34.6%, 13.7%, and 6.1%, respec vely. infections since the early 1900s, various factors have been blamed for the high rate of infec on in war wounds like delays in evacuation of casualties, inadequate debridement and inability to close dura and skin water ght, lack of an bio cs, coma, extent of injuries, especially mul ple lobe and ventricle involvement, retained bone fragments and cerebrospinal fl uid fi stulas. missile head wounds are contaminated wounds. the extent to which contamina ng organisms contribute to deep wound infections is debatable. deep infec on remains the most important aspect of pbi that a neurosurgeon has to deal with. a follow-up revealed that in a popula on of 1221 pa ents with penetra ng cerebral trauma incurred in the vietnam war, there was 3 percent incidence of brain abscess.4 this complica on usually occurred during the second or third week of injury. no rela onship existed between the presence of retained fragments and the development of either a seizure disorder or a subsequent cns infec on. overall, past military experiences have shown that mely evacua on and prophylac c ins tu on of broad-spectrum an bio cs followed by careful debridement of penetra ng craniocerebral wounds signifi cantly reduce the incidence of cns infec on. csf fi stulas should be treated most expedi ously to prevent the severe neurological sequelae of the cns infec on. dehiscence of a scalp fl ap incision is usually a result of infec on in an otherwise healthy young trauma vic m, but it can result from a failure in technical aspect of dural or scalp closure. posttraumatic epilepsy the rela on of epilepsy to brain trauma has been recognized since the days of hippocrates, but the pathogenesis of the pos rauma c epilepsy is s ll not clearly understood. pa ents with focal neurological signs or large lesions has increased risk of epilepsy, and the site of the lesion may have been more important than size in determining in occurrence. trauma c brain injury greatly increases the risk for a number of mental health problems and is one of the most common causes of medically intractable epilepsy in humans6. several models of trauma c brain injury have been developed to inves gate the rela onship between trauma, seizures, and epilepsy-related changes in neural circuit func on. these studies have shown that the brain ini ates immediate neuronal and glial responses following an injury, usually leading to signifi cant cell loss in areas of the injured brain. over me, long-term changes in the organiza on of neural circuits, par cularly in neocortex and hippocampus lead to an imbalance between excitatory and inhibitory neurotransmission and increased risk for spontaneous seizures. these include altera ons to inhibitory interneurons and forma on of new, excessive recurrent excitatory synap c connec vity.6 penetra ng brain injury is one of the major risk factor for pos rauma c epilepsy. studies of veterans from world war i, world war ii, and the korean, vietnam, and iran-iraq wars indicate that between 34% and 50% vic ms of penetra ng brain injury become epileptic when monitored for 2 to 15 years. follow-up studies indicated that the incidence of pos rauma c epilepsy in vic ms of pbi is higher than that in vic ms of closed head injury.5 the guidelines for “management and prognosis of penetra ng brain injury” recommend prophylac c an -seizure medica ons for the fi rst week a er pbi but not beyond that. cerebrospinal fluid leak 115 cerebrospinal fl uid fi stulas in penetra ng craniocerebral wounds cons tute a serious complica on, which can increase morbidity and mortality. cerebrospinal fl uid leak develops because of the dural tear by the missile along with a failure to adequately seal the defect by normal ssue healing processes.8 csf leaks can present through the entry or exit sites of the projec le as well as through the ear or nose when the mastoid hair cells and open air sinuses have been violated, respec vely. the drainage of csf from the site of opera ve debridement is o en caused by incomplete closure of the dural lacera on at the base of the skull or by a convexity dural suture line that is too ght. if the csf leak develops several days later, in the absence of hydrocephalus or of mass eff ect and/or haematoma, one should assume and treat for wound infec on. when there is an injury of the frontal fossa fl oor, recurring csf leaks usually result from an ini al incomplete explora on of the fossa fl oor. during the recent confl ict this has led to an aggressive strategy of early skull base repair with tanium mesh, local pericranium, fat, temporalis fascia, and muscle. this step is followed by more extensive skull base reconstruc on at level fi ve medical centers consis ng of rota onal or myocutaneous free fl aps in pa ents with persistent csf leaks, progressive skull base deformity, and encephalocele. pseudoaneurysms and arteriovenous fistulas vascular injuries are thought to be one of the main causes of fi eld mortality among pa ents with missile wounds to the head. trauma c intracranial aneurysms are rela vely rare lesions most commonly associated with penetra ng wounds of the brain.9 trauma c aneurysms are formed a er the par al or complete rupture of the arterial wall. the true incidence of trauma c neurovascular injury in pa ents with blast overpressure, closed brain injury, and pbi remains largely specula ve.¹² although fi rst described in 1895 by guibert, trauma c intracranial aneurysms have received li le a en on in the literature. the incidence of trauma c internal caro d artery aneurysm (tica) a er such injuries ranges from 3% to 40%, depending on the ming of imaging studies. the ming of angiography a er a missile head wound may be an important factor in the detec ng aneurysms. in one report from the iran-iraq war, cerebral angiography an average of 17 days a er missile head wounds in 255 pa ents disclosed 8 aneurysms (3%). jinkins and coworkers performed cerebral angiography within 24 hours of gunshot wounds to the head in 12 pa ents and found 3 internal caro d/vertebral and one combined aneurysm/arteriovenous fi stula (33%). risk factors include orbitofaciocraniocerebral injuries, injuries near the pterion, and pa ents harboring intracranial haematomas. it is recommended that any pa ent with these risk factors undergo either ct angiography or conven onal angiography to rule out tica. these injuries are treated endovascularly with either coiling or stentassisted coiling, which resulted in preserva on of the parent artery. despite endovascular treatment some pa ents need defi ni ve clip exclusion. before the fi rst reported series of endovascular management of ticas in 1993, treatment op ons available to the neurosurgeons were limited to balloon occlusion, balloon trapping, copper wire thrombosis, surgical liga on, and clipping or occlusion of the parent artery with or without bypass. endovascular techniques are the methods of choice for the treatment of pa ents with caro d cavernous fi stulas. there is no general consensus regarding op mal management of internal caro d artery dissec on, but the choice among medical, endovascular, and surgical op ons may depend on the type of injury, the anatomic loca on, the mechanism of injury, coexis ng injuries, and comorbid condi ons. an coagulant therapy should be ini ated when a thrombus is detected. outcome and prognosis penetrating brain injury, though less prevalent than closed head trauma, carries a worse prognosis. many studies have a empted to associate various prognos c factors with outcome. the most important prognos c factor currently recognized is the glasgow coma scale a er cardiopulmonary resuscita on. tradi onally, the higher the gcs a er resuscita on, the be er the pa ent outcome. extensive studies have evaluated long-term survival and cogni ve, behavioral, and func onal outcome a er pbi, especially in war injuries sustained in world war ii and korean and vietnam confl icts. the vietnam head injury study has demonstrated that there are no truly silent area of the brain when it comes to penetra ng injuries. regardless of how well pa ents seem to recover, very complex psychobehavioral and cogni ve func ons are adversely aff ected, and community adjustment is never perfect. for this reason, every approach to the treatment of penetra ng head injury must emphasize the preservation of brain tissue. a critical factor in early treatment decisions and long-term outcome a er penetra ng head injuries is the pa ent’s ini al level of consciousness.¹³ low glasgow coma scale is associated with an unfavorable outcome in both civilian and military pbi. gcs score of 3 with bilaterally fi xed and dilated pupils, and high ini al intracranial pressure have been correlated with worse outcomes in pbi pa ents. increasing age, suicide a empt, coagulopathy, bihemispheric lesion, multilobar injuries, intraventricular haemorrhage, subarachnoid haemorrhage, transventricular injury, uncal hernia on, respiratory distress and hypotension all are associated with poor outcome. there is evidence that soldiers returning home from combat du es in iraq and afghanistan may suffer from poor general ap sharma 116 journal of lumbini medical college health and be more susceptible to cardiovascular complica ons, both of which can ul mately aff ect their job performance and produc vity. it is possible that mild trauma c brain injury (mtbi) under unusually stressful circumstances, such as blast injuries resul ng from the explosive eff ects of improvised explosive devices (ieds), may aff ect the neuronal circuitry designed to monitor stressful conditions, such as the amygdala, lateral hypothalamus, and pituitary/adrenal axis. this eff ect may result in excessive amount of stressful hormones and icosanoids and deposi on of implicit memory of trauma that will result in pos rauma c stress disorder. a multiphasic research project is currently ongoing to inves gate pathogenesis and best ways to manage mtbi and ptsd. research in this area is highly warranted as pbi pa ents s ll present a signifi cant challenge to practicing neurosurgeons worldwide. patients with craniocerebral missile wounds who arrive at the hospital alive o en receive variable treatment despite low gcs scores and o en dismal prognoses, because there is a lack of consensus regarding appropriate treatment and predictable outcome in these pa ents. in par cular, wide varia ons exist in the amount of surgical debridement performed, the use of icp monitoring, and the use of various medical therapies. conclusion gunshot wounds of the head are on increase. penetra ng head injuries can be the result of numerous inten onal or uninten onal events, including missile wounds, stab wounds, and motor vehicle or occupa onal accidents (nails, screwdrivers). the pathological consequences of penetra ng head wounds depend on the circumstances of the injury, including the proper es of the weapon or missile, the energy of the impact, and the loca on and characteris cs of the intracranial trajectory. the clinical condi on of the pa ent depends mainly on the mechanism, anatomical loca on of the lesions, and associated injuries. the assessment of pa ents with penetra ng brain injuries should include rou ne laboratory tests, coagulation profile and imaging studies. pa ents with severe penetra ng brain injuries should receive resuscita on according to advanced trauma life support guidelines. the introduc on of guidelines for the management of penetra ng brain injury has revolutionized the medical and surgical management of pbi during the last decade. there has been a paradigm shi toward a less aggressive debridement of deep seated fragments and a more aggressive an bio cs prophylaxis in an eff ort to improve outcomes.¹¹ morbidity and mortality rates associated with penetrating brain injury remain unacceptably high. considerable research con nues in the area of neurotrauma. once the secondary mechanisms of injury are be er understood and the treatment modali es are studied in prospec ve randomized clinical trials, less varia on in management of penetra ng head injury is likely to occur. the medical community as a whole will become more successful in the treatment of these pa ents. references 1. benny brandvold, m.d., lion levi, m.d., moshe feinsod, m.d. et al. penetra ng craniocerebral injuries in the israeli involvement in the lebanese confl ict, 1982-1985. analysis of a less aggressive surgical approach. j neurosurg 1990; 72: 15-21. 2. bizhan aarabi b, m.d., f.r.c.s.c. surgical outcome in 435 pa ents who sustained missile head wounds during the iran-iraq war. j neurosurg 1990; 27: 692-695. 3. espocito, domenic p. md, facs; walker, james b. md. contemporary management of penetra ng brain injury. neurosurg quarterly 2009; 19: 249-254. 4. aarabi, bizhan md; taghipour, musa md; alibaii, ehsanali md. et al. central nervous system infec ons a er military missile head wounds. j neurosurg 1998; 42: 500-9. 5. andres m. salazar, md; bahman jabbari, md; stephen c vance, md. et al. epilepsy a er penetra ng head injury. i. clinical correlates: a report of the vietnam head injury study. j neurol 1995; 35: 1406-14. 6. robert f. hunt. jeff ery a. boychuk. bret n, smith. neural circuit mechanisms of pos rauma c epilepsy. journal fron ers in cellular. neuroscience 2013; 7: 89. 7. syed farak kazim, muhammad shahzad shamim muhammad zubair tahir, syed ather enam. et al. management of penetrating brain injury. journal of emergencies, trauma, and shock. jul-sec; 4: pp 395402. 8. arnold m. meirowsky, md; william f. caveness, md; james d. dillon, md. et al. cerebrospinal fl uid fi stulas complica ng missile wounds of the brain. j neurosurg 1981; 54: 44-8. 9. sharma a.p, md, frcs(ed). nature and management of penetra ng craniocerebral missile injuries at shree birendra hospital from november 2001 to november 2002. med j shree birendra hospital 2002; 5: 1-6. 10. fuad sami haddad, md, f.r.c.s.(c), f.a.c.s.; georges f. haddad, md; and jamal taha, md. trauma c intracranial aneurysms caused by missiles: their presenta on and management. j neurosurg 1991; 28: 1-7. 11. michael e. carey, m.d. the treatment of war me brain wounds: tradi onal versus minimal debridement. surg neurol 2003; 60: 112-9. 12. bizhan aaribi, m.d, f.r.c.s (c). trauma c aneurysms of the brain due to high velocity missile head wounds. journal of neurosurgery 1998; 22: 1056-1063. 13. michael l. levy, m.d. outcome prediction following penetra ng craniocerebral injury in a civilian popula on: aggressive surgical management in patients with admission glasgow coma scale scores of 6 to 15. neurosurgery focus 1999; 8: ar cle 2. 14. schneiderman ai, braver er, kang hk. understanding sequelae of injury mechanisms and mild trauma c brain injury incurred during the confl icts in iraq and afghanistan: persistent post concussive symptoms and pos rauma c stress disorder. am j epidemiol 2008; 167: 1446-52. lmc journal vol. 2.indd 108 journal of lumbini medical college indica ons of caesarean sec onstudy of 200 cases in lumbini medical college shrestha bk department of obstretics and gynaecology, lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. buddhi kumar shrestha, lecturer, department of obstretics and gynaecology, lumbini medical college teaching hospital, palpa, nepal; e-mailvictor_522004@hotmail.com abstract background: a caesarean sec on is a surgical procedure in which one or more incisions are made through a mother's abdomen (laparotomy) and uterus to deliver one or more babies, or, rarely, to remove a dead fetus. methods and materials: this study was a prospec ve descrip ve one. it was done in lumbini medical college from 2068 shrawan to 2069 ashad. a total of 1419 deliveries occurred of which 234 deliveries by lscs, incidence of lscs was 16%. the commonest age group being operated ranged from 21-25 years (47.5%). most of the pa ents who had undergone lscs were mul gravida-50.5%. the sec on was due to various indica ons, the most commonest cause in this study were fetal distress and obstructed labour, non progress of labour, the primary rate of lscs was 85% while repeat sec on being 15%. results: the peak range of opera ons were done. in pa ents with 5 feet 2 inches height, the rate of elec ve lscs 26.5%. where emergency cs were done in 73.5% of cases. regarding fetel outcome 97.5% survived and 2.5% had death. conclusions : fetal distress and non progress of labor was the commonest indica on for caesarean sec on in our ins tui on. keyword: caesarean sec on,incisions, indica ons introduction caesarean sec on is a common opera ve procedure in obstetrics prac ce. though it was introduced in clinical prac ce as a lifesaving procedure both for mother and newborn. the rising trend of caesarian section in modern obstetrics is a major concern in health care system all over the world.1 according to who rates of lscs in many countries have increased beyond the recommended level of 15%, specially in france, australia, north america, uk, brazil, china and india the rate of lscs in america 23% ll 1991. the na onal c sec on rate of canada was 20% and italy was 17.5%.1 even though the indica on of cs have not changed so far and these remain foetal distress, malpresenta on, mul ple gesta on, previous caesarean, protracted labour and cs on demand, current available data from developed countries revealed morbidity and mortality from cs is more than in vaginal delivery for both the mother and fetus. thus this study was conducted to evaluate the rate and indica on for cs in various indica on. method of study this prospec ve study was carried out in the department of obstetrics and gynecology, lumbini medical college, palpa from 2068 asadh to 2069 shrwan. total 200 cases were selected after taking consent, detailed history was taken from all cases, examina on was done from date of admission up to the day of discharge. 34 cases were excluded because of improper anc records which was done outside. cpd was tested mainly by clinically pelvimetry labor patient was monitored by doing partogram. in elective cases-all investigation done. puerperal period up to the day of discharge was observed. 90% of pa ent operated by spinal anesthesia, 10% under ga. blood donor was kept ready in selected cases such as placenta preavia, repeat lscs and eclampsia. result a total of 1419 deliveries occurred the study period of which 1185 deliveries were by vaginally and 234 delivery by lscs. the rate of lscs among all these delivery 16%. indica on of caeserian-sec onstudy of 200 cases in lumbini medical college, palpa. discussion caesarean sec on is used in cases in which vaginal delivery either is not feasible or would impose undue risk on mother or baby. due to greater awareness of serious fetal distress & avoidance of mid forceps & vaginal breech deliveries the rate of lscs has steadily increased from (5% to 20%).2 in this study the total number of deliveries was 1419 and of which 234 (16%) was caesarean deliveries. the incidence of lscs only 16% in our study which was nearing the who recommenda on. analysis of age of the pa ent showed that 72.5% of cases (table 1) were in the age group of maximum fer lity i.e. between 2030yrs. a study in ipgmr showed 89% amongst this age group.3 the study of la n american hospital showed original article l m coll j 2013; 1(2): 108-110 109 bk shrestha maximum incidence >30 years in primi pa ents, which might refl ect delayed marriage in (western countries).4 table-1: age of pa ent who underwent lscs (n=200) age groups (years) percentage 15-20 20% 21-25 47.5% 26-30 25% 31-35 5% 36-40 25% total 100% this table shows lscs % maximum at age 21-25yrs. short maternal height has been associated with an increased of cpd, in our study (table 2) showed that 68% patent were more than 5 feet. alam showed 76% pa ent >5' and zaman showed 70% >5' in their studies.5,6 this may be explained by the fact that all the lscs were not only due to cpd. table-2: incidence of lscs in rela on to height of the pa ent (n=200) height (feet) percentage 40 2% 408" 4% 4.90-5" 26% 5.1" 28% 5.2" 25% 5.3" 12% above 5.4" 3% total 100% from the above table, 68% patent were above 5 feet in height-32% were below 5 feet study in ipgmr 1987, sir sallimullah medical college (ssmc) & mi ord hospital 1992 showed higher incidence in mul .4-6 present study also correlates with it (fig. i). in the developed countries in the past decade indica ons of lscs were breech presenta on, fetal distress, previous sec on & dystocia.7 in this study, common indica ons were fetal distress 22%, nopl 16.5%, previous lscs 12.5%, obstructed labor 10%, pre-eclampsia and eclampsia 9.5%, breech 8%, bad obstetric history 5%. table-3: indica on for lscs (n=200) indica on total prime mul previous lscs 30 0 30 foetal distress 44 26 18 obstructed labour 20 15 5 npol (induc on failed) 33 23 10 pre-eclampsia 15 9 6 bad obstetric history 10 10 breech px 16 8 8 cpd 13 7 6 transverse lie 3 2 1 placenta praevia 2 2 0 eclampsia 4 3 1 cord prolapse 4 1 3 face presenta on 3 2 1 brow presenta on 3 1 2 this table shows fetal distress and npol(non progress of labor). mainly responsible for lscs in primigravida. previous cs was main indication in multigravidia among all, fetal distress occupiese the highest indication of lscs table-4: nature of opera ons with indica on (n=200) indica on nature of elec ve (%) emergency (%) previous cs 12.5% 2.5% foetal disetres 0 22% obstructed labour 0 10% npol 0 16.5% pre-eclampsia 1% 6.5% eclampsia 0 2% bad obstetric history 5% 0 breech presenta on 5% 3% placenta pravia 1% 0 cpd 2% 4.5% corel prolapse 0 2% face presenta on 0 1.5% brow presenta on 0 1.5% transverse lie 0 1.5% total 26.5% 73.5% the table shows emergency lscs was 73.5% and elective lscs was 26.5%. table-5: comparison of primary and repeat sec on (n=200) caeserean sec on percentage primary 85% repeat 12% third sec on 3% this section show primary section was more relation to repeat section. repeat sec ons cons tute the commonest indica on for lscs in most other countries. it varies from 35% of all lscs in the usa to 23% in norway, the lowest 18% being in hungry.8but in our college in 200 cases lowest repeat sec on 15%. in a study in ipgmr elective lscs was 52% and 110 journal of lumbini medical college emergency lscs was 48%.6 this was because pa ents due to previous opera on or pregnancy associated complica ons, admi ed in that ins tute for elec ve lscs. there are high incidence of elective lscs in western countries because of their sophisticated electronic foetal monitoring system.9 diff erent studies from india showed incidence of emergency sec on was 82.7% and 85.92%.10 study in ssmc & mi ord hospital fi ndings of emergency lscs was 69.71% and elec ve lscs was 30.29%.4 this correlates with our study, where emergency lscs was 73.5% and elec ve was 26.5%. this may be explained by the fact that the pa ents were brought into hospital when crises arise, when tradi onal birth a endants may have failed to deliver them with utmost a empt. in a study by dawn and chakrabar at eden hospital, kolkata, the incidence of morbidity was 37.5% and abdominal wound infec on was major morbidity.11 hammouda reported a maternal morbidity rate of 28.5% in the form of wound and urinary tract infec on & there were no maternal death.12 present experience was similar to this study. conclusion in modern obstetrics, caesarean sec on is a major surgical procedure for delivery. in spite of its low rate of maternal morbidity and mortality due to improved surgical technique and modern anesthetic skill, it s ll carries a slightly greater risk than normal vaginal delivery and more risk in subsequent pregnancies. those risks can be reduced by giving advice for a strict and regular antenatal check up during pregnancies to emphasize the need for an elec ve opera on, if the indica ons are recurrent one. though we need to have more sophis cated modali es to diagnose it in a proper way, in our study we found that most common indica ons for cesarean sec on is fetal distress and non progress of labor reference 1. c a e s a re a n s e c t i o n . po st n o te n o . 1 8 4 . l o n d o n : parliamentary offi ce of science and technology; 2002. available from: http://www.parliament.uk/post/ pn184pdf. 2. placek pj, taff el sm. moien mc sec on rise; vbacs inch upwards. am j pub health 1988; 78m: 562-3. 3. zaman n. a clinical study on caesarian sec on in ipgmar (disserta on). dhaka. bangladesh college of physicians; p 84-92. 4. geen je, meclean f, usher sr. caeserean sec on study of la n american hospital. am j obstet gynaecol 1982; 142. 5. zaman n. a clinical study on caesarian sec on in ipgmr (disserta on). dhaka. bangladesh college of physicians & surgeons; p 84-92. 6. alam me, study of indica ons of caesarean sec on in teaching hospital (dissertation). dhaka. bangladesh college of physician and surgeons 1994; p 80-9. 7. panel and planning of the na onal consensus conference on aspects of casarean birth. indica on for caesarean sec on : final statement of the panel of the na onal consensus conference on aspects of caesesean birth. can med asso j 1986; 134: 1342-52. 8. magnaun ef. winchester ml. factors adversely aff ec ng pregnancy outcome. am j perinatal 1995; 12: 464. 9. amrika h. evan tn. zone wb. caeserean sec on: a 15 years review of changes in incidence of induc on and risk: am j obstet gynaecol 1984; 104: 81-90. 10. pardey js, jain m. pandy lk. ten years profi le of caesarean sec on. j obstet gynaecol india 1986: 36: 448.. 11. chakravorty dk. dawn cs. morbidity following caeserean sec on. j obstet gynaecol india 1985; 35: 1037. 12. hammouda aa. caeserean sec on in the young gravida. am j obstet gynaecol 1968; 100: 267-9. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 22 may, 2020 accepted: 24 may, 2020 published: 30 may, 2020 a assistant professor, bprofessor and head, bdepartment of anatomy, gsvm medical college, kanpur, india. corresponding author: nidhi gupta email: drnidhianat@gmail.com orcid: https://orcid.org/0000-0002-9183-2392 how to cite this article: gupta n. pandey s. disruption of anatomy dissection practical in covid-19 pandemic: challenges, problems and solutions. journal of lumbini medical college.2020;8(1):2 pages. doi: https://doi. org/10.22502/jlmc.v8i1.350 epub: 2020 may 30._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.350 nidhi gupta,a,c suniti pandey b,c disruption of anatomy dissection practical in covid-19 pandemic: challenges, problems and solutions background we are undergoing crisis for humanity with corona virus disease (covid-19) causing extensive damage to life and its aspects. moreover we do not know how this will unfold in near future. all the academic classes are suspended during nationwide lockdown to alleviate the propagation. it is high time to rethink ways to deliver quality medical education under restriction of social isolation and absenteeism in real time teachings and discussions. we propose, based upon our experiences, replacement of didactic gross anatomy dissection with handmade dissection videos and its implications. it has its own challenges which could be overcome with planned directives based upon current experience. what is the magnitude of problem? in this gloomy environment of forced absenteeism, reluctance in study plans and procrastination requires counseling for emphasizing the importance of tight declining schedule and benefits of timely curriculum for covering huge syllabus. traditional methods of face-to-face educational didactics, lectures and chalk talks has been compromised like no other time in past. use of education technology at a mass scale for economically deprived countries, limited availability of techno friendly medical educators and adaptation of student to newer teaching techniques was already restrained in pre-pandemic time. also, the alignment of new teaching format with amount of content and duration of topic coverage, necessary and safe enough to train for effective practice of problem-based learning warrants reorganizing available resources. from student’s perspective, accommodation and fooding concerns in lockdown, poor internet access with intermittent disconnection, lack of high-end laptops and absenteeism are major concerns, which precluded us from live streaming of gross anatomy dissection. also, it is to be ensured that changes in teaching style have positive impact on amount and depth of concerned knowledge. why dissection is irreplaceable? cadaveric dissections are not a trivial activity and have tremendous ethical consideration with regards to the great souls who donated their body for medical education. gross anatomy teaching of structures of the human body is fundamental to health professional education. vast content of this subject was taught classically via didactic pedagogy. cadaveric dissection and preserved model studies create simulation for surgical field.[1] it is a preliminary stage for foundations of patho-anatomy and rehearsal for surgical orientation. schematic illustration of dissection can adversely lead to student turning into information recipient only instead of becoming active learner implying thinking, reflecting and discovering at individual interest level.[2] successful accomplishment of dissection tasks generates motivation, self-confidence and esteem.[2] what are the aims of new teaching design? three essential steps were aimed for a new teaching design: gupta n, et al. disruption of anatomy dissection practical in covid-19 pandemic: challenges, problems and solutions. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 1. to provide relevant self recorded videos and powerpoint presentations to maintain scheduled curriculum as far as possible with reference to pre-defined academic calendar and timings of classes. 2. a declarative preconditioning about the new changes in dissection demonstration plans was given to a small number of class representatives for discussion with peers. additionally, co-ordination amongst peer faculties were made to prevent overlaps in schedule. 3. record and discuss non-verbal communications inputs of students through social media for quality control in every next video shooting. what were the methods for faculty and content developments? using departmental simple camera with gimbal handled by academic media staff of the institute at anatomy dissection laboratory in compliance with administration orders, we focused on creating few short and easy videos with small file size (<250mb) of 15-20 minutes for every dissection topic. how will dissection videos help? considering academic schedule pressure and vast syllabus, the problem was addressed through recorded videos on selected topics. presently, with smart phones widely available and accessible, producing and sharing videos is quite easy. videos improve learning as it enables the formation of mental image close to the real dynamic structures. technological advancement has created the ability to view dissections or prosections without having to be physically present which has been viewed to be a valuable tool to anatomy education with the growing pressures affecting it.[1] although in assessment, student can identify a structure and correlate clinical anatomy, yet the benefit of holistic trainings exceeds significantly when they dissect with peers while discussing therefore acquaintance with realistic pictures of dissected cadaver must not be missed with passing time.[1] what are odds against not choosing from available open source? there are reasons as why not to choose and recommend nonspecific you-tube videos, as they seriously fail in delivering the complex learning process.[2] the most envisaged hazard in open source information is potentially inaccurate content ‘heads that know how to think or heads full of information’. [2] also the social media can be useful virtual outlet but lack depth and organization to reliably transmit. why teachers should proactively make videos? there is a dynamic in communication between teachers with students in particular explaining details of the content. faculty involvement in dissections facilitates association between theoretical concept and practical implications. positive affective relationship can be generated by dialogues at table side. faculty’s considerations it lies in brisk orientation of teachers as well as students to adapt with online learning stages. teacher shyness to acclimatize to new format, with nil face to face interaction was a matter of concern, hence dealt with peer interaction and sharing feedbacks. also, videos used for education will vary for every teacher; the reason being, preparedness, promptness, and creating interest in the session. with decreased cadaver availability and time-consuming dissections, videos are placed as possible solution. student’s consideration we should try to modify student perception for acceptance of changes in traditional methods and motivate them with interesting presentation. also, they can be encouraged to interact digitally for queries and feedback. in new arrangement of dissection, there is a requirement to adapt to sensitize for viewing the video guides on practical procedure of prosected specimens for adequate exposure to anatomical content as a replacement to pedagogical approach of student participation in dissection process. what are long term future correlates of the contents as a carry forward of this crisis scenario? although short videos are not exact replacement of hands-on practical training, yet it does not add up much to pre-existing workload and can be suitably used in revision strategies at times of doubt in entire curriculum when suitably stored. as the specialist is involved, the videos can be customized to learning conclusion, and ethical knowledge bank of the faculties of the institute. pressure on educators to respond earliest in crisis nowadays, need to be replaced by strategic view in a long term. the quality and length of self recorded videos as a preparatory tool needs long term audit to produce optimum contents at professional level. we also call for comparing examination and assessment outcome of traditional vs. newer method in short term and longterm assessment. cohort for analysis of feedback provided by students can be taken up in case futuristic curriculum demands replacement of didactic lectures with audio-visual trainings. the current scenario scrutinizes the options of developing and integrating student teacher interaction as a component of video, thereby incorporate problem-based learning. where will temporary scenario might lead to based upon upcoming evidences, shall it change the entire time-honored study design? lack of trained faculties able to lead a dissection task, acquisitions and maintenance of corpses, has prompted to go for alternative methods like model and software.[1] it has been hypothesized that future of gross anatomy education will see replacement of text books with videos filled with explanation of morphological variations and clinical relevance adherent with problem based learnings.[3] under lights of evidences, automation, virtual reality and 3dvisualization seems potentially inciting the age old didactic teachings.[3] however, the classification of recommendation and level of evidence is still not available, so presently anatomy videos how so ever promising still falls in ambit of poorly defined role in anatomy education. even complete exclusion of cadavers from teaching program is pointed, however without established evidences of benefits, the prospect remains obscure.[3] few years down the lane, professionally created tracks of audiovisuals will be accountable and scholarly values will be citable much in congruence with evidence based medicine video journals.[4] potential recommendations and conclusions this new format does not deny the traditional instructive hegemonic model, but rather puts up the ways of overcoming them in present where its applicability is compromised. still the challenges that remain are focused on effort regulation, goal settings, self-monitoring of understanding, time management and help seeking. hence, we recommend faculty development through acquaintance with professional technologies and student skills enhancement by balancing between traditional ‘directed self-learning’ to ‘self-directed learning’. we conclude with advocating dissection in anatomy is inevitable for medical education. although tedious, new variations in teaching methodology will up bring critical thinking, investigative acumen and integrative approach in students. any lack will be disadvantageous. even in the ongoing crisis, dissection videos should be taken as a clinical practical cycle followed by interactive discussion of students amongst themselves and with the teacher. we emphasize on triad of development, implementation and evaluation. together the educator and students can craft tailored podcast and goodwill. conflict of interest: the authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. hulme a, strkalj g. videos in anatomy education: history, present usage and future prospects. int j morphol. 2017;35(4):1540-6. available from: https://scielo.conicyt.cl/pdf/ijmorphol/ v35n4/0717-9502-ijmorphol-35-04-01540.pdf 2. ghosh sk. cadaveric dissection as an educational tool for anatomical sciences in the 21st century. anat sci educ. 2017;10(3):286‐299. pmid: 27574911 doi: https://doi.org/10.1002/ase.1649 3. patel sb, mauro d, fenn j, sharkey dr, jones c. is dissection the only way to learn anatomy? thoughts from students at a non-dissecting based medical school. perspect med educ. 2015;4(5):259-60. pmid: 26353886 pmcid: pmc4602014 doi: https://doi.org/10.1007/ s40037-015-0206-8 4. bergman em. discussing dissection in anatomy education. perspect med educ. 2015;4(5):211-3. pmid: 26358977 pmcid: pmc4602012 doi: https://doi.org/10.1007/s40037-015-0207-7 gupta n, et al. disruption of anatomy dissection practical in covid-19 pandemic: challenges, problems and solutions. j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 jlmc.edu.np licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1 jan-june 2020 ___________________________________________________________________________________ submitted: 26 may, 2020 accepted: 31 may, 2020 published: 02 june, 2020 arising freshman, bjudy genshaft honors college, university of south florida, tampa, usa. cneurosurgeon, suncoast advanced surgery, springhill, fl, usa. dadjunct faculty, lincoln memorial university-debusk college of osteopathic medicine, harrogate, tn, usa. eindependent college and medical school admission counselor. findiana university, bloomington, usa. corresponding author: lindsey conger e-mail: lindsey@moonprep.com orcid: https://orcid.org/0000-0002-0572-9429 how to cite this article: babel s, jain s, conger l. covid-19: emerging challenges for students in medicine and schools in the united states. journal of lumbini medical college. 2020;8(1):2 pages.2020;8(1):2 pages. doi: https://doi. org/10.22502/jlmc.v8i1.359 epub: 2020 june 02._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.359 shrinit babel,a,b surbhi jain,c,d lindsey conger e,f covid-19: emerging challenges for students in medicine and schools in the united states the coronavirus pandemic has changed the world everywhere, including the lives of high schoolers in america. the sudden sharp rise in coronavirus cases forced the closure of schools in mid-march to curb the further spread of the virus. several end-of-the-year celebrations, school activities, and examinations were canceled. at the same time, the cancellations gave a chance for the youth to adapt to uncertain situations and learn a different perspective of life. living in florida, a state that battles hurricanes for almost half a year, school closures have become the norm: it is not rare for students to be reminded to keep their textbooks and notes home for a week or two. prepared from past closures due to hurricanes, the school district board already had a virtual school platform, and the principal instructed all students to shift to zoom and alternative elearning. however, when the coronavirus pandemic led to the indefinite closure of high schools across the country, this was something new, different, and unexpected that school communities had to face. the excitement of not having to wake up early to commute to school soon faded as the preparation to move to online platforms became more of a burden. outreach to students of indigent backgrounds was the first hold-up, but some districts were able to deliver computers and hot spots to bridge the digital divide. the loss in formal instruction was another obstacle as student-teacher interactions decreased significantly during the first few weeks. not only does this hinder teachers’ abilities to spot learning difficulties in their pupils, but it also adds difficulty for students to consult peers or their teachers regarding a particular topic. however, for other districts, moving education online didn’t go as smoothly. some schools simply sent out workbooks that covered some of the planned learning material, while others set up a similar school structure, but online. for those with parents who are still working full-time, it might have been harder for students to self-motivate or find structure within their school day. students might have to share laptops or e-devices with family members, limiting the amount of time they can spend online in classes. for rural students, the educational divide is growing greater, as many of these students don’t have access to home internet.[1] while telecommunication companies like at&t, charter communications, comcast, and verizon stepped up to bridge that gap and provide free wifi or accessible hot spots to people all across the country, it still was not easy for every student to e-learn. yet another road bump for students was the college application preparation process. students typically must take the scholastic assessment test (sat) or american college testing (act) as a standardized admission test and submit the school when applying to schools. a survey by the national association for college admission counseling (nacac) discovered before the coronavirus outbreak, more than 80% of colleges considered babel s, et al. covid-19: emerging challenges for students in medicine and schools in the united states. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1 jan-june 2020 the sat or act score of considerable or moderate importance.[2] starting in march, both the act and sat were canceled through june, causing many rising seniors to panic about how they will get these necessary scores.[3] however, universities across the country have moved to a test-optional or testflexible system, helping to relieve the pressure off of students applying during the 2020-2021 cycle. most notably, new york university, university of california, and villanova university have made this unprecedented change. another disrupting factor was advanced placement (ap) exams moving online. these exams—administered by the college board— give students the chance to earn college credit if they perform well.[4] ap exams are meant to be a standardized evaluation that checks the knowledge learned in the school class; however, the online test given in mid-may was anything but standard this year. the test-taking environment varied greatly from household to household, with some students lacking a quiet place to take the exam. even worse, many students were unable to submit their answers due to a technical glitch, and are now suing the college board to accept their responses.[5] it is clear that more work needs to be done to ensure that students are given an equal and fair chance to test online and earn college credit at home. it is not just high school students that are impacted by the shift to tele-education. aspiring medical school students have had their plans disrupted, as colleges move their classes online, and eight mcat dates from march 27 through may 21 were canceled. for the rest of 2020, students will be taking a shorter mcat test and, for the foreseeable future, have to wear a mask while taking the exam. once again, this raises questions of how standard the mcat is, and if it will accurately reflect who should gain a coveted spot at a medical school. despite the cancellations, students are still as eager as ever to become doctors.[6] according to alison whelan, aamc’s chief medical education officer, more students than ever before have started the applications for medical school.[6] the u.s. is currently experiencing a physician shortage, and the problem has been made worse by the pandemic, as more doctors have been called to the frontlines to assist in helping the increasingly full hospitals. countless nurses and doctors have come out of retirement to assist. this has put medical schools in an interesting predicament, as they struggle with how to graduate seniors who have not fully completed the requirements. some schools, like columbia, the icahn school of medicine at mount sinai, and new york university (nyc) grossman school of medicine fast-tracked the graduation of their students to ensure that they can help doctors in areas that need it the most. however, for other medical colleges, it is not as easy to push the graduate date of their students forward. while tele-education classes are adequate for lecture-based classes, a medical student is required to complete other requirements like labbased class and clinic rotations, which are impossible to complete virtually. this has put several pre-med and medical students in limbo, as they wait to finish these requirements before graduating. ultimately, the reality is that every student learns differently, and while some might struggle under these new learning conditions, others might thrive. it is unclear how the educational gap might grow or how the education system will evolve. the importance schools place on exams like the sat, act and, even the mcat might shift in the upcoming years as the struggles of the students to complete these exams online might require changes to be made. there is also a big consideration on whether classes will resume to normal in the fall; will universities and other schools still be doing virtual classes? medical school and undergraduate require students to invest a lot of time, energy, and financial resources into their education, and they might not be as willing or able to do so if the classes will be online. at the same time, there were many positive outlooks to the same situation that could be seen as a blessing in disguise. many american teens have successfully retrieved coping mechanisms from their childhood by spending quality time with their families and engaging positively in arts and activities. as the youth adapted to the online set-up, several high schoolers joyfully reported that they “were able to finish the work of a whole school day in three hours,” which would otherwise take most of the day. high schoolers are alleviated from the stresses of spending most of their day outside and away from the comfort of their home or spending all-nighters trying to complete assigned work. as the youth generation transitions through jlmc.edu.np their adolescence, the recent unprecedented events will only mature and allow students to adapt to unfriendly situations. the sudden deviation from the “status quo” not only teaches a lesson about tolerance, compromise, and adaptation but also shines a light on problem-solving in the real world. the traditional classroom environment is absent and may never be the same again. however, with the advent of virtual lectures and online material, students are able to delegate their time to improve on their academics, spend more time with their families, and learn something new. as life eases back to the new normal, schools will have to transition across the globe. high schools, universities, and medical schools will all have to adapt to fit the changes that have occurred and will continue to occur in the upcoming months and years. the hope, particularly for schools in america, is that there will be a balance in both worlds: where school instruction and virtual learning is optimized in the school curricula, so that kids remain connected to their families and values, and that the stress of long hours in school does not serve as a leeway for adapting unhealthy social practices. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. lauren c. schools struggle to educate students with disabilities amid pandemic. u.s. news & world report, u.s. news & world report. 2020 april 15. available from: www.usnews. com/news/education-news/articles/2020-04-15/ schools-struggle-to-educate-students-withdisabilities-amid-pandemic 2. character and the college admission process. character collaborative. available from: https:// www.nacacnet.org/globalassets/documents/ publications/research/character-brief/nacac_ brief_character-0120_2.pdf 3. kristen m. is the coronavirus preventing students from taking the sat? forbes. 2020 march 17. available from: www.forbes. com/sites/kristenmoon/2020/03/11/is-thecoronavirus-preventing-students-from-takingthe-sat/#7d67e79a7c92 4. the collegeboard. the college board college admissions sat university & college search tool. available from: www.collegeboard.org/ 5. anna es. the college board is sued over ap test glitches. forbes. 2020 may 21. available from: www.forbes.com/sites/ annaesakismith/2020/05/20/the-college-boardis-sued-over-ap-test-glitches/#6fd8031416a9. 6. kristen m. how covid-19 is upending medical school admissions tests. forbes. 2020 may 19. available from: www.forbes. com/sites/kristenmoon/2020/05/18/how-covid19-is-upending-medical-school-admissionstests/#2c0810f273ca babel s, et al. covid-19: emerging challenges for students in medicine and schools in the united states. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 jlmc.edu.np j. lumbini. med. coll. vol 8, no 2, july-dec 2020 sigdel b, et al. microscopic antegrade parotidectomy for different types of parotid tumor. 233 jlmc.edu.np ___________________________________________________________________________________ submitted: 12 may, 2020 accepted: 15 october, 2020 published: 05 november, 2020 aassociate professor and hod, blecturer, cdepartment of otolaryngology & head and neck surgery, gandaki medical college, pokhara, nepal. corresponding author: brihaspati sigdel e-mail: brihassig1@gmail.com orcid: https://orcid.org/0000-0002-8546-6699_______________________________________________________ abstract: introduction: salivary gland tumor accounts for about 5% of all the neoplasms of the head and neck. 75% of such tumors occur in the parotid glands. pleomorphic adenoma is the most common type of benign salivary gland tumor. it tends to recur after inappropriate treatment. surgery of parotid tumor includes enucleation, superficial parotidectomy and total parotidectomy. identification and preservation of facial nerve trunk and its branches is very important in parotid surgery. advancement of microsurgical technique has helped in better visualization, identification and preservation of the facial nerve. methods: this prospective study included twenty-seven patients. preoperative ultrasonography and fine needle aspiration cytology were done for all cases. computed tomography/magnetic resonance imaging were performed in some cases when needed. standard microsurgical technique with the help of microscope was performed for antegrade parotidectomy. data analysis was done using spss version 26.0. results: the patients age ranged from 12 to 78 years. fifteen (55.6%) patients were female and 12 (44. 4%) were males. sixteen (59.3%) tumors were located on the right side whereas 11 (40.7%) were on the left side. most of the tumors (n=18, 66.7%) were pleomorphic adenoma. two (7.4%) of the patients had temporary facial paralysis which improved with time. two (7.4%) patients had developed hematoma. frey’s syndrome was not found in follow-up. conclusion: this study showed low morbidity in parotidectomy using microsurgical techniques. no permanent injury to the facial nerve was found. keywords: antegrade parotidectomy, facial nerve trunk, microsurgical technique original research articlehttps://doi.org/10.22502/jlmc.v8i2.338 brihaspati sigdel,a,c tulika dubey b,c microscopic antegrade parotidectomy for different types of parotid tumor how to cite this article:how to cite this article: sigdel b, dubey t. microscopic antegrade parotidectomy for different types of parotid tumor. journal of lumbini medical college. 2020;8(2):233-237. doi: https://doi.org/10.22502/jlmc. v8i2.338 epub: 2020 november 05. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: salivary gland tumors account for about 5% of all the neoplasms of the head and neck. 75% of such tumors occur in the parotid glands.[1,2] pleomorphic adenoma (pa) is the most common type of benign salivary gland tumor comprising 40-60% of all salivary gland tumors.[3] parotidectomy is a common surgical procedure for parotid tumor.[4] in total parotidectomy, the parotid tissue present on the lateral and medial side of the nerve is to be removed, whereas in case of superficial parotidectomy, the parotid tissue lateral to the facial nerve is to be removed along with the tumor. in extracapsular dissection, 2 to 3 mm rim of healthy tissue should be removed together with the tumor.[5] the main concept behind the antegrade parotidectomy is to identify the trunk of the facial nerve coming from the stylomastoid foramen. the trunk of this nerve lies about 1cm deep and inferior to the tragal point. the landmark needed to identify the trunk are tympano-mastoid suture, posterior belly of digastric, and mastoid tip. in contrast to an antegrade method, the retrograde method requires identification of the buccal branch of the facial nerve which is about 4 cm anterior to the tragus along the alatragal line. this branch is dissected in a retrograde fashion as far as the main trunk of the j. lumbini. med. coll. vol 8, no 2, july-dec 2020 sigdel b, et al. microscopic antegrade parotidectomy for different types of parotid tumor. 234 jlmc.edu.np facial nerve. the remaining branches of the facial nerve are dissected in an antegrade fashion.[6] the concept of the microsurgical method in parotid surgery is a recent technique. the use of a microscope in such surgeries is to improve the clarity of dissection, to identify the trunk and branches of the nerve. the main aim of this research is the preservation of the facial nerve function in various types of parotid tumours in microscopic assisted parotidectomy. methods: this prospective study involving a consecutive cohort of 27 patients were conducted in the department of otolaryngology and head and neck surgery, gandaki medical college, pokhara, nepal from february 2017 to january 2020. the study was approved by the institutional ethical committee. informed consent was taken from all the patients included in the study. preoperative ultrasonography and fine needle aspiration cytology (fnac) were done in all cases. the histological diagnosis was established based on the preoperative fnac. computed tomography (ct) and magnetic resonance imaging (mri) were performed if necessary. the patients who had undergone surgery by antegrade method for parotid tumor with stage t1-t4a, any n, m0 and those patients requiring revision surgery were included in the study. tumors with stage t4b, m1and those performed with the retrograde method were excluded. surgical technique: all the cases were performed under general anesthesia. required aseptic precaution was taken. local infiltration was done with 2%xylocaine and 1:200000 adrenaline solution in the incision line. modified blair incision was given. the anterior and posterior flaps were elevated. a microscope (zeiss opmi or leica) was used for further dissection. greater auricular nerve was identified and the posterior branch was saved. tragal pointer, mastoid tip, and the posterior belly of digastric muscles were identified. the facial nerve trunk was identified in each case. tracing of each branch of the facial nerve was done (fig.1). all the branches of nerve were identified and each branch was preserved (fig.2). the tumor was removed. depending on the histopathological type of tumor, further dissection was done. in cases where the deep lobe of parotid was involved by tumor, tumor removal was performed in between the two branches of facial nerve. lateral neck dissection was done in mucoepidermoid carcinoma and adenoid cystic carcinoma. we observed temporary or permanent injury to the various branches of the facial nerve, the occurrence of frey’s syndrome, and aesthetic satisfaction. the mean follows up period was 20 months. data were entered in ms excel spreadsheet. analysis was done by using statistical package for social sciences (spsstm) software version 26.0. percentage and frequency were calculated using descriptive statistics. figure 1. intraoperative microscopic view of the right main trunk and the branches of the facial nerve. figure 2. showing intraoperative microscopic view of main trunk and superior division in parotid lymphangioma pleomorphic adenoma. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 sigdel b, et al. microscopic antegrade parotidectomy for different types of parotid tumor. 235 jlmc.edu.np results: the mean age of the patients was 30±16.4 years, with a range from 12 to 78 years. fifteen (55.6%) patients were female and 12(44. 4%) were males. sixteen (59.3%) tumors were located on the right side whereas 11(40.7%) were on the left side. the average operation time in the superficial parotidectomy group was 2hours and 30 minutes (range: 2 hours to 3hours and 40 minutes) and for total parotidectomy, the average operation time was 3 hours 30 minutes (range: 2 hours 50 minutes to 6hours 30 minutes). most of the tumors were pleomorphic adenoma (n=18, 66.7%) (table 1). most commonly performed surgery was superficial adequate parotidectomy (23, 85.2%) (table 2). table 1. types of parotid tumor (n=27). type of tumor frequency (%) pleomorphic adenoma 18 (66.7) monomorphic adenoma 2 (7.4) warthin tumor 2 (7.4) mucoepidermoid carcinoma 2 (7.4) adenoid cystic carcinoma 1 (3.7) lymphangioma 1 (3.7) tuberculosis 1 (3.7) total 27 (100) table 2. treatment of parotid tumor. type of surgery frequency (%) superficial adequate parotidectomy 23 (85.2) total conservative parotidectomy with neck dissection 2 (7.4) total parotidectomy with neck dissection 2 (7.4) post-operative complications were assessed. two (7.4%) of patients had temporary facial paralysis which improved with time. one (3.7%) patient had developed a hematoma. one (3.7%) had permanent facial paralysis as the nerve was sectioned due to the infiltration of the nerve by adenoid-cystic carcinoma. frey’s syndrome was found in none in follow-up. discussion: in the early 20th century, parotid surgery was concerned more with damaging either the trunk or branches of the facial nerve rather than the recurrence of the disease.[7] in those days, injury to the facial nerve was avoided by simple enucleation of the tumor. recurrence rate was high (20-40%) in such cases.[8] tumor satellites could be missed during enucleation. superficial parotidectomy was performed in an attempt to lower the recurrence rate. a study by webb a and eveson j reported 1-4% of recurrence rate while using the above procedure.[9] in our study, 81.5 % of tumors were found to be benign, whereas in the study done by bussu et al.,[10], 88.7% cases were benign. superficial or total parotidectomy was considered the standard method for the treatment of parotid tumors.[11,12,13] undesired complications were seen because the tumor was in contact with one or more branches of facial nerve and due to involvement of deep lobe and parapharyngeal space.[14,15] we applied modified blair incision in all cases. the posterior branch of the greater auricular nerve was saved which supplies lobule and infrauricular area. we closed wounds meticulously thereby providing better cosmetics results.[16] aiding the microscope in surgery helps better visualization of not only the main trunk of the facial nerve but also its branches.[17] we first identified the main trunk of the facial nerve then followed the branches. according to witt et al., tympanomastoid suture is the key structure used to identify the main trunk of the facial nerve.[18] although it is a constant landmark, it lies deeper and is difficult to identify each time. so, more superficial and widely used landmarks are posterior belly of digastric and tragal pointer. we felt the microscope aided surgery was better in identifying the facial trunk and branches and in dissecting the tumor from the facial nerve or its branches due to better visualization and magnification. but it is difficult to handle for new surgeons and has a slow and steady learning curve. in our study, 7.4% of patients had temporary facial paralysis which improved over time. one (3.7%) had permanent facial paralysis as the nerve was sectioned due to the infiltration of the nerve by adenoid-cystic carcinoma. numbness of ear lobule was found in 14.8% cases which improved over three to five months. hematoma developed in one case of lymphangioma which was managed by evacuation of the hematoma, daily pressure dressing and use j. lumbini. med. coll. vol 8, no 2, july-dec 2020 sigdel b, et al. microscopic antegrade parotidectomy for different types of parotid tumor. 236 jlmc.edu.np of amitriptyline for 10 days. it was completely subsided. none of the patients developed frey’s syndrome post-surgery. but is recognized that a high proportion of patients will develop frey’s syndrome after parotidectomy.[19,20] use of a microscope during parotid surgeries enables better identification and therefore preservation of the associated and surrounding nerves which might be injured during the conventional method. there are some limitations of the study. it is a single center study and the sample size is small. this calls for further similar multicenter studies with larger sample size. conclusion: this study found that microscopic assisted antegrade parotidectomy led to fewer complications than reported for conventional methods. the use of a microscope in surgery may represent a useful tool in improving accuracy and minimizing local tissue trauma and thus decreasing facial nerve paresis. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available for the study. references: 1. hoda sa, hoda rs. rubin’s pathology: clinicopathologic foundations of medicine. the journal of american medical association. 2007;298(17):2070-75. doi: http://dx.doi. org/10.1001/jama.298.17.2073 2. spiro rh. salivary neoplasms: overview of a 35‐year experience with 2,807 patients. head neck surg. 1986;8(3):177-84. pmid: 3744850. doi: https://doi.org/10.1002/hed.2890080309 3. woods je, chong gc, beahrs oh. experience with 1,360 primary parotid tumors. the american journal of surgery 1975;130(4):460-62. doi: https://doi.org/10.1016/0002-9610(75)90484-5 4. carta f, chuchueva n, gerosa c, sionis s, caria r, puxeddu r. parotid tumours: clinical and oncologic outcomes after microscopeassisted parotidectomy with intraoperative nerve monitoring. acta otorhinolaryngologica italica. 2017;37(5):375-86. available from: https:// www.actaitalica.it/issues/2017/5-2017/03_ carta.pdf 5. klintworth n, zenk j, koch m, iro h. postoperative complications after extracapsular dissection of benign parotid lesions with particular reference to facial nerve function. the laryngoscope. 2010;120(3):484-90. doi: https://doi.org/10.1002/lary.20801 6. anjum k, revington p, irvine gh. superficial parotidectomy: antegrade compared with modified retrograde dissections of the facial nerve. british journal of oral and maxillofacial surgery. 2008;46(6):433-34. doi: https://doi. org/10.1016/j.bjoms.2008.03.018 7. janes rm. tumours of the parotid gland. ann r coll of surg engl. 1957;21(1):1-20. pmid: 13445068 8. park sy, han kt, kim m, lim js. recurrent pleomorphic adenoma of the parotid gland. arch craniofac surg. 2016;17(2):90-92. pmid: 28913262. doi: https://doi.org/10.7181/ acfs.2016.17.2.90 9. webb aj, eveson jw. pleomorphic adenomas of the major salivary glands: a study of the capsular form in relation to surgical management. clinical otolaryngology & allied sciences. 2001;26(2):134-42. doi: https://doi. org/10.1046/j.1365-2273.2001.00440.x j. lumbini. med. coll. vol 8, no 2, july-dec 2020 sigdel b, et al. microscopic antegrade parotidectomy for different types of parotid tumor. 237 jlmc.edu.np 10. bussu f, parrilla c, rizzo d, almadori g, paludetti g, galli j. clinical approach and treatment of benign and malignant parotid masses, personal experience. acta otorhinolaryngol ital. 2011;31(3):135-43. pmid: 22058591 11. harish k. management of primary malignant epithelial parotid tumors. surgical oncology. 2004;13(1):7-16. doi: https://doi.org/10.1016/j. suronc.2003.10.002 12. johnson jt, ferlito a, fagan jj, bradley pj, rinaldo a. role of limited parotidectomy in management of pleomorphic adenoma. j laryngol otol. 2007;121(12):1126-8. pmid: 17666140. doi: https://doi.org/10.1017/ s0022215107000345 13. o’brien cj. current management of benign parotid tumors--the role of limited superficial parotidectomy. head neck. 2003;25(11):946-52. pmid: 14603455. doi: https://doi.org/10.1002/ hed.10312 14. frankenthaler ra, luna ma, lee ss, ang kk, byers rm, guillamondegui om, et al. prognostic variables in parotid gland cancer. arch otolaryngol head neck surg. 1991;117(11):1251-6. pmid: 1747227. doi: https://doi.org/10.1001/ archotol.1991.01870230067009 15. hoff sr, mohyuddin n, yao m. complications of parotid surgery. operative techniques in otolaryngology-head and neck surgery. 2009;20(2):123-30. doi: https://doi. org/10.1016/j.otot.2009.04.001 16. salgarelli ac, bellini p, consolo u, collini m. technical tips for a cosmetic approach to parotid surgery. journal of craniofacial surgery. 2012;23(2):e106-e108. available from: https://journals.lww.com/jcraniofacialsurgery/ toc/2012/03000 17. nicoli f, d’ambrosia c, lazzeri d, orfaniotis g, ciudad p, maruccia m, et al. microsurgical dissection of facial nerve in parotidectomy: a discussion of techniques and long-term results. gland surgery. 2017;6(4):308-14. available from: https://www.researchgate.net/ publication/319045637 18. witt rl. facial nerve function after partial superficial parotidectomy: an 11-year review (1987-1997). otolaryngol head neck surg. 1999;121(3):210-3. pmid: 10471859. doi: https://doi.org/10.1016/s0194-5998(99)70173-7 19. mcgurk m, renehan a, gleave e, hancock bd. clinical significance of the tumour capsule in the treatment of parotid pleomorphic adenomas. british journal of surgery 1996;83(12):1747-49. doi: https://doi.org/10.1002/bjs.1800831227 20. rodopoulou s, keramidas e, metaxotos n, tagaris g, tsati e, ioannovich j. treatment of frey’s syndrome using botulinum toxin type a. european journal of plastic surgery. 2001;24(6):297-302. doi: https://doi. org/10.1007/s002380100297 open reduction of complex metacarpo-phalangeal joint dislocations ruban raj joshia —–————————————————————————————————————————————— abstract: the metacarpophalangeal (mp) joint is resistant to injury due to its strong capsuloligamentous structures, which include the volar plate, deep transverse metacarpal and collateral ligaments. complex mp joint dislocations are, by definition, irreducible by closed means and require open reduction, as the volar plate becomes entrapped between the metacarpal head and proximal phalanx. two cases of isolated closed & one case of open complex dislocation of the metacarpophalangeal joint of the three different fingers are presented. such dislocations require open reduction, and the dorsal approach is simple and effective. keywords: complex dislocation • metacarpophalangeal joint • open reduction • volar plate ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer department of orthopedics and traumatology lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. ruban raj joshi e-mail: dr_rubanjoshi@yahoo.com how to cite this article: joshi rr. open reduction of complex metacarpo-phalangeal joint dislocations. journal of lumbini medical college. 2013;1(2):128-32. doi:10.22502/jlmc.v1i2.33. ___________________________________________________________________________________ j. lumbini. med. coll. vol 1, no 2, july-dec 2013 case report jlmc.edu.np https://doi.org/10.22502/jlmc.v1i2.33 background: traumatic dislocation of the metacarpophalangeal (mcp) joint is considered a rare injury, although the experience of hunt et al. indicates that it might be an infrequently reported injury rather than one that rarely occurs. they can be classified directionally as either being volar or dorsal, and are further categorized as simple or complex complete. a dislocation is considered to be simple when it is easily reducible with closed manipulation and complex when open reduction is necessary (fig 1). dorsal mp joint dislocations tend to occur most frequently among the exposed border digits, with the index finger most commonly affected, followed by the small finger.9,10 the long and ring fingers are protected by the deep transverse metacarpal ligaments and the border digits such that they rarely suff er an isolated dislocation.11 complex mp joint dislocations, by definition, require open reduction. this may be accomplished via either a volar or dorsal approach. this artocle reviews the operative technique for open reduction of complex mp joint dislocations using a dorsal approach. historical review and pathoanatomy: complex dislocation of the mcp joint was originally described by fara-beuf in 1876.2 however, not until 1957 did we begin to develop a better understanding of the difference between simple and complex forms. in that year, kaplan published his now classic article describing the pathologic anatomy of the metacarpal head buttonholing into the palm and the factors preventing closed reduction.3 fig 1: simple and complex mcp dislocation 128 j. lumbini. med. coll. vol 1, no 2, july-dec 2013 jlmc.edu.np joshi rr. et al. open reduction of complex metacarpo-phalangeal joint dislocations. the volar plate becomes entrapped between the metacarpal head and base of the proximal phalanx by its attachment to the deep transverse metacarpal ligament, thus becoming the primary impediment to reduction.4,5 the flexor tendons, pretendinous band of the palmar fascia slips ulnarward, and lumbrical muscles shift radially forming a noose around the dislocated mp joint, further inhibiting closed reduction (fig 2). initial attempts at reduction using traction will further tighten this noose, possibly interposing additional structures. this underscores the need for clinical and radiographic recognition of this injury pattern. the radial digital nerve of the finger is under tension and often assumes a precarious position between the metacarpal head and the skin, making it susceptible to injury during the volar approach. clinical findings and radiology: on examination, the patient with a complex mp joint dislocation will have a relatively benign clinical appearance consisting of mild extension and ulnar deviation at the mp joint, as well as flexion of the interphalangeal (ip) joints (fig 3,7a,8b). a pathognomonic sign of palmar skin puckering over the head of the metacarpal may be observed.3 the posteroanterior (pa) plain radiograph demonstrates increase in mcp joint space (figure 4b), while the oblique radiograph shows a dorsal dislocation with the mp joint in slight hyperextension (fig 4a). the presence of sesamoid interposition within the mp joint, best visualized on the oblique radiograph, is pathognomonic.6 materials and methods: case 1: a 11 year old boy, reported to department of orthopaedics, lumbini medical college teaching hospital , palpa, with pain, swelling and deformity of mcp joint of index finger of left hand for one day. fig 2: structures that prevent dislocation reduction of a metacarpophalangeal joint dislocation fig 3 : (case 1) 11 years boy with dorsal mcp dislocation of left index finger fig 4: right hand pa view showing increase in mcp joint space of index finger and right hand oblique view showing dorsal dislocation of second mcp joint. fig 5: repair of extensor mechanism fig 6: intraoperative fluoroscopic image of mcp reduction of index finger 129 j. lumbini. med. coll. vol 1, no 2, july-dec 2013 joshi rr. et al. open reduction of complex metacarpo-phalangeal joint dislocations. jlmc.edu.np there was an alleged history of fall on out-stretched hand while playing. on clinical examination, there was mild extension and ulnar deviation at the mp joint, as well as flexion of the interphalangeal (ip) joints of right index fi nger (fig: 3). a pathognomonic sign of palmar skin puckering over the head of the metacarpal was noted. a volar prominence was palpated at the mp joint corresponding to the metacarpal head with a void dorsally. radiographs demonstrated dorsal dislocation of the proximal phalanx of the index finger without fracture (fig: 4 a & b). attempted reduction under anesthesia were unsuccessful. given the clinical and radiographic picture of a complex mp joint dislocation, we proceeded with operative reduction via a dorsal approach case 2: a 39-year old man was examined at a local hospital ten hours after sustaining a hyperextension injury to his right ring finger. he complained of pain, swelling and limitation of active motion at the metacarpophalngeal joint of ring finger (fig 7a). radiographs showed volar dislocation of that joint (fig 7b). case 3: a 24 years old female injured her left thumb following a fall on her outstretched left hand from a moving tractor. soon after injury, she was brought to our hospital where a diagnosis of made (fig 8 a and b). radiographs showed volar proximal phalanx (fig 9) open, volar dislocation of the mp joint of the thumb was dislocation metacarpophalangeal joint of the thumb with a osteochondral fracture of base of proximaphalanx. surgical technique: an arm tourniquet is applied, and under regional anesthesia the upper extremity is prepped and draped in the usual sterile fashion. a curvilinear incision is made overlying the mp joint. the sagittal band of the extensor mechanism is incised and later repaired. the capsule is incised longitudinally and inspection of the joint is undertaken (figure 5). the collateral and accessory collateral ligaments may be imbricated into the joint. the volar plate is the most common impediment to reduction and must be carefully assessed. often, the volar plate remains attached to the proximal phalanx and may become completely dorsally translocated over the metacarpal head. initially the volar plate may be confused with the articular surface of the metacarpal head as it is fig 7 (a) : (case 2 ) 40 years male with mcp dislocation right ring finger. (b) radiograph showing volar dislocation of mcp ring finger fig 8 (a and b): (case 3) 24 years female with open complex dislocation of left thumb mcp joint 130 j. lumbini. med. coll. vol 1, no 2, july-dec 2013 jlmc.edu.np joshi rr. et al. open reduction of complex metacarpo-phalangeal joint dislocations. taut, shiny, and white, with an appearance similar to articular cartilage. close inspection and proper identification of anatomic structures is critical for proper reduction of the mcp joint. manipulation of the volar plate with a freer elevator may be attempted in an effort to reduce the joint maintaining the continuity of the volar plate. more commonly, a longitudinal incision in the volar plate (with articular protection afforded by a freer elevator passed over the metacarpal head) will allow it to be reduced over the metacarpal head. the leaflets of the volar plate are allowed to subluxate radial and ulnar to the metacarpal head. as the metacarpal head is being reduced, care must be taken to identify any osteochondral fracture. this allows for a concentric, stable reduction without injury to the articular surfaces. direct visualization and intraoperative fluoroscopic evaluation confirms a stable reduction through a full arc of motion (figure 8). a transarticular k-wire fixation was needed for the open complex mcp dislocation (fig 10 and 11) the capsule and the extensor mechanism is reapproximated with 4-0 vicryl (ethicon) to prevent iatrogenic subluxation (fig 5b). skin is closed with nonabsorbable horizontal mattress sutures after tourniquet deflation and hemostasis is confirmed. the patient is then placed into a gutter splint with the wrist in gentle extension, the mp joint in 70° to 90° of flexion, and the ip joints in extension. early protected mobilization with a gutter-type splint is initiated after a few days to allow early wound healing. strengthening begins at six weeks to allow for ligamentous healing. results: at three months follow-up, case 1 and case 2 active range of motion consisted of mp joint hyperextension to 5° and 60° of flexion, and 75° of flexion respectively. case 3 with open dislocation had dorsal skin necrosis which healed by second intention. two-point discrimination was within normal limits. radiographs demonstrated maintenance of reduction. discussion: complex mp joint dislocations are classically described as complete. irreducible dislocations, and require a surgical approach for reduction and proper alignment. they occur most commonly in the index and little fingers. they are relatively rare in the thumb, and exceedingly uncommon in the long or ring fingers.12 the most common structure that inhibits a closed reduction of a complex mp joint dislocation is the volar plate.13 it usually ruptures from its weakest proximal attachments to metacarpal bone, remains attached to the base of the proximal phalanx, and flips over the metacarpal head, becoming trapped between the base of the proximal phalanx dorsally and the head of the metacarpal volarly. any attempts at reducing the proximal phalanx over the metacarpal head are then impossible because the volar plate remains wedged within the joint space. other culprits sesamoid bones, collateral ligaments, bony fragments and the flexor pollicis longus tendon. if closed reduction is unsuccessful, an operative reduction is required. there is some controversy in the literature regarding the preferred approach to open reduction. farabeuf first described the dorsal approach, claiming it offers good visualization to release the entrapped volar plate without any risk of injury to neurovascular structures.2 kaplan later described the volar approach, concluding that this approach could better address under more direct visualization the anatomical pathology most commonly involved in these irreducible dislocations, namely the volar plate or flexor pollicis longus tendon.3 in the volar approach, a bruner type incision is made on the volar aspect of the mp joint. care is taken not to damage the displaced and more superficially located neurovascular bundles.3 the a1 pulley is released, the flexor tendon is moved radially or ulnarly, the fig 9: oblique radiograph (right thumb) at presentation demonstrating a complex complete volarly dislocated metacarpophalangeal joint. note possible sesamoid bone within the joint space. fig10: metacarpophalangeal joint was reduced after releasing the entrapped volar plate, splittng it longitudinally and allowing it to slip back to its anatomical position volar to the metacarpal head 131 j. lumbini. med. coll. vol 1, no 2, july-dec 2013 joshi rr. et al. open reduction of complex metacarpo-phalangeal joint dislocations. jlmc.edu.np joint is inspected and the off ending anatomical structure(s) removed from the joint space under direct visualization. in the dorsal approach, the extensor apparatus is split longitudinally and the joint approached from a dorsal direction. a trapped interposed volar plate is usually easily identified, split longitudinally and anatomically reduced. proponents of the dorsal approach cite several advantages. these include lower risk of injury to the digital neurovascular bundles, full visualization of a dorsally entrapped volar plate and, if present, a better management of associated osteochondral fractures.2,5 unfortunately, the dorsal open reduction is also associated with its own drawbacks. it requires vertical splittng of volar plate to reduce it and the metacarpal head. it has been hypothesized that splittng of the volar plate could reduce long-term stability of the mp joint. we found as others that in a dorsal dislocation of the mpj, the volar plate, which is detached from its weakest attachment to the neck of the metacarpal, is always interposed into the joint and represents the most important element preventing reduction.14,15 the deep transverse ligament lies in direct continuity with the volar plate ; this anatomic relationship is also, in part, responsible for the irreducibility.13,14 we also found the dorsal approach to be simple and effective in our cases. it avoids the risk to damage the digital nerve and it allows better access to the frequently associated osteochondral fracture of the metacarpal head. postoperatively, there is some debate over the period of immobilization. some authors recommend an early mobilization protocol, while others prefer immobilization for three to four weeks postoperatively.13,14,16 as a guide, it is important to stress the mp joint postreduction to assess the degree of joint stability. if it feels stable, an earlier mobilization protocol is reasonable. if it is unstable, splinting and/or k-wires are required to stabilize the joint, preferably in approximately 25 degrees of flexion. in this instance, most recommend three to four weeks of immobilization followed by range-of-motion exercises guided by a trained hand therapist and gradual weaning of the splint. conclusion: three cases of complex dislocations of the mp joint of three different digits approached from a dorsal incision was presented. the volar and dorsal approaches are viable options in the treatment of complex mp joint dislocations of the fingers. the dorsal approach may offer the critical advantage of decreased risk of neurovascular injury, as well as the ability to manage associated osteochondral fractures. awareness and knowledge regarding necessity of open reduction and operative approaches to the dislocated complex mp joint are imperative. fig 11: postoperative radiographs with transarticular kwires references: 1. betz rr, browne ez, perry gb, resnick ej. the complex volar metacarpophalangeal-joint dislocation. a case report and review of the literature. j bone joint surg am. 1982; 64:1374-5. 2. farabeuf lhf. de la luxation du ponce en arrière. bull soc chir. 1876;11:21-62. 3. kaplan eb: dorsal dislocation of the metacarpophalangeal joint of the index finger. j bone joint surg am. 1957;39: 1081-108. 4. johnson ae, bagg mr. ipsilateral complex dorsal dislocations of the index and long finger metacarpophalangeal joint. am j orthop. 2005;34(5):2415. 5. becton jl, christian jd jr, goodwin hn, jackson jg iii. a simplified technique for treating the complex dislocation of the index metacarpophalangeal joint. j bone joint surg am. 1975;57(5):698-700. 6. tavin e, wray rc jr. complex dislocation of the index metacarpophalangeal joint with entrapment of a sesamoid. ann plast surg. 1998; 40(1):59-61. 7. minami a, an kn, cooney wp iii, linscheid rl, chao ey. ligament stability of the metacarpophalangeal joint: a biomechanical study. j hand surg am. 1985;10(2):255 260. 8. al-qattan mm, robertson ga. an anatomical study of the deep transverse metacarpal ligament. j anat. 1993;182(pt 3):443-6. 9. mclaughlin hl. complex “locked” dislocation of the metacarpophalangeal joints. j trauma. 1965;5(6):683-8. 10. deenstra w. dorsal dislocation of the metacarpophalangeal joint of the index finger. neth j surg. 1981; 33(5):243-6. 11. may jw jr, rohrich rj, sheppard j. closed complex dorsal dislocation of the middle finger metacarpophalangeal joint: anatomic considerations and treatment. plast reconstr surg. 1988;82(4):690-3. 12. posner ma, retaillaud jl. metacarpophalangeal jointinjuries of the thumb. hand clin. 1992;8:713-32. 13. green dp, terry gc. complex dislocation of the metacarpophalangeal joint. correlative pathological anatomy. j bone joint surg am. 1973;55:1480-6. 14. barry k, mc gee h, curtin j. complex dislocation of the metacarpophalangeal joint of the index finger : a comparison of the surgical approaches. j hand surg 1988;13-b:466-468. 15. gilbert a. luxations métacarpophalangiennes chez l’enfant. in : tubiana r. et hueston j.t (eds) : chirurgie des os et des articulations, 3rd ed, expansion scientifique française, paris, 1986, pp 796-800. 16. eglseder wa jr, gens dr, burgess ar. multiple ipsilateral dorsal metacarpophalangeal and proximal interphalangeal joint dislocations: a case report. j trauma. 1995;38:955-7. 132 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 04 march, 2020 accepted: 20 may, 2020 published: 11 june, 2020 a assistant professor, department of forensic medicine, b lecturer, department of community medicine, c lumbini medical college teaching hospital, palpa, nepal. dkathmandu medical college teaching hospital, kathmandu, nepal. corresponding author: alok atreya e-mail: alokraj67@hotmail.com orcid: http://orcid.org/0000-0001-6657-7871_______________________________________________________ –————————————————————————————————————————— abstract introduction: as medicine is an ever-changing field, it necessitates medical students to develop independent learning skills for continuous learning process. self-directed learning (sdl) is a learning strategy where students take the initiative to learn on their own. it is basically an independent study where the students use available resources and learn independently of the subject. methods: this self-administered questionnaire study assessed five domains of sdl consisting of 60 items. the responses were made on a five-point likert scale: from 5 = always to 1 = never. the level of self-directed learning was categorized as high, moderate and low if the scoring range was between 221-300, 141-220 or 60-140 respectively. any student scoring in the range between 221 and 300 was considered an effective selfdirected learner. results: the present study found three out of four the students (74.7%, n=56) were active self-directed learners. however, one out of four students were half-way in becoming self-directed learners. conclusion: sdl skill is crucial not only for the students but also for the clinicians in a complex learning process for continuous advancement of knowledge in medical profession. the findings of the present study showed that majority of the students were effective self-directed learners. the effectiveness of sdl process can be accomplished if the students are encouraged and motivated during problem based learning (pbl) sessions. identifying the factors that spark interest amongst the students to learn on their own can be achieved by active feedback sessions. keywords: medical education, nepal, problem based learning (pbl), self-directed learning (sdl) original research articlehttps://doi.org/10.22502/jlmc.v8i1.319 alok atreya,a,c samata nepal,b,c jenash acharya a,d self-rating on self-directed learning: a crosssectional survey on a cohort of medical undergraduates from nepal. how to cite this article:how to cite this article: atreya a, nepal s, acharya j. self-rating on self-directed learning: atreya a, nepal s, acharya j. self-rating on self-directed learning: a cross-sectional survey on a cohort of medical undergraduates a cross-sectional survey on a cohort of medical undergraduates from nepal. journal of lumbini medical college. 2020;8(1): 5 pages. from nepal. journal of lumbini medical college. 2020;8(1): 5 pages. doi: doi: https://doi.org/10.22502/jlmc.v8i1.331199. epub: 2020 june 11.. epub: 2020 june 11. introduction: although 42 years have passed from the start of medical education in nepal, very few studies have been conducted in terms of quality of medical education.[1] the quality of medical education is assessed by nepal medical council, which in 1994, recommended all the medical colleges to establish a medical education unit/ department.[2] however, researches concerning improvement of medical education in nepal is sparse. medical education is vast and limitless. although medical colleges have syllabus and guidelines for the contents to be taught during the academic years in medical school, it also prepares students to face challenges to treat new diseases or ailments that were not present or taught during the formal undergraduate training. as medicine is an ever changing field, it has been emphasized that medical students develop independent learning skills for continuous learning process.[3] selfdirected learning (sdl) is a learning strategy where students take the initiative to learn on their own. [4] it is basically an independent study where the students use their available resources and learn j. lumbini. med. coll. vol 8, no 1, jan-june 2020 atreya a, et al. self-rating on self-directed learning: a cross-sectional survey on a cohort of medical undergraduates from nepal.atreya a, et al. self-rating on self-directed learning: a cross-sectional survey on a cohort of medical undergraduates from nepal. jlmc.edu.np independently about the subject.[4] as defined by malcolm knowles in 1975: “in its broadest meaning, self-directed learning describes a process in which individuals take the initiative, with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies, and evaluating learning outcomes.”[5] the approach of problem based learning (pbl) was introduced during mid-1960s as an innovative approach in medical education.[4,6] the curriculum for initial years of medical school usually focuses upon basic science subjects which the students see least relevant as future doctors. the concept of pbl was to overcome this disappointment. [6] the students in pbl are presented with a realistic medical ‘problem’ that physicians commonly encounter in clinical settings.[6] pbl method is a problem centric approach where problems are the starting point of the learning process. solving the given problem will conceptualize a student of the given disease or condition. all the medical colleges in nepal have adopted the concept of pbl for undergraduate teachings.[7,8,9] in contrast to pbl students need to identify the problem by themselves in sdl. sdl and selfregulated learning (srl) share some common features; srl is however a different concept where a learner has a control over their own learning. it is argued that pbl can foster sdl.[4] the present study is a preliminary survey on the level of self-directed learning in medical students. methods: the present cross-sectional study was conducted among undergraduate medical students in their 7th semester, of lumbini medical college teaching hospital, palpa, nepal. a self-rating scale of self-directed learning, developed by swapna naskar williamson was used in this study as a data collection tool.[10] the students were explained about the objectives of the study. the study questionnaire was then distributed to the students who consented through an informed consent to participate in the study. confidentiality of the students was maintained as no individual identification was included in the questionnaire. ethical clearance for the study was obtained from the institutional research committee of the institution (irc-lmc 01-c/020). the questionnaire contained 60 items categorized under five broad areas, each consisting of 12 items on self-directed learning as mentioned below: a. awareness: evaluated the awareness of the learner about the factors to become self-directed learner. b. learning strategies: explained the strategies the self -directed learner should adopt. c. learning activities: explained the activities the self-learner should actively engage upon. d. evaluation: evaluate learner’s self-learning process. e. interpersonal skills: evaluate learner’s interpersonal skills necessary for self -directed learning. the response to each item was assessed using a five-point likert scale: 5 = always; 4 = often; 3 = sometimes; 2 = seldom; 1 = never. based on the individual response, the minimum and maximum score will be within 60 and 300. the level of self-directed learning was categorized as high, moderate and low if the scoring range was between 221-300, 141-220 or 60-140 respectively as per the recommendation of the tool used. any student scoring in the range between 221 to 300 was considered effective selfdirected learner whereas the score between 60 and 140 designated students as poor selfdirected learners who needed guidance from the teachers. all analyses were performed using statistical package for social sciences (spsstm) software version 16.0. results: the questionnaire was initially distributed to 89 students of which 14 students either voluntarily opted out from the study or failed to respond to all the items, making a response rate of 84.27%. the total number of students in the present study was 75 of which 42 were females (56%) and 33 males (44%). the mean age of the students was 22.03 ± 0.99 years. the mean score of the students in the five broad areas of sdl is presented in table 1. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 atreya a, et al. self-rating on self-directed learning: a cross-sectional survey on a cohort of medical undergraduates from nepal.atreya a, et al. self-rating on self-directed learning: a cross-sectional survey on a cohort of medical undergraduates from nepal. jlmc.edu.np table 1. mean score in five broad areas of sdl (n=75). areas of sdl mean ± standard deviation score male (n=33) female (n=42) total awareness 3.96±0.41 3.98±0.44 3.97±0.42 learning strategy 4.19±0.40 4.12±0.37 4.15±0.38 learning activity 3.71±0.52 3.72±0.43 3.71±0.47 evaluation 3.89±0.56 3.92±0.43 3.91±0.49 interpersonal skills 3.94±0.62 3.73±0.42 3.82±0.52 it was observed that none of the students in the present study had a score that was in the range between 60 to 140. the present study found majority of the students were active self-directed learners. however, 25.3% of the students were half-way in becoming self-directed learners. the mean total score of the students is categorized as per gender in table 2. table 2. level of sdl in the students and obtained mean score (n=75). level of self-directed learning (n,%) mean score ± sd gender high moderate low male 24 (32.0%) 9 (12.0%) 0 236.36 ± 25.54 female 32 (42.7%) 10 (13.3%) 0 233.40 ± 20.32 total 56 (74.7%) 19 (25.3%) 0 234.71 ± 22.65 discussion: the students showed positive learning strategy required for effective self-directed learning. majority of the students had a higher score in the items pertained to group discussions, peer coaching, role-play, interactive teaching learning sessions, simulation in teaching-learning, learning from case studies, concept mapping etc. unlike in the past, where books and didactic lectures were the only source of information; technological advancements in twenty first century have opened door for easy access to limitless resources. with emerging new trend of morbidity, medical doctors too need to adapt to face new challenges.[11] to overcome this, they need to foster the ability to utilize various resources to learn to solve problems. the present study showed a positive attitude of the students towards independent learning. the process of triggering a solution to problems during pbl is one of the reasons of them being self-directed learners.[12] in nepalese context, if pbl method is made effective, the students will be effective selfdirected learners. medical education in nepal is not without challenges. lucrative business of medical education has attracted much attention of the businessmen as there are more medical colleges to get accredited in the pipeline.[13] least has been thought on improving the quality of medical education by the stake holders of majority of medical colleges.[14] the approaches to improve medical education in nepal has been observed at patan academy of health sciences. implying evidence-based practice in teaching and treating and facilitating peer-assisted learning for the students has been reported from this deemed institution.[9,15] the existing medical curriculum in nepal has made it mandatory for pbl to be conducted. the pbl approach is effective if implied correctly. the freshly passed graduates who join medical school as faculties without proper training in pbl system will do more harm than good to the students. the students are to be guided in such a way that they are always ready to explore their resources and learn. the ability to learn is an individual process and is different from others. it is prompted by motivation, enthusiasm and guidance. it has been postulated that setting a learning goal would make it easier for students and the faculties identify the learning need. [3] the other approach for effective pbl would be blending pbls by adding e-learning elements.[16] lack of faculties is considered one of the setbacks in quality of medical education in nepal.[2,17] in one study conducted on medical j. lumbini. med. coll. vol 8, no 1, jan-june 2020 atreya a, et al. self-rating on self-directed learning: a cross-sectional survey on a cohort of medical undergraduates from nepal.atreya a, et al. self-rating on self-directed learning: a cross-sectional survey on a cohort of medical undergraduates from nepal. jlmc.edu.np education from rural nepal, it was quoted “in the authors’ experience, passive learning is often the default in nepali medical education, with didactics, rote memorization, and fact-based, rather than student-centered learning.”[18] conceptualizing innovative methods for effective student centric learning is a need of time in nepalese scenario. regular training of the trainers initiated by medical education department (med) will make the trainers competent. frequent evaluation of the trainee and the trainers will show the lacunae where more emphasis has to be intervened. interactive sessions among the educators and the learners might bring out a noble way of effective teaching in a given scenario. the present study is not without limitations. a single center study with a small sample size from a single batch of students are the shortcomings. questionnaire used in the study was used in its original form. the authors felt that if the questionnaire was translated in native local language, modified and designed to fit in the nepalese context, students would have had a clear understanding of what was being asked. follow up studies in similar setting from other colleges will give a clear picture of effective sdl in nepalese medical students that would pave way for effective development of medical curriculum. conclusion: sdl skill is crucial not only for the students but also for the clinicians for complex learning process for continuing advancement of knowledge in medical profession. the findings of the present study showed majority of the students were effective self-directed learners, one third had a moderate sdl score. the effectiveness of sdl process can be accomplished if the students are encouraged and motivated during student-centered teaching-learning method like pbl sessions. identifying the factors that sparks interest amongst the students to learn can be achieved by active feedback sessions during and after the pbl sessions. the slow learners can be identified and guided and should not be compared with quick learners. although classroom blackboards have been replaced with whiteboards and overhead projectors have been replaced by multimedia projectors, least has been observed in regards to medical education innovation in nepal. it is a need of time to find innovative methods to develop quality medical education and fulfill the dearth of literatures on medical education in nepalese scenario. acknowledgement: professor dr. hemang dixit, chairperson, medical education department, kathmandu medical college teaching hospital, nepal. dr. swapna naskar williamson, associate professor, college of nursing, midwifery and healthcare, university of west london, uk. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 atreya a, et al. self-rating on self-directed learning: a cross-sectional survey on a cohort of medical undergraduates from nepal.atreya a, et al. self-rating on self-directed learning: a cross-sectional survey on a cohort of medical undergraduates from nepal. jlmc.edu.np references: 1. dixit h, marahatta sb. medical education and training in nepal: swot analysis. kathmandu univ med j (kumj).2008;6(23):412-420. pmid: 20071831 doi: https://doi.org/10.3126/ kumj.v6i3.1725 2. dixit h. development of medical education in nepal. kathmandu univ med j (kumj).2009;7(25):8-10. pmid: 19483445 doi:https://doi.org/10.3126/kumj.v7i1.1757 3. wolff m, stojan j, buckler s, cranford j, whitman l, gruppen l, et al. coaching to improve self-directed learning. clin teach.2019; [epub ahead of print]. pmid: 31749307 doi:https://doi.org/10.1111/tct.13109 4. loyens sm, magda j, rikers rmj. self-directed learning in problem-based learning and its relationships with self-regulated learning. educ psychol rev.2008;20(4):411-427. doi:https:// doi.org/10.1007/s10648-008-9082-7 5. knowles ms. self-directed learning: a guide for learners and teachers. cambridge adult education; 1975. doi: https://doi. org/10.1177/105960117700200220 6. barrows hs, tamblyn rm. problem-based learning: an approach to medical education. springer publishing company; 1980. https:// books.google.nl/books?hl=nl&lr=&id=9u-5dju qq2uc&oi=fnd&pg=pr5&ots=k2shpy6inb& sig=cyk72gl5_x3369-z5qppk80uzvc&redir_ esc=y#v=onepage&q&f=false 7. mansur di, kayastha sr, makaju r, dongol m. problem based learning in medical education. kathmandu univ med j (kumj).2012;10(40):7882.pmid: 23575059doi: https://doi. org/10.3126/kumj.v10i4.11002 8. pradhan b, ranjit e, ghimire m, dixit h. history of problem based learning in nepal and experiences at kathmandu medical college. journal of kathmandu medical college. 2012;1(1):37-44. https://doi.org/10.3126/jkmc. v1i1.7255 9. kc a, karki s. reflection on peer assisted learning at pahs. journal of patan academy of health sciences. 2015;1(1):54-6. doi: https:// doi.org/10.3126/jpahs.v1i1.13021 10. williamson sn. development of a selfrating scale of self-directed learning. nurse res.2007;14(2):66-83. pmid: 17315780 doi: https://doi.org/10.7748/nr2007.01.14.2.66. c6022 11. ge x, chua bl. the role of self-directed learning in pbl. in: the wiley handbook of problem‐based learning.(eds m. moallem, w. hung, n. dabbagh), 2020;367-388. doi: https:// doi.org/10.1002/9781119173243.ch16 12. shokar gs, shokar nk, romero cm, bulik rj. self-directed learning: looking at outcomes with medical students. fam med.2002;34(3):197200. pmid: 11922535 13. magar a. need of medical education system reform in nepal. jnma j nepal med assoc.2013;52(191):i-ii. pmid: 24907969 14. adhikari b, mishra sr. urgent need for reform in nepal’s medical education. lancet.2016;388(10061):2739-2740. https://doi. org/10.1016/s0140-6736(16)32423-0 15. paudel s, acharya bm, pun km, paudel s, kc kb, arjyal a. evidence-based practice at patan academy of health sciences, nepal: knowledge, attitude, behavior and barriers.journal of patan academy of health sciences. 2018;5(1):82-89. doi:https://doi.org/10.3126/jpahs.v5i1.24049 16. shimizu i, nakazawa h, sato y, wolfhagen ihap, könings kd. does blended problembased learning make asian medical students active learners?: a prospective comparative study. bmc med educ. 2019;19(1):147. pmid: 31092243doi: https://doi.org/10.1186/s12909019-1575-1 17. ansari m. quality of medical education in nepal. educ health (abingdon).2012;25(2):130. doi:https://doi.org/10.4103/1357-6283.103462 18. mehanni s, wong l, acharya b, agrawal p, aryal a, basnet m, et al. transition to active learning in rural nepal: an adaptable and scalable curriculum development model. bmc med educ. 2019;19(1):61.pmid: 30786884 doi: https://doi.org/10.1186/s12909-019-1492-3 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 kandel s, et al. sexual dimorphism of maxillary sinus: a morphometric analysis using computed tomography. 264 jlmc.edu.np ___________________________________________________________________________________ submitted: 17 june, 2020 accepted: 20 september, 2020 published: 29 december, 2020 alecturer, department of dental surgery, bassistant professor, department of radiodiagnosis, clecturer, department of forensic medicine, dlumbini medical college teaching hospital, palpa, nepal. corresponding author: santosh kandel e-mail: drsantoshkandel@gmail.com orcid: https://orcid.org/0000-0002-5788-5263_______________________________________________________ abstract: introduction: gender determination is the important aspect of forensic science. most of the bones used for sex determination are badly disfigured and found in incomplete state, thus bones recovered intact are used. maxillary sinus being recovered intact can be used for gender determination by measuring maxillary sinus dimension through computed tomography (ct). the aim of this study was to assess sexual dimorphism using morphometric maxillary sinus measurements through ct scan. methods: this analytical cross-sectional study included ct scan images of 80 patients (40 males and 40 females). maxillary sinus mediolateral (ml), superoinferior (si), anteroposterior (ap) linear dimensions and volume were measured. all the measured parameters were then subjected to student’s t-test to determine mean difference between males and females and discriminative statistical analysis to determine gender. results: the mean value of maxillary sinus length, width, height and volume in males on both right and left sides were (3.80±0.175, 3.74±0.209) cm, (2.57±0.317, 2.51±0.295) cm, (3.55±0.338, 3.5±0.286) cm and (17.49±3.909, 16.54±3.274) cm3 respectively and in females (3.67±0.250, 3.64±0.256) cm, (2.37±0.297, 2.34±0.3222) cm, (3.29±0.280, 3.23±0.254) cm and (14.42±2.935, 13.81±2.779) cm3 respectively. the discriminative analysis showed that the accuracy of maxillary sinus measurements was 72.5% in females and 75% ofmales (overall accuracy = 73.8%). conclusion: the maxillary sinus measurements are valuable guide for sex determination with relatively good accuracy rate. keywords: computed tomography, maxillary sinus, sex determination original research articlehttps://doi.org/10.22502/jlmc.v8i2.382 santosh kandel,a,d raju shrestha,a,d rupesh sharma,b,d sanjay kumar sahc,d sexual dimorphism of maxillary sinus: a morphometric analysis using computed tomography how to cite this article:how to cite this article: kandel s, shrestha r, sharma r, sah sk. sexual dimorphism of maxillary sinus: a morphometric analysis using computed tomography. journal of lumbini medical college. 2020;8(2):264269. doi: https://doi.org/10.22502/jlmc.v8i2.382 epub: 2020 december 29. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction sex determination of skeletal remains is one of the major concerns in forensic anthropology, apart from age, race and stature.[1]there are various situations like mass disaster, road traffic accidents, fire, air crashes where it becomes very difficult to identify the individual and also to investigate the criminal cases. thus, depending upon the uniqueness of anatomical structure, forensic anthropology can be used to identify the unknown deceased person. it becomes impossible to use the conventional skeletal bones for sex determination because most of the skeleton of unknown human remains are either fragmented or recovered in incomplete state.[2,3] thus, bones like maxillary sinus which are reported to get recovered intact even in case of severe destruction of skull and other skeletal bones are used.[2] maxillary sinuses are the largest paranasal sinus, located in maxillary bone bilaterally. they are the first paranasal sinus to develop, appearing at the end of second embryonic month and maturing at about 20 years of age. they are usually stable after j. lumbini. med. coll. vol 8, no 2, july-dec 2020 kandel s, et al. sexual dimorphism of maxillary sinus: a morphometric analysis using computed tomography. 265 jlmc.edu.np second decade of life and radiographic images can provide necessary measurements for morphometric forensic analysis.[4] ct scan is considered gold standard method to evaluate sinonasal cavities as they provide accurate dimension assessment owing to anatomic complexity of paranasal sinuses.[5] the size and shape of maxillary sinus differ among individuals, between genders, and in various populations. ct measurements of the length, width, height and volume of maxillary sinus can be used for gender determination.[5] the aim of this study was to evaluate sexual dimorphism using maxillary sinus mediolateral (ml), superoinferior (si), and anteroposterior (ap) linear dimensions and volume through ct scan. methods: the present analytical cross-sectional study was carried out in the department of radiodiagnosis, lumbini medical college and teaching hospital, palpa. the sample size was calculated using the formula n= 2sd2(zα/2+zβ) 2/d2 for comparing two means using mean and standard deviation. where, α= 0.05, β=0.02. mean and standard deviation taken from previous similar study were mean1=36.9, mean2=39.3, sd1=3.8, sd2=3.8.[6] ethical clearance (irc-lmc 018-a/19) was obtained from institutional review committee. a total of 80 patients including 40 males and 40 females were selected from march, 2019 to december, 2019 who underwent ct examination for other medical problems not related to the maxillary sinus. patients ranging from 20-70 years undergoing ct scan who were free from sinus pathology were included. patients with history of facial trauma, sinus surgery, cleft palate, supernumerary tooth, missing tooth, periapical infections, periodontal infections and with developmental maxillofacial anomaly were excluded. after obtaining the informed consent, the patients were examined on siemens somatom scope 16 slice spiral computed tomography scanner. maxillary sinus dimensions (length, width and height) measurements were done directly on computer on dicom (digital imaging and communications in medicine) images using electronic calliper inbuilt in dicom viewer software by one observer who was blind to the sex of patients. in order to evaluate intra examiner error and reliability, 10 randomly selected ct images were retracted by same observer at the interval of 10 days and interclass correlation coefficients were calculated for each parameter. the greatest dimension was taken after going through different slices in coronal and sagittal sections. • the length was determined on axial reconstructed image, the longest distance antero-posteriorly from the most anterior point to the most posterior point. (fig. 1) • estimation of height was done on coronal reconstructed images, the longest distance from the lowest point of the sinus floor to the highest point on sinus roof. (fig. 2) • the width was obtained on axial reconstructed images, the longest distance perpendicular to medial wall of the sinus to the outermost point of lateral wall of the lateral process of the maxillary sinus. (fig. 1) • the volume of maxillary sinus was calculated using the formula: height x width x length x 0.5.[7] fig. 1: vertical line shows the length of maxillary sinus; horizonatal line shows the width of maxillary sinus. fig.2: vertical line denotes the height of maxillary sinus. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 kandel s, et al. sexual dimorphism of maxillary sinus: a morphometric analysis using computed tomography. 266 jlmc.edu.np statistical methods the data of maxillary sinus dimensions and volume were entered to microsoft excel spreadsheet and imported to statistical package for social sciences (spsstm) software version 20 for analysis. the student’s t-test was used to determine mean difference of different parameters between males and females.all the measured parameters data was then subjected to discriminant statistical analysis to determine gender. the p value was considered significant when it was< 0.05. results: the present study evaluated ct scans of 80 patients, with equal distribution among males and females. among males, 13.75% belonged to the age group 31-40 whereas, in females 15% of ct scans belonged to 41-50 years age group. maxillary sinus length the mean values of maxillary sinus length for both right and left side of males were greater in males (3.80±0.175, 3.74±0.209) cm than females (3.67±0.250, 3.64±0.256)cm respectively, with statistically significant difference of sexual dimorphism in only right side (p-value = 0.009) (table 1) maxillary sinus width the mean value of maxillary sinus width on right and left side of male group was 2.57±0.317 cm and 2.51±0.295 cm respectively. female group had significantly lower values for both sides (2.37±0.297, 2.34±0.3222) cm with p values of 0.004 for right side and 0.016 for left side. maxillary sinus height the mean value of maxillary sinus height in male group for both right and left sides (3.55±0.338, 3.5±0.286) cm was significantly larger than that of female group (3.29±0.280, 3.23±0.254) cm respectively with the p-values of <0.001 on both sides. maxillary sinus volume the volume of maxillary sinus was significantly greater in males than that of females for right and left sides with p-values of <0.001 on both sides. mean volume in right and left side for male was (17.49±3.909, 16.54±3.274) cm3 whereas that for female group was (14.42±2.935, 13.81±2.779) cm3respectively. table 1. gender differences using right maxillary sinus dimension (n=80) parameter gender mean±sd p-value length (cm) male female 3.80±0.17 3.67±0.25 0.009 width (cm) male female 2.57±0.31 2.37±0.29 0.004 height (cm) male female 3.55±0.33 3.29±0.28 <0.001 volume (cm3) male female 17.49±3.90 14.42±2.93 <0.001 table 2. gender differences using left maxillary sinus dimension (n=80) parameter gender mean±sd p-value length (cm) male female 3.74±0.20 3.64±0.25 0.052 width (cm) male female 2.51±0.29 2.34±0.32 0.016 height (cm) male female 3.50±0.28 3.23±0.25 <0.001 volume (cm3) male female 16.54±3.27 13.81±2.77 <0.001 the discriminant analysis showed that right maxillary sinus volume was best discriminate parameter that was 80% of female and 62.5% of male (overall accuracy of 71.2%). combining both right and left maxillary sinus measurements, overall classification accuracy was improved to 75% for male and 72.5% for female (overall accuracy of 73.8%) discussion: sex determination is a key step in forensic science to identify unknown person skeletal remnants. different body parts like pelvis, skull, long bones with an epiphysis and a metaphysis, paranasal sinus, mastoid process and foramen magnum have been used for gender determination. maxillary sinus being relatively intact among other skeletal remnants can become useful in most difficult times for forensic experts. as maxillary sinus is a complex structure, diagnostic modality like cone beam computed tomography (cbct), magnetic resonance imaging (mri) and ct scan j. lumbini. med. coll. vol 8, no 2, july-dec 2020 kandel s, et al. sexual dimorphism of maxillary sinus: a morphometric analysis using computed tomography. 267 jlmc.edu.np are used to evaluate the true anatomy of maxillary sinus.[8] however, due to high cost of mri and limited availability of cbct in the western region of nepal, ct scan was used to determine gender in this study. this study highlights the use of various sinus dimension measurement through analysis of ct scan as a method for sex determination. the review article by xavier et al. concluded that maxillary sinus provides important information in forensic and allows for sex determination.[9] in this study, except for left maxillary sinus length, overall mean dimension of other parameters was statistically greater among males, which is consistent with numerous other researches .[2,4,10] the reason for greater dimension is possibly due to sex specific differences like bigger body size, larger, robust cranial and postcranial skeleton in males. the volume of maxillary sinus among males was significantly larger than females with higher percentage of sexual dimorphism in our study. kanthemet al., kawariet al., fernandes and sahlstrand-johnson et al. in their study found that mean volume of maxillary sinus were significantly larger in males than in females.the larger dimension and volume of maxillary sinus in males is comparable to many previous studies, and thus can be used for gender determination.[7,11,12,13] table 3. discriminant analysis using right or left maxillary sinus measurement to distinguish between males and females parameters wilks lambda predicted male percent predicted female percent predicted overall percent right maxillary sinus length 0.916 75% 75% 75% left maxillary sinus length 0.952 70% 67.5% 68.8% right maxillary sinus width 0.901 55% 72.5% 63.8% left maxillary sinus width 0.928 52.5% 67.5% 60% right maxillary sinus height 0.852 72.5% 55% 63.8% left maxillary sinus height 0.797 75% 60% 67.5% right maxillary sinus volume 0.832 62.5% 80% 71.2% left maxillary sinus volume 0.828 70% 75% 72.5% table 4. discriminant analysis using alone right or left maxillary sinus measurements to distinguish between males and females wilks lambda predicted male percent predicted female percent predicted overall percent right maxillary sinus measurements* 0.803 67.5% 62.5% 65% left maxillary sinus measurements* 0.754 72.5% 75% 73.8% *right maxillary sinus measurements include length, width, height and volume. *left maxillary sinus measurements include length, width, height and volume. table 5. discriminant analysis using both right and left maxillary sinus measurements to distinguish between males and females wilks lambda predicted male percent predicted female percent predicted overall percent right maxillary sinus measurements* left maxillary sinus measurements* 0.707 75% 72.5% 73.8% *right maxillary sinus measurements include length, width, height and volume. *left maxillary sinus measurements include length, width, height and volume. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 kandel s, et al. sexual dimorphism of maxillary sinus: a morphometric analysis using computed tomography. 268 jlmc.edu.np based on our data, the right maxillary sinus volume was the best discriminate parameter with 80% prediction of female and 62.5% of male with overall accuracy of 71.2%. apart from volume, right maxillary sinus length showed the prediction of 75% for both males and females. kanthemet al.[11] concluded that volume of right maxillary sinus can be used as accurate diagnostic parameter for sex determination. similarly, previous studies by urooge et al., sharma et al. and uthman et al. mentioned left width, ap dimension and height as the best discriminative parameter respectively.[6,8,14] the overall accuracy rate in terms of determining sex by using all the parameters was 73.8% (75% of males and 72.5% of females). the results are similar to those presented in a study by uthman et al., attia et al., tekeet al. with overall accuracy of 71.6%, 69.9%, and 69.3% respectively. [6,15,16] even greater overall accuracy rate was seen in the study performed by s. dangoreet al. (86%), prabhat et al. (83.3%) and bangiet al. (88%). [2,5,17] the reason for this variation is likely due to factors such as different ethnicity, race, environment, genetic factors, differences in body morphology, stature etc. past infections, pneumatization process of maxillary sinus in different age groups, apposition and resorption process in the maxillary sinus also may influence the overall result. gender determination using anthropometry has few limitations. since, the study was population specific and carried in patients from western region of nepal, the discriminate functions cannot be generalized for the general population of nepal. conclusion: although most of the bones are recovered incomplete or fragmented, maxillary sinus is reported to remain intact in victims who are incinerated. ctscan is considered one of the excellent modalities to view complex anatomy of maxillary sinus. the results in this study showed that anatomic variation exists between genders. maxillary sinus dimension and volume measured using ct can be used to determine sex if cranium of unknown origin is found. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 kandel s, et al. sexual dimorphism of maxillary sinus: a morphometric analysis using computed tomography. 269 jlmc.edu.np references 1. sah sk, jeelani ba. hand indexa forensic tool for sexual dimorphism. journal of lumbini medical college. 2019;7(1):13-7. doi: https:// doi.org/10.22502/jlmc.v7i1.272 2. dangore-khasbage s, bhowate r. utility of the morphometry of the maxillary sinuses for gender determination by using computed tomography. dent med probl. 2018;55(4):411-17. pmid: 30648366. doi: https://doi.org/10.17219/ dmp/99622 3. ahmed ag, gataa is, fateh sm, mohammed gn. ct scan images analysis of maxillary sinus dimensions as a forensic tool for sexual and racial detection in a sample of kurdish population. european scentifici journal. 2015;11(18):272-281. available from: https:// eujournal.org/index.php/esj/article/view/5838 4. ravali ct. gender determination of maxillary sinus using cbct. international journal of applied dental sciences. 2017;3(4):221-24. available from: https://www.oraljournal.com/ pdf/2017/vol3issue4/partd/3-4-41-609.pdf 5. bangi bb, ginjupally u, nadendla lk, vadla b. 3d evaluation of maxillary sinus using computed tomography: a sexual dimorphic study. int j dent. 2017;2017(0):9017078. pmid: 28473853. doi: https://doi.org/10.1155/2017/9017078 6. uthman at, al-rawi nh, al-naaimi as, al-timimi jf. evaluation of maxillary sinus dimensions in gender determination using helical ct scanning. j forensic sci. 2011;56(2):403-8. pmid: 21210803. doi: https://doi.org/10.1111/ j.1556-4029.2010.01642.x 7. sahlstrand-johnson p, jannert m, strömbeck a, abul-kasim k. computed tomography measurements of different dimensions of maxillary and frontal sinuses. bmc med imaging. 2011;11(0):8. pmid: 21466703. doi: https://doi.org/10.1186/1471-2342-11-8 8. urooge a, patil ba. sexual dimorphism of maxillary sinus: a morphometric analysis using cone beam computed tomography. j clin diagn res. 2017;11(3):zc67-zc70. pmid: 28511513. doi: https://doi.org/10.7860/ jcdr/2017/25159.9584 9. xavier ta, terada assd, alves da silva rh. forensic application of the frontal and maxillary sinuses: a literature review. journal of forensic radiology and imaging. 2015;3(2):105-10. doi: https://doi.org/10.1016/j.jofri.2015.05.001 10. paknahad m, shahidi s, zarei z. sexual dimorphism of maxillary sinus dimensions using cone-beam computed tomography. j forensic sci. 2017;62(2):395-98. pmid: 27864961. doi: https://doi.org/10.1111/15564029.13272 11. kanthem rk, guttikonda vr, yeluri s, kumari g. sex determination using maxillary sinus. 2015;7(2):163-7. pmid: 26005308. doi: https://doi.org/10.4103/0975-1475.154595 12. kawarai y, fukushima k, ogawa t, nishizaki k, gunduz m, fujimoto m, et al. volume quantification of healthy paranasal cavity by three-dimensional ct imaging. acta otolaryngol suppl. 1999;540:45-9. pmid: 10445079 13. fernandes cl. forensic ethnic identification of crania: the role of the maxillary sinus -a new approach. am j forensic med pathol.2004;25(4):302-13. pmid: 15577519. doi: https://doi.org/10.1097/01. paf.0000146379.85804.da 14. sharma sk, jehan m, kumar a. measurements of maxillary sinus volume and dimensions by computed tomography scan for gender determination. journal of the anatomical society of india. 2014;63(1):36-42. doi: https://doi. org/10.1016/j.jasi.2014.04.007 15. attia am, el-badrawy am, shebel hm. gender identification from maxillary sinus using multidetector computed tomography. mansoura journal of forensic medicine and clinical toxicology. 2012;20(1):17-28. doi: https:// dx.doi.org/10.21608/mjfmct.2012.47769 16. teke hy, duran s, canturk n, canturk g. determination of gender by measuring the size of the maxillary sinuses in computerized tomography scans. surg radiol anat. pmid: 17171233. doi: https://doi.org/10.1007/s00276006-0157-1 17. prabhat m, rai s, kaur m, prabhat k, bhatnagar p, panjwani s. computed tomography based forensic gender determination by measuring the size and volume of the maxillary sinuses. j forensic dent sci. 2106;8(1):40-6. pmid: 27051222. doi: https://doi.org/10.4103/09751475.176950 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 01 june, 2020 accepted: 03 june, 2020 published: 13 june, 2020 a-resident, department of community medicine, b-assistant professor, department of community medicine, ccollege of medical sciences, bharatpur, nepal. dkathmandu university school of medical sciences, dhulikhel, nepal. corresponding author: dipesh tamrakar e-mail: dipesht@kusms.edu.np orcid: https://orcid.org/0000-0002-0772-3653 how to cite this article: koirala p, tamrakar d. threat of dengue outbreak in nepal in context of covid-19 pandemic. journal of lumbini medical college.2020;8(1):2 pages. doi: https://doi.org/10.22502/jlmc. v8i1.365 epub: 2020 june 13._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.365 pallavi koirala,a,c dipesh tamrakar b,d threat of dengue outbreak in nepal in context of covid-19 pandemic the world has been chained with corona virus disease (covid-19) pandemic today. it has affected more than 200 countries in just about a few months since december 2019.[1] the virus has engulfed the world at a momentum never seen before. considering the chances of disease being spread through asymptomatic transmission, social distancing has become a norm.[2] this has brought a huge shift in how we live, work or interact with each other. it is feared that after the pandemic is over, the world would suffer a period of economic loss, as huge as the greatest depression of the 1930s or even more.[3] with the world making medieval inventions and science doing wonders, we seem helpless to fight this pandemic. it has also drawn us to a realization that pandemic response cannot be extemporaneous. it is evident that different countries are going through this pandemic in different timelines. till may 15, 2020, a total of 43,07,287 cases of covid-19 have been reported along with 2,95,101 casualties.[1] the official figures for nepal on the same date confirmed 258 confirmed cases with no mortality.[1] world health organization(who) had predicted that covid19 might not die out and it could increase throughout the year.[4] nepal has been facing an outbreak of dengue since 2010. during the last five years, yearly outbreak of dengue has been reported.[5] the largest was in 2019 where more than 14,000 cases were detected including six deaths.[5] the number of people affected in 2019 was nearly ten times more than in 2018 and the possible reasons for such a huge number of cases could be : i) new area affected by dengue involving 68 districts in the year 2019 in comparison to 45 districts in 2018 ii) outbreak started early from may while previously the outbreak started from july along with monsoon and peaked at august-september post monsoon.[6] the first case was seen in sunsari district on 13 may, and iii) large number of cases were reported from metropolitan cities with dense population including the capital city kathmandu which alone confirmed 1583 cases. [7] from the public health perspective, last year’s outbreak was also important because the newly affected areas happened to be hills and mountainous region of the country. these geographical locations reported minimal cases of vector borne diseases in the past. the probable reasons for the increase in size and area were increase in vectors and suitable environment for breeding.[8] the case fatality rate may rise this year than the previous year due to subsequent infection by other serotypes resulting in severe dengue in the population who were infected previously. thus, this year, focus is required on prevention of severe outbreaks of dengue in addition to the ongoing covid-19 pandemic. one of the many challenges faced are similar in clinical presentation and laboratory test results of dengue and covid-19. fever, headache, malaise, lymphocytopenia are common presentation in both the diseases which might create confusion resulting in improper care for the dengue cases due to the fear of the covid-19. secondly, covid-19 could cross react with dengue serological tests as seen in singapore giving false positive dengue test.[9] the treating clinician might be more conscious and would use personal protective equipment due to fear koirala p, et al. threat of dengue outbreak in nepal in context of covid-19 pandemic. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 of being infected of covid-19.[9] this might be perceived as a sign of neglect in part of the patient. thirdly, since the dengue endemic area and high cases of covid-19 seem to overlap, the health care delivery system will be overwhelmed if any outbreak in dengue is reported in the current scenario. finally, due to mitigation efforts like lockdown and the focus on containment of the covid-19 prevention, the dengue outbreak might get overshadowed and large outbreak remains a possibility. a strategic action plan from government of nepal (gon) is required at the earliest to alleviate the expected morbidity and mortality of both diseases. dengue prevention activities targeting the endemic areas and also those areas which reported high cases last year is a need of time in addition to ongoing effort for covid-19 management. gon should implement: i) early case detection, diagnosis and management of dengue, ii) dengue disease surveillance, iii) mosquito vector surveillance in municipalities, iv) integrated vector control approach directed towards containment and source reduction, and v) community mobilization in vector control. [10] philosopher george santayana said, “those who cannot remember the past are condemned to repeat it.” so, let us all focus on the current pandemic without neglecting the possible epidemics that could captivate us and work towards its control measures. remember prevention not panic. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. world health organization corona virus disease (covid 19) outbreak situation. 2020 may 15. available from: https://www.who.int/ emergencies/diseases/novel-coronavirus-2019 2. acharya b, cao c, xu m, khanal l, naeem s, pandit s. present and future of dengue fever in nepal: mapping climatic suitability by ecological niche model. international journal of environmental research and public health. 2018;15(2):187. doi: http://dx.doi.org/10.3390/ ijerph15020187 3. editors. great depression history. history. 2020 feb 28 accessed from: https://www.history.com/ topics/great-depression/great-depression-history [accessed 2020 may 16]. 4. jacqueline howard and zamira rahim coronavirus may ‘never go away,’ says who official cnn health. 2020 may 14. accessed from: https://edition.cnn.com/2020/05/14/ health/coronavirus-endemic-who-mike-ryanintl/index.html [accessed 2020 may 16]. 5. adhikari n, subedi d. the alarming outbreaks of dengue in nepal. trop med health. 2020;48 [epub ahead of print]. doi: https://doi. org/10.1186/s41182-020-0194-1 6. gupta bp, singh s, kurmi r, malla r, sreekumar e, manandhar kd. re-emergence of dengue virus serotype 2 strains in the 2013 outbreak in nepal. indian j med res. 2015;142 suppl(suppl 1):s1-6. pmid: 26905233 pmcid: pmc4795338 doi: https://doi.org/10.4103/0971-5916.176564 7. dengue updates (nov, 2019). http://edcd.gov. np/news/download/dengue-updates1 [accessed 2020 apr 30]. 8. acharya bk, cao c, xu m, khanal l, naeem s, pandit s. present and future of dengue fever in nepal: mapping climatic suitability by ecological niche model. int j environ res public health. 2018;15(2):187. doi: https://doi. org/10.3390/ijerph15020187 9. yan g, lee c, lam l et al. covert covid-19 and false-positive dengue serology in singapore. lancet infect dis. 2020;20(5):536. pmid: 32145189 pmcid: pmc7128937 doi: https://doi.org/10.1016/s1473-3099(20)30158-4 10. dengue control program 2019. ministry of health and population: epidemiology and disease control division, kathmandu; 2018. available from: http://www.edcd.gov.np/section/denguecontrol-program [accessed 2020 apr 30]. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 19 may, 2020 accepted: 25 may, 2020 published: 27 may, 2020 aemiretus professor, department of surgery, blecturer, department of surgery, cregistrar, department of anaesthetics and intensive care, d-the university of the west indies, st. augustine, trinidad & tobago, west indies. corresponding author: vijay narayansingh email: vnarayan@gmail.com orcid: https://orcid.org/0000-0001-5099-6203 how to cite this article: naraynsingh v, harnanan d, maharaj r, naraynsingh r. covid-19 in the west indies: trinidad and tobago experience. journal of lumbini medical college. 2020;8(1):2pages. doi: https://doi. org/10.22502/jlmc.v8i1.347 epub: 2020 may 27. _______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.347 vijay naraynsingh,a,d dave harnanan,b,d ravi maharaj,b,d roshni naraynsingh c,d covid-19 in the west indies: trinidad and tobago experience trinidad and tobago (t+t) is a small twinisland state in the caribbean, eight miles off the coast of venezuela. it has an area of approximately 5431 square kilometres and population of 1.4 million. at the present time, there are 116 corona virus disease (covid-19) cases and eight deaths, with no new cases or deaths for the last 21 days (may 17, 2020). its covid-19 story is one of the prompts, with early control and great success. there has been no such instance where the health services were stretched or unable to cope. even before the first case was identified, the t+t government restricted entry to travellers from china, japan, singapore, south korea and several european countries. the first case of covid-19 identified in t+t was on march 12, 2020. the patient had returned from switzerland. the next day, a second positive case was a person who had returned from usa. on march 13, 2020, t+t started progressive lockdown. cruise ships were not allowed to dock, schools and universities were closed and people were advised not to congregate. by march 16, most businesses were closed except for pharmacies and supermarkets. food outlets were allowed to operate but no in-house dining was permitted one had to order, pick-up and take away. even these were completely closed 24 days after diagnosis of the first case. wearing of face masks was strongly and repeatedly advised by the chief medical officer and minister of health on their twice-daily public briefings on national television. on march 22, churches, mosques and temples stopped congregations. hindus cancelled phagwa, ram navami and hanuman jayanti celebrations. just 10 days after the first case, all ports were closed. the government stuck fairly rigid to these restrictions despite numerous protests and appeals from citizens stranded abroad. very few exceptions were made. in one case, 68 citizens, returning from a cruise were stranded on gaudeloupe island, just after the borders were closed. after much protest and appeals to the concerned authorities, they were allowed on the condition of strict institutional quarantine for 14 days and covid-19 testing as deemed necessary. this turned out to have magical beneficial consequences as 49 of them turned to be covid-19 positive. had they entered the country and gone home, even on ‘voluntary home isolation’, the outbreak could have been massive and uncontrollable. although no cases were identified locally, the government had already started making preparations for the epidemic in january 2020. by mid-february, the regional laboratory (carpha), based in t+t was equipped to do pcr testing. sites were identified, completely separate from the present active hospitals, to quarantine and manage covid-19 cases. thus, a parallel ‘new’ system was set up where neither the beds, wards, institutions nor health care personnel dedicated to covid-19 patients, mixed with the usual hospital population. this was possible by utilizing two existing unused hospitals, modifying two sporting naraynsingh v, et al. covid-19 in the west indies: trinidad and tobago experience jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 complexes, an unoccupied university campus and a church camp. this ‘new’ parallel system provided about 500 beds, 24 icu beds, 24 ventilators and also quarantine facilities for those who were positive; these were not allowed home until they had a 14day quarantine and two negative tests. patients who went to the general hospitals with covid-19 like symptoms were screened in a tent outside the main building and transferred to one of the covid-19 centres if tested positive. all the elective surgeries and non-emergency clinic services were halted from march 13. this served the important purposes of minimizing human traffic as well as keeping hospital facilities and staff as additional available resource if the designated centres were overwhelmed; fortunately, this never happened. the total number of cases remains at 116 with eight deaths. at no time was any hospital or quarantine site saturated. although provision existed for 24 icu patients with ventilators, the maximum number on any day was three for icu cases and 70 for non-critical cases. now that we are resuming elective surgeries from 18th may, there is much debate about the ‘safest’ way to achieve this. the usual hand sanitizing, face masks, social distancing, minimal visitors are already in place. the more difficult decisions are: a. should all patients be tested pre-operatively? b. should health care workers, especially operating theatre staff be tested, and how often? c. how elaborate should the personal protective equipment (ppe) be for these surgeries? d. should high risk procedures involving the airway, nose, eyes be introduced later? e. should laparoscopy, in which there may be aerosolization of body fluids, be postponed? these are important questions since the operating theatre is a high-risk environment as patients often cough, splutter and aerosolise their respiratory tract secretions in a relatively closed space with many staff present. the other high-risk decision, in our protective island setting, is reopening the borders to air and sea travel. the success of our measures, thus far, is due mainly to early lockdown of entry ports, strict institutional isolation (not allowing ‘home quarantine’), no community gatherings, early closure of businesses, no prayer congregations, twice daily national briefings and instructions as well as the utilization of two parallel health care staff and institutions. our testing has been quite inadequate about 2,000 people tested in a population of 1.4 million. this demonstrates that other measures could be highly effective even with minimal, focused testing. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 30 may, 2020 accepted: 01 june, 2020 published: 05 june, 2020 a student, bsc. nursing, b lecturer, department of nursing, clumbini medical college teaching hospital, palpa, nepal. corresponding author: chandra kumari garbuja e-mail: garbujachandra@gmail.com orcid: https://orcid.org/0000-0002-6540-3391 how to cite this article: surkhali b, garbuja ck. virtual learning during covid-19 pandemic: pros and cons. journal of lumbini medical college.2020;8(1):2 pages. doi: https://doi.org/10.22502/jlmc. v8i1.363 epub: 2020 june 05._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.345 bipana surkhali,a,c chandra kumari garbuja b,c virtual learning during covid-19 pandemic: pros and cons the current outbreak of corona virus disease (covid-19), declared as public health emergency of national and international concern by world health organization (who), led to unprecedented public health responses in nepal and many countries around the world including travel restriction, closure of educational institutions, curfews in some places and quarantines. this pandemic has affected lives of millions in different ways in different geographic locations worldwide. beyond the immediate threat to health, unemployment, insecurity etc., education is one of the sensitive areas which has been affected tremendously, students in nepal not being an exception. the closure of all educational institutions effective from 18th march, 2020 followed by the nationwide lockdown from 24th march, 2020 till date enforced by government of nepal (gon) as an effort to limit the spread of covid-19 has shed a light on numerous issues affecting the access to education.[1,2] as per the united nations educational, scientific and cultural organization (unesco) report 2020, a total of 1,190,287,189 learners are currently affected constituting 68% of the total enrolled learners worldwide because of temporary or indefinite country wide school closures implemented by the respective governments in an attempt to slow the spread of covid-19. in nepal alone 8,796,624 students have reportedly been affected.[3] at this time of crisis, various national level examinations such as secondary education examination (see), higher secondary education board (hseb) and universities exams have been postponed as well as affected various teaching and learning programs. thus, various educational institutions have proactively encouraged and embraced online education system through introduction of virtual classes ensuring that learning persists for all the students across the country as best solution for the continuation of learning processes. with these initiations, nepal has got a window to redefine education system during lockdown. virtual education even gave an opportunity of emotional and moral support for both the students and teachers to stay connected. with appropriate availability of technology, online learning can be advantageous and effective in numerous ways since they can offer a great deal of contents, interactions, flexibilities and reinforcements. learners can keep themselves engaged from any place using any devices such as mobile phone, laptop or computer at their convenience. in general, online learning is beneficial in accelerating learning and reinforces students and teachers at the comfort of home during this time of global crisis. even though distance learning is a new horizon with exciting possibilities for various developing countries like nepal, it is not without limitations. firstly, in nepal, there is still a lack of easily accessible and affordable internet connection, appropriate electronic devices and availability of public internet centers and cyber cafes which are mostly centered in urban cities across the country. surkhali b, et al. virtual learning during covid-19 pandemic: pros and cons jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 almost one third of nepal’s population is not covered by 3g networks while 4g networks cover less than 20% of the population.[4] it should be kept in mind that many students who belong to rural areas have little or no access to internet. moreover, the technical skills of teachers and students for handling virtual education may be insufficient. while students with good internet accessibility and appropriate technologies are being able to continue their study smoothly, it concerns those students who are deprived of good internet and electronic devices. this inequality has not been addressed properly and effectively. also, low internet bandwidth and technical difficulties are the barriers to use online courses for both students and teachers which lead to less engagement and disturbance during online lectures. secondly, there may be a feeling of isolation and less interaction as compared to classroom environment which may potentially lead to minimal participation, distractions, withdrawl or complete disappearance of students. a lot of peerbased learning, two-way communication and group discussion during online classes are not as fruitful as in traditional classroom settings. online learning is a challenge especially among medical students when the topic is related to specific clinical procedures and is practice based. without face-to-face interactions, it is difficult even for teachers to be aware of nonverbal behavioral cues and ensure if students are disengaged, frustrated and disinterested in participation. also, teachers and students cannot share their emotions easily which could hinder encouragement and enthusiasm for both parties. thirdly, there is certain amount of social pressure in traditional classroom as such showing up on time, submitting assignment on time, following structured routines etc. to keep students in rules and regulation which may lack in virtual classes. lastly, spending extended amount of time in front of a computer or any other devices could produce negative physical effect. over engagement and staring closely at the screen for hours without taking break is monotonous and may potentially lead to wide range of health problems including visual discomfort, exhaustion, and muscle or joint aches. lack of socialization and isolation may ultimately result in decreased academic achievement and even mental distress. while in the era of advanced science and technology, virtual education in nepal which is just flourishing could be challenging with lots of obstacles but yet not unattainable especially at these time of crisis by covid-19 pandemic. the virtual education requires refinements in terms of reliable and affordable internet, proper implementation of infrastructures, advancement in technologies and provision of well guided technical supports to all so that it can be well utilized, improvised and adapted in future which could ultimately enhance the learning process and broaden the scope of innovative ways of successful learning. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. notice. kathmandu, nepal: ministry of education, science and technology; 2020. available from: http://www.moe.gov.np/ a s s e t s / u p l o a d s / f i l e s / n e w _ d o c _ 2 0 2 0 0 3 18_21.52_.28_1-converted_.pdf [accessed 2020 may 25]. 2. decision of the 12th meeting of hlcc on vovid-1924 march 2020 and its unofficial translation. kathmandu, nepal: ministry of foreign affairs; 2020. available from: https:// mofa.gov.np/decision-of-the-12th-meetingof-hlcc-on-vovid-19-24-march-2020-and-itsunofficial-translation [accessed 2020 may 25]. 3. covid-19 educational disruption and response. paris, france: unesco; 2020. available from: https://en.unesco.org/covid19/ educationresponse [accessed 2020 may 30]. 4. kharel s. information and communication technology for the rural development in nepal. tribhuvan univ j. 2018;32(2):177–90. doi: https://doi.org/10.3126/tuj.v32i2.24714 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 24 may, 2020 accepted: 28 may, 2020 published: 01 june, 2020 a-editor in chief, journal of lumbini medical collage. b-professor, department of ophthalmology, lumbini medical college teaching hospital, palpa, nepal. corresponding author: bhagavat prasad nepal e-mail: bhagavatn61@gmail.com orcid: https://orcid.org/0000-0001-5199-8825 how to cite this article: nepal bp. coping with covid-19. journal of lumbini medical college.2020;8(1):2 pages. doi: https://doi.org/10.22502/jlmc. v8i1.355 epub: 2020 june 01._______________________________________________________ editorialhttps://doi.org/10.22502/jlmc.v8i1.355 bhagavat prasad nepal a,b coping with covid-19 severe acute respiratory syndrome corona virus (sars-cov-2) virus made its first appearance in wuhan, china in december 2019. it has since spread like a wild fire across the globe with over five million corona virus disease (covid-19) confirmed cases and almost three hundred fifty thousand deaths at the time of writing this article. this could however be only the tip of the iceberg considering the contagious nature of the sars-cov-2 virus and the rate at which it is spreading across the globe. china did well to contain the virus with strict lockdown measures, sealing the affected areas, active case finding, tracing, tracking and treating the covid-19 cases at an astonishing speed. in the absence of specific treatment available as yet, treatment consists of mainly symptomatic management with some experimental medications. antivirals, specifically remdesivir has been a strong candidate for the treatment of covid-19.[1,2]. however, it has yet to receive universal acceptance for the treatment of covid-19. chloroquine and hydroxychloroquine seem to be effective in limiting the replication of sars-cov-2 virus in vitro.[3]. covid-19 is highly pandemic in countries where malaria is least prevalent and least pandemic in countries where malaria is highly prevalent. these findings suggest the hypothesis that anti-malarial drugs have efficacy in the treatment of covid-19. [4,5] addition of zinc is believed to improve the efficacy of chloroquine and hydroxychloroquine against sars-cov-2.[6] ivermectin inhibits sars-cov-2 in vitro up to 48 hours. however, the concentration resulting in 50% inhibition was found to be 35 times higher than the maximum plasma concentration after oral administration of the approved dose of ivermectin when given fasted.[7]. vitamin d lowers the viral replication rate and reduces the plasma concentration of pro-inflammatory cytokines which produce inflammation that injures the lining of the lungs, leading to pneumonia. this could possible reduce the risk of infection and death in covid-19.[8,9] plasma from patients recovered from covid-19 that contains antibodies against sarscov-2 virus has shown promising results in patients with severe covid-19.[10] this combined with moderate dose of corticosteroids might improve the outcome which might accelerate the recovery from covid-19.[10]. however, use of corticosteroids for the treatment of covid-19 is still far from standard practice. with this perspective regarding treatment of covid-19, prevention seems to be the only viable option against the disease. vaccine against covid-19 is being developed in several countries in the world with variable success.[11]. however, it is unlikely that it will be available any time soon for routine use. alternative strategy would be to allow the sars-cov-2 to spread to increase herd immunity of the population. given that the case fatality rate (cfr) can be anything between 0.253% or even more of a country’s population, the estimated number of people who could possibly die from covid-19 may be difficult to anticipate.[12] we are now back to square one. the preventive measures at present are still basically lockdown, physical distancing, frequent hand washing and nepal bp. coping with covid-19 jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 universal use of face mask along with vigorous testing, tracing, tracking and treating covid-19. if measures like work from home, distant education and public health awareness regarding the importance of physical distancing, hand washing and universal use of face mask were effectively communicated to the public and rigidly enforced, it would lead to decrease in the number of infected cases each day leading to flattening of the curve. these measures would prevent overwhelming of the scarce health care facilities and would also help in lifting draconian measures like lock down for a long time. however, work from home and distant education have logistic and realistic problems in low income country like nepal. as public health authorities consider lifting lockdown, it is critical that robust surveillance is put in place. aim of surveillance should be to limit the spread of disease, manage the risk of covid-19, enable economic and sociable activities to resume to the extent possible and monitor the long-term trend of covid-19 transmission.[13] conflict of interest: the author declares that no competing interest exists. funding: no funds were available for the study. references: 1. hendaus ma. remdsivir in the treatment of corona virus disease (covid-19): a simplified summary. j biomol struct dyn. 2020; [epub ahead of print] pmid: 32396771 doi: https:// doi.org/10.1080/07391102.2020.1767691 2. al-tawfiq ja, al-homoud ah, memish za. remdesivir as a possible therapeutic option for the covid-19. travel med infect dis. 2020;34:101615. pmid: 32145386 pmcid: pmc7129391 doi: https://doi.org/10.1016/j. tmaid.2020.101615 3. cortegiani a, ingoglia g, ippolito m, giarratano a, einav s. a systematic review on efficacy and safety of chloroquine for treatment of covid-19. j crit care. 2020;57: 279-283. pmid: 32173110 doi: https://doi.org/10.1016/j.jcrc.2020.03.005 4. meo sa, klonoff dc, akram j. efficacy of chloroquine and hydroxychloroquine in the treatment of covid-19. eur rev med pharmacol sci. 2020;28(8):4539-4547. doi: https://doi.org/ 10.26355/eurrev_202004_21038 5. ferner re, aronson jk. chloroquine and hydroxychloroquine in covid-19. bmj. 2020;369:m1432. doi: https://doi.org/10.1136/ bmj.m1432 6. shitto mo, afolami oi. improving efficacy of chloroquine and hydroxychloroquine against sars-cov-2 may require zinc additives-a better synergy for future covid-19 clinical trails. infez med. 2020;28(2):192-197. pmid: 32335560 7. schmith vd, zhou jj, lohmer lr. the approved dose of ivermectin alone is not the ideal dose for the treatment of covid-19. clin pharmacol ther. 2020; [epub ahead of print]. doi: https:// doi.org/10.1002/cpt.1889 8. mccartney dm, byrne dg. optimization of vitamin d status for enhanced immune-protection against covid-19. ir med j. 2020;113(4):58. pmid: 32268051 9. grant wb, lahore h, mcdonnell sl, baggerly ca, fench cb, aliano jl, et al. evidence that vitamin d supplementation could reduce risk of influenza and covid-19 infections and deaths. nutrients. 2020;12(4):e988. doi: https://doi. org/10.3390/nu12040988 10. saghazadeh a, rezaei n. towards treatment planning of covid-19: rationale and hypothesis for the use of multiple immunosuppressive agents: antibodies, immunoglobulin and cortcosteroids. int immunopharmacol. 2020;84:106560. doi: https://doi.org/10.1016/j.intimp.2020.106560 11. yang l, tian d, liu w. strategies for vaccine development of covid-19. sheng wu gong cheng xue bao. 2020;36(4):593-604. pmid: 32347054 doi: https://doi.org/10.13345/j. cjb.200094 12. kwok kd, lai f, wei wi, wang sys, tang jwt. herd immunity-estimating the level required to halt covid-19 epidemics in affected countries, j infect. 2020;80(6):e32-e33. pmid: 32209383 pmcid: pmc7151357 doi: https:// doi.org/10.1016/j.jinf.2020.03.027 13. world health organization. surveillance strategies for covid-19 human infection: interim guidance, 10 may 2020. world health organization, 2020. available from: https:// apps.who.int/iris/handle/10665/332051 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 14 may, 2020 accepted: 24 may, 2020 published: 31 may, 2020 a lecturer, department of general practice and emergency medicine, b lumbini medical college teaching hospital, palpa, nepal. corresponding author: rabin bom e-mail: rabinbom@gmail.com orcid: https://orcid.org/0000-0001-6469-1355 how to cite this article: bom r. planning, preparedness and challenges during covid-19 pandemic: experiences from emergency department. journal of lumbini medical college.2020;8(1):2 pages. doi: https://doi. org/10.22502/jlmc.v8i1.345 epub: 2020 may 31._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.345 rabin bom a,b planning, preparedness and challenges during covid-19 pandemic: experiences from emergency department two months have already passed since the declaration of countrywide lockdown on last week of march 2020. the number of corona virus disease (covid-19) infected cases are gradually increasing in nepal till date. with a steady increase of covid-19 cases the burden of planning and preparedness is also getting bigger. outpatient departments (opds) were closed for the first few weeks and all patients visiting the hospital were screened at fever clinic established at the hospital entry point. suspected covid-19 cases were then quarantined at special covid-19 isolation ward using a different route. those patients whose history excluded the suspicion of covid-19 were then allowed to proceed to emergency department (ed). following were the experiences from ed during the first few weeks of covid-19 pandemic. knowledge about covid infection: although it was already a known fact about the corona virus and covid-19 epidemic first being noted and spread in wuhan, china, during late 2019; it was still unclear about the transmission and effects on the human body. treatment plan and protocols were not clear and ed medical staffs were in dilemma on how to manage if any suspected case got admitted to ed. there was fear and chaos among the staffs if they would contract the disease. personal protective equipment (ppe): not many of us at ed knew the proper use of ppe. those who knew had not much experience of ‘donning and duffing’ the ppe. the covid-19 task force team demonstrated the technique of proper ‘donning and doffing of ppe’. initially there was an acute shortage of ppes. once it was made available, the staffs felt discomfort to have been wearing it for 12 hours; many of them would drench in sweat within a few hours of donning it. every now and then the staffs had to be reminded of hand hygiene; as it was regarded that contact was the way of transmission of infection. regardless of initial discomfort, staffs later got accustomed to the donning of compulsory ppe during duty hours. handling of the patients: ed formulated their plans and protocols on handling patients. all the patients were asked to put on the mask as they entered the ed. two alternate protocols were followed on the basis of suspicious/ confirmed cases. those patients who come to ed after screening through fever clinic and were at low risk to have acquired covid-19 infection were allowed in the general ed ward. in cases where a suspicion arose upon the case being covid-19 positive, they were not allowed into general ward but were moved to isolation unit temporarily established adjacent to but separate from ed. it was recommended that all the cases be handled following precautionary measures. patients requiring airway protection: there were few cases where airway support via intubation had to be done in ed. during intubation a head box (specially made from plastic bom r. planning, preparedness and challenges during covid-19 pandemic: experiences from emergency department. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 glass with multiple ports) was kept over the patient’s upper body which helped in controlling direct droplet/aerosol transmission. immediately after use; the instruments, equipment including the head box was sent to the central sterile services department (cssd) to be made ready for next use. lack of resources: the fear of acquiring covid-19 amongst the hospital staffs and the dramatic decline on the patients visiting hospital, the staffs applied for leave during the nationwide lockdown. many staffs in the initial phase were insisted by the family members to take forced leave. as the opds were shut too, there was a lack of helping staffs for which the nonmedical ed staffs were running on their toes for all the major to minor work which was not their duty or responsibility. the ed helpers were also occupied in transporting patients to other concerned departments for specialized treatment. on the other hand, due to lockdown and sealing of borders the import of medical items was affected in the entire nation. the available stock of gloves, shoes cover, caps, surgical/n95 masks, medical equipment like catheter was already dissipated. this had direct impact in ed which were left unprotected. however, there was enough stockpile of essential and lifesaving medicines and saline solution. end of the day: after the 12-hour shift, the ed staffs were afraid to go home due to the fear of transmitting covid-19 to their dear and near ones. most of the staffs preferred for 24 or 48 hours of duty because they were more concerned of not squandering the ppe. we realized that a facility to take shower before and after duty would have been an ideal for personal hygiene and infection control. the new beginning: after few weeks of covid-19 pandemic, the patient flow has started to rise. opds have resumed their services with standard precaution measures. fever clinic from temporary trampoline makeshift has been providing its service from a concrete building with all the necessary protection for the medical staffs. ed is serving again to the genuine emergency cases. it is still not the end of covid-19 pandemic in nepal, rather a mere beginning. with increasing number of new cases, there is no doubt we will be soon receiving a covid-19 positive case in the fever clinic and/or ed; and without hesitancy we are ready to serve those who come to us whether they test covid-19 positive or not. conflict of interest: author declares that no competing interest exists. funding: no funds were available for the study. experience of laparoscopic cholecystectomy at lumbini medical college teaching hospital nabin pokharel,a,d prakash sapkota,b,d binay kc,c,d rajan shakya,c,d sunil thapac,d —–————————————————————————————————————————————— abstract: introduction: the difficult gallbladder is the most common difficult laparoscopy being performed by general surgeons all over the world and the potential one that places the patient at significant risk. the present study aimed to study all the cases of laparoscopic cholecystectomy conducted in current setup at lumbini medical college and teaching hospital, to compare the results with the published literature and also analyze the complications and ways to decrease the incidence of conversion to open procedure. methods: five hundred twenty five patients age 10-90 years, male:female ratio of 1:3.86 with body weight 45-65 kilogram, who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis without choledocholithiasis from april 2011 to april 2013 were studied. results: all the laparoscopic cholecystectomy (lc) were without major complications. only nineteen out of five hundred twentyfive (3.6%) required conversion to open cholecystectomy (oc). reasons for conversion included: dense omental or visceral adhesions; two (0.38%), unclear anatomy; 16 (3.04%), common bile duct injury; one (0.19%). there were 20 cases of shrunken gallbladder suspicious of malignancy but didn’t required conversion. conclusion: laparoscopic cholecystectomy is the preferred method in our setup even in difficult cases. keywords: cholecystitis • cholelithiasis • conversion • laparoscopic cholecystectomy ——————————————————————————————————————————————— ___________________________________________________________________________________ a assistant professor b lecturer c medical officer d department of surgery lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. nabin pokharel e-mail: nabindai@yahoo.com how to cite this article: pokharel n, sapkota p, kc binay, shakya r, thapa s. experience of laparoscopic cholecystectomy at lumbini medical college teaching hospital. journal of lumbini medical college. 2013;1(1):25-7. doi:10.22502/jlmc.v1i1.8. ___________________________________________________________________________________ j. lumbini. med. coll. vol 1, no 1, jan-june 2013 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v1i1.8 introduction: diseases of biliary tract constitute a major portion of digestive tract disorder. among these gall stone disease is the most common biliary pathology.1 carl-langenbuch performed first ever cholecystectomy on a 42 years old man in 15 july 1882, berlin. laparoscopic cholecystectomy (lc) first of all performed by philipe moret in lyon, france in march 1987 has in fact revolutionized the treatment of cholelithasis.1 after national institutes of health consensus conference in 1993, lc has replaced open cholecystectomy as the gold standard in the treatment of patients with symptomatic cholelithiasis.2 the outcome of lc is influenced greatly by the training, experience, skill and judgment of the surgeon performing the procedure.3 the difficult gallbladder is the most common difficult lc. this difficult lc has potential of significant risk for patient. a number of researches have emphasized promising role of lc.4-6 in the beginning, patients like acute cholecystitis, empyema, gangrenous gallbladder, cirrhotic liver, and mirizzi syndrome were contraindicated for lc because of high risk of complications and conversion rate.5,6 after years of practice surgeons have gained expertise to manage difficult gallbladder. we thought it imperative to reassess the feasibility of lc in these (complicated cases) in terms of conversion rate. the present study aimed to study all the cases of laparoscopic cholecystectomy conducted in current setup at lumbini medical college and teaching hospital, to compare the results with the published literature and also analyze the complications and ways to decrease 25 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np pokharel n. et al. experience of laparoscopic cholecystectomy the incidence of conversion to open procedure. methods: a retrospective study was conducted to identify the results of all the lc performed and also the rate of conversion from lc to oc at our tertiary care hospital. all patients who underwent lc from april 2011 to april 2013 were identified from the medical records maintained in the department of surgery. five hundred twenty five patients age 10-90 years, male:female ratio of 1:3.86 with body weight 45-65 kilogram, who had underwent laparoscopic cholecystectomy for symptomatic cholelithiasis without choledocholithiasis from april 2011 to april 2013 were studied. patients who were converted to oc were studied for the reason of conversion. cases with incomplete records with respect to anthropometry, laboratory investigations, and ultrasound findings were excluded. standard laparoscopic cholecystectomy procedure was performed. adhesions of gall bladder (gb) were separated by blunt, sharp and electro dissection and by use of suction cannula. distended gbs were decompressed by suction and aspiration. cystic duct and cystic artery identified, ligated and divided with endoclips. wide cystic ducts (not clipped by 10 mm clips) were suture ligated and divided. gbs were dissected from gb fossa by use of hook/spatula/scissors. hemostasis was maintained by using monopolar cautery. gb extracted through epigastric port or umbilical port. gb fossa re-examined and suction dried. drains were kept through 5 mm port at anterior axillary line. port closure was used for port site bleeding. skin closure was done with skin stapler or suture. the camera was used of striker and the monitor as well. two surgeons performed all the operation who had experience of more than 100 lc. all gb specimen were sent routinely for histopathology confirmation. results: nineteen (3.6%) patients out of 525 patients during the study period had to be converted to open cholecystectomy owing to various reasons as enumerated in table 1. two out of 50 acute cholecystitis and 16 out of 280 chronic cholecystitis patients were converted to oc. none of the cases had major wound infections. fifty cases had minor port site discharge which was table 1: causes of conversion from laparoscopic to open cholecystectomy (n=6) managed with regular dressings. all the 110 cases where drain was placed was removed on 1st and 2nd post-operative days. all the patient who underwent lc were discharged on the 3rd post-operative day and those who required conversion were discharged on 7th post-operative days. discussion: initially, the complication rate with lc was high but as the experience has grown, it has reached a remarkably low level at 2-6%.7,8 complications are same but is more severe when it occurs in lc.9 since 1990 many surgeons have attempted lc with reasonable success in difficult cases.4-6,9,10 their results indicated that extensive experience with both open and laparoscopic biliary tract surgery is the most important ingredient of a successful outcome in the setting of difficult cases. the clinical profile of a patient can predict a difficult gallbladder surgery.9 based on our experience we feel that even in a patient anticipated to have a difficult gallbladder one can complete the procedure laparoscopically. hence our policy has been to take up all the cases fit to undergo laparoscopy for lc. conversion to open surgery is not visualized as a complication, rather a matter of sound importance. in cases where we faced difficulty, we took longer time for dissection of calot’s triangle. in some cases, we had to aspirate the contents of gall bladder to make the dissection easier. four cases we had to use suture ligature instead of using clips. in our study the overall conversion rate was 3.6% of the total lc which is in accordance with the literature 2-6%.11 dense adhesions at calot's triangle was the most common reason for conversion to open surgery in our series. one conversion was due to common bile duct injury, identified and was managed intraoperatively in the same sitting. one 26 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 pokharel n. et al. experience of laparoscopic cholecystectomy jlmc.edu.np patient having minimal bile leak postoperatively was managed conservatively with wait and watch policy, the leak ceased spontaneously within two days. since the rate of conversion in patients with acutely inflamed gallbladder was 2 (0.38%), we recommend lc in acute cholecystitis where feasible as has been reported in the literature.12 we still believe from our experience that within 72 hours of symptoms the tissue planes are edematous and inflamed but are easier to dissect, having no adhesions at all.12 we took up 50 patients for lc even after 72 hrs and complete them without conversion even though it was difficult and took longer (90 versus 50 min) p>0.05. conclusions: good laparoscopic skill, adequate experience and good equipment all are prerequisites for safe laparoscopic cholecystectomy and low conversion rate. laparoscopic cholecystectomy is the preferred method in our setup which is comparable to other literatures. references: 1. mouret p. from the first laparoscopic cholecystectomy to the frontier of laparoscopic surgery: the future perspective. dig surg. 1991;8:124-5. 2. nih consensus conference. gallstones and laparoscopic cholecystectomy. j am med assoc.1993;269:1018-24. 3. lo cm, fan st, liu cl. early decision for conversion of laparoscopic to open cholecystectomy for treatment of acute cholecystitis. am j surg. 1997;173:513-7. 4. cameron jc, gadacz tr. laparoscopic cholecystectomy. ann surg. 1991;213:1-2. 5. kum ck, goh pmy, isaac jr. laparoscopic cholecystectomy for acute cholecystitis. br j surg. 1994;81:1651-4. 6. rattner dw, ferguson c,warshaw al. factors associated with successful laparoscopic cholecystectomy for acute cholecystitis. ann surg.1993;217:233-6. 7. zucker ka, bailey rw, flowers j. laparoscopic management of acute and chronic cholecystitis. surg clin north am. 1992;2:1045-67. 8. gadacz tr. update on laparoscopic cholecystectomy, including a clinical pathway. surg clin north am. 2000;80:1127-45. 9. dubois f, icard p, berthelot g. coelioscopic cholecystectomy. preliminary report of 36. ann surg. 1990;211:60-4. 10. faber jm, fagot h, domergue j. laparoscopic cholecystectomy in complicated cholelithiasis. surg endosc. 1989;3:1198-201. 11. rosen m, fred b, jeffery p. predictive factors for conversion of laparoscopic cholecystectomy. am j surg. 2002;184:2548. 12. peng wk, sheikh z, nixon sj, paterson-brown s. role of laparoscopic cholecystectomy in the early management of acute gallbladder disease. br j surg. 2005; online pub: march 18. 27 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 29 may, 2020 accepted: 31 may, 2020 published: 10 june, 2020 a consultant surgeon, bconsultant physician, c nepal korea friendship municipality hospital. corresponding author: ijendra prajapati e-mail: ijenprajapati@gmail.com orcid: https://orcid.org/0000-0002-2181-1035 how to cite this article: prajapati i, kayastha g. preparedness of community hospital against covid-19. journal of lumbini medical college.2020;8(1):3 pages. doi: https://doi.org/10.22502/jlmc. v8i1.360 epub: 2020 june 10._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.360 ijendra prajapati,a,c gyan kayastha b,c preparedness of community hospital against covid-19 government of nepal (gon) imposed a nationwide lockdown on 24th march, 2020 with an effort to limit the spread of novel corona virus which is responsible for corona virus disease (covid-19). covid-19 nepal: preparedness and response plan (nprp) was implicated on april 2020 which stated sukraraj infectious and tropical disease hospital (stidh) in the capital, kathmandu has been designated by the gon as the primary hospital along with patan hospital and the armed police forces hospital in the kathmandu valley. the ministry of health and population (mohp) had requested the 25 hub and satellite hospital networks across the country; designated for managing mass casualty events; to be ready with infection prevention and control measures, and critical care beds where available.[1] hospitals with less than 50 beds viz community-based municipality hospitals were left feeble against the surge of the pandemic. waiting for the aid and support from government was the only option for some hospitals that lacked resources to combat this invisible culprit of global pandemic. however, nepal korea friendship municipality hospital (nkfmh) located in thimi, bhaktapur determined itself to fight against this pandemic with limited resources. this hospital not only serves the local community but also patients coming from all over province 3 due to government insurance facilities provided by this hospital. with interaction and support from the hospital director, mayor of the municipality, korea international cooperation agency (koica), bhaktapur red cross, hospital board, hospital staffs, medical team, adminstration, interpid and locals in the community prompt preparedness action plan was formulated through various meeting at different levels and acted upon. the pathogen of covid‐19, severe acute respiratory syndrome coronavirus2 (sarscov-2), was confirmed to have human‐to‐human transmission which supposedly originated in wuhan, china spread not only to other cities in china but also throughout the world via case transportation. [2,3] health worker are more vulnerable groups as the reports show 1.1% of the reported cases in china were healthcare workers.[4] sars-cov-2 is believed to transmit from person to person via large respiratory droplets, either being inhaled or deposited on mucosal surfaces. other routes implicated in transmission of this virus include contact with contaminated fomites and inhalation of aerosols produced during aerosol generating procedures (agps). the relative role of droplet, fomite and aerosol transmission for sars-cov-2, the protection provided by the different components of personal protective equipment (ppe) and the transmissibility of the virus at different stages of the disease remain unclear. caution should therefore be exercised when considering these elements.[5,6] providing ppe to health care worker is vital in avoiding occupational exposure and infection. disease control and prevention for covid‐19 infection control of health care personnels prajapati i, et al. preparedness of community hospital against covid-19 jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 recommended gloves, gowns, respiratory protection, and eye protection as standardized ppe.[7] however, protective clothing, n95 respirators, and goggles are not commonly used in clinical practice and hence are not in bulk stock. screening of patients is the most important step which was started from the day of lockdown at the entrance of hospital. patients with fever were seen in fever clinics from 28th march, 2020. after evaluation of fever, rapid diagnostic test (rdt) and polymerase chain reaction (pcr) are being done in suspected paients. nkfmh started its own pcr lab from 7th april, 2020, 738 pcr and 137 rdt have been performed till date. protecting heathcare worker and establishment of isolation for covid-19 patients were given the utmost priority. ppe has been provided for frontline health workers collected in collaboration with koica, municipality and bhaktapur red cross, and most of them were purchased. four hundred and eighty n95 masks have been distributed and rest are kept in stock for future. the orthopedic ward has been converted to isolation room six beds with facility of cctv monitoring where suspected covid-19 cases are kept. on april 24, 2020 ten bedded negative pressure, individual chambered, isolation ward with two ventilators was established to treat covid-19 positive cases, with backup of five bedded normal icu and three ventilators. medical officers, nurses and health assistant were trained to do intubation, cpr and educated about the covid-19. mock drill exercise on management of suspected cases was done on may 1, 2020 with cooperation from municipality, bhaktapur red cross, hopsital staff, interpid and centre for molecular dynamic management. surgical, gynecology and obstetrics, orthopedic emergency/semi-elective surgery (total 110) have been performed following the guidelines for performing operation for safety of both patient and medical staff. surgery in covid-19 suspected/ positive patient is a challenging scenario for which a separate covid-19 operation theater (with negative pressure) was established on may 1, 2020. list of preparedness for covid-19. • fever clinic • quarantine/isolation: 10 single rooms in a guest house for suspected patients. • swab collection booth • covid-19 isolation room, six bed with cctv surveillance • negative pressure covid ward, 10 bed with 2 ventilators. (additional 3 ventilators in icu) • upgraded 50 bedded hospital to 75 bed hospital • separate pcr lab. • seprerate covid-19 negative pressure operation theater. • training of medical officers, nurses, health assistant about intubation, basic cpr, donning and doffing. • donning and doffing room. • screening of high-risk group in community. (total 739) o high-risk front-line hospital staff o municipality coworkers (sweepers, garbage collectors) o identifying and screening of suspected people returning from abroad. o frontline workers in community service  local leaders  politicians  red cross staff  journalist.  social workers • level ii ppe for hospital frontline workers. our hospital nkfmh leading by example adopted interim measures, including online consultation, region separation, and epidemic priority, to alleviate the pressure in the clinical work, reduce the cross-infection, and strengthen the protection of high-risk staff. however, there are still some limitations. first, the supply protocol compromised the health protection of low-risk personnel without standardized ppe. second, the interim management strategies could not resist largescale outbreak and long-term ppe shortage. with the increasing number of covid-19 patients in country and the burden sustain by the government allocated hospital is beyond imagination. preparedness of other hospitals including private sectors is the prime concern. among them community hospitals will play the important role in managing the pandemic in coming future conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. united nations nepal, covid-19 nepal: preparedness and response plan (nprp). april 2020. availablr from: https://www.who.int/ docs/default-source/nepal-documents/novelcoronavirus/covid-19-nepal-preparednessa n d r e s p o n s e p l a n ( n p r p ) d r a f t a p r i l 9 . pdf?sfvrsn=808a970a_2 2. huang c, wang y, li x, ren l, zhao j, hu y, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet. 2020;395:497–506. pmid: 31986264 doi: https://doi.org/10.1016/s0140-6736(20)30183-5 3. du z, wang l, cauchemez s, xu x, wang x, cowling bj, meyers la. risk for transportation of 2019 novel coronavirus disease from wuhan to other cities in china. emerg infect dis. 2020;26:1049-52. pmid: 32053479 doi: https://doi.org/10.3201/eid2605.200146 4. lai x, wang m, qin c, tan l, ran l, chen d, et al. coronavirus disease 2019 (covid-2019) infection among health care workers and implications for prevention measures in a tertiary hospital in wuhan, china. jama network open. 2020;3(5):e209666. pmid: 32437575 pmcid: pmc7243089 doi: https://dx.doi.org/10.1001/ jamanetworkopen.2020.9666 5. rothe c, schunk m, sothmann p, bretzel g, froeschl g, wallrauch c, et al. transmission of 2019-ncov infection from an asymptomatic contact in germany. n england j med. 2020;382:970-1. pmid: 32003551 doi: https:// dx.doi.org/10.1056/2fnejmc2001468 6. ong swx, tan yk, chia py, lee th, ng ot, wong msy, et al. air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sarscov-2) from a symptomatic patient. jama. 2020;323(16):1610-1612. pmid: 32129805 doi: https://doi.org/10.1001/jama.2020.3227 7. us centers for disease control and prevention. interim infection prevention and control recommendations for patients with confirmed 2019 novel coronavirus (2019ncov) or patie nts under investigation for sars-cov-2 in healthcare settings. atlanta, ga: us centers for disease control and prevention, 2020. available from: https://www.cdc.gov/coronavirus/2019ncov/hcp/infection-control-recommendations. html prajapati i, et al. preparedness of community hospital against covid-19 j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 jlmc.edu.np licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 07 may, 2020 accepted: 22 may, 2020 published: 22 may, 2020 a mbbs student, b assistant professor, department of forensic medicine, c lumbini medical college teaching hospital, palpa nepal. corresponding author: alok atreya e-mail: alokraj67@hotmail.com orcid: https://orcid.org/0000-0001-6657-7871 how to cite this article: nepal b, atreya a. online medical education in nepal: barking a wrong tree. journal of lumbini medical college. 2020;8(1):2 2020;8(1):2 pages. doi: pages. doi: https://doi.org/10.22502/jlmc.v8i1.325 epub: 2020 epub: 2020 may 22. may 22. _______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.325 binu nepal,a,c alok atreya b,c online medical education in nepal: barking a wrong tree to combat the global pandemic of covid-19, the government of nepal declared a country wide lockdown on 24 march, 2020. the lockdown affected all the institutions, medical schools being no exception. to keep in pace with the academic calendar, most of the universities instructed their affiliated medical schools to start online classes for medical undergraduates. kathmandu university which affiliates ten medical schools under its umbrella circulated a notice to start online classes. to facilitate this, the most important requisite is internet connection. a working device in the form of a laptop, desktop or smartphone is needed to login through the internet. after the lock down, when all the medical schools closed, the students went home. we should not forget the fact that many students are from rural locality with no access to internet at their home. the mobile internet data is costly and more data is consumed during video conferencing in online classes. the geographical remoteness further hinders the network coverage across the country. mobile internet providers charge around rs. 45 in nepalese currency for 1 gb of data used. for students who are using mobile data for more than four weeks of online classes, it is making a hole in their pockets. failure to attend online lectures hinders the student’s chances of appearing in the final examinations due to lack of class attendance which is recorded during the online lectures. although it seems feasible for majority of students from urban cities and well-todo families, students from adverse families are hard hit. until recently, virtual classes were least emphasized in our educational system as the traditional method of education was widely implemented. as the country was unprepared for this pandemic, all the institutions were shut, exams postponed and the students sent back home. the books and study materials were left behind in the hostel cupboards as the initial lockdown was only for 10 days. extension of the lockdown made university to compel their colleges for online classes without any proper homework. implementation of online classes without any feasibility study has been like a wild goose chase set up by educational officials. without access to the books and notes, the taught content of an hour-long lecture is hard to revise after the classes are over. from a student’s perspective ‘nothing hunts more than those highlighted books and notes left behind in hostel’. teachers do perform face reading and mind reading of students because of which they are able to deliver best lectures. virtual learning burns the spiritual bridge between teachers and student as they are unable to pay attention to every student. to answer the queries of students individually among hundreds of students during online classes, teachers ought to have a magic wand. no gesture, no body language, and delivering lectures sitting idly in a chair makes the teaching learning process unproductive. lack of two-way communication makes it difficult to analyze the effectiveness of the class. skipping classes has become easier to those students who always have clouds in their heads. online classes practised in the educational field in lack of the devices to go online or proper economic internet connection, lack of training to teachers, unstable internet, unstable mobile data nepal b et al. online medical education in nepal: barking a wrong tree. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 connection, and unpreparedness of syllabus is like barking up a wrong tree to deal with recent problems. although it has been observed that virtual learning methods are equally effective as traditional educational methods,[1] teachers and students are required to have a minimal knowledge to run devices for internet-based learning. even a good teacher on class might not know how to run effectively classes online and even the good students might not be able to use online classes as much as they do with the physical ones. trends and habits will affect both teachers and students. the unnecessary advertisements in the forms of bots further adds fuel to the fire. those who can afford internet are even facing the problem of unstable internet and untimely power cut schedule. heavy rain and thunder storms are more likely in the months of june-july. heavy rain with thunderstorms and/or hailstorm is one of the reasons for sudden power cuts which will interrupt lectures. even the mobile data users are not spared. teachers and students who share screen both change into statue and with this paused internet lectures and data pack both are wasted. it has been very difficult for students to maintain focus amidst the chaos of covid 19 pandemic.[2] university looks confused in taking proper decision and method of assessment of students as alternatives for exams. university should look forward to all the hardships, sweats, tears, sleepless nights painted by both students and teachers will not go in vain. this instability and uncertainty of future might give rise to various mental health issues among students. as every cloud has a silver lining, online classes have made students, those who can afford with stable connection, to get involved in studies. is it rational to deliver online lectures to only those who can afford more? who will be responsible for this disconnection of underprivileged student? looking at developed countries and just copying them will not be a solution as we should not bite more than we can chew. before conduction of any new system or methodology, sample survey should be done, problems should be solved on priorities, feasible alternatives can be selected and implemented then only expected outcome will become fruitful as people say well begun is half done. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. cook da, levinson aj, garside s, dupras dm, erwin pj, montori vm. internet-based learning in the health professions: a metaanalysis. jama. 2008;300(10):1181-96. pmid: 18780847 doi: https://doi.org/10.1001/ jama.300.10.1181 2. atreya a, nepal b. covid-19 pandemic and nepal. medico-legal j. 2020; [epub ahead of print]. pmid: 32427512 doi: https://dx.doi. org/10.1177/0025817220923690 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 10 may, 2020 accepted: 24 may, 2020 published: 26 may, 2020 a mch neurosurgeon, department of neurosurgery, upendra devkota memorial national institute of neurological and allied sciences, bansbari, kathmandu, nepal. corresponding author: suresh bishokarma e-mail: drsureshbk@gmail.com orcid: https://orcid.org/0000-0001-9448-842x how to cite this article: bishokarma s. covid-19 pandemic: a neurological perspective. journal of lumbini medical college. 2020;8(1):3 pages doi: 2020;8(1):3 pages doi: https:// doi.org/10.22502/jlmc.v8i1.334 epub: 2020 may epub: 2020 may 26._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.334 suresh bishokarma a covid-19 pandemic: a neurological perspective introduction: even though severe acute respiratory syndrome coronavirus 2 (sars-cov-2) primarily affects the respiratory system, the nervous system is not spared either. sars-cov-2 has been isolated from the brain, olfactory bulb and cerebrospinal fluid. during the sars (sars-cov-1) outbreak in 2002 to 2003, neurons had been found to be highly susceptible for infection and the virus could cause extensive neuronal damage. similar to sars-cov-1, sars-cov-2 exploits the angiotensin-converting enzyme 2 (ace-2) receptor to gain entry and infect both glial and neuronal cells which express ace-2 receptors.[1] sars-cov-2 affects the central as well as peripheral nervous system presenting with diverse manifestations like myelitis, cerebrovascular events (cve) and encephalitis to mention a few.[2,3] indepth understanding of neurotropic potential of this virus will be helpful to individualize the treatment protocol from a neurological perspective. review: the first report of the viral infection attracted attention in late december 2019 in wuhan, the capital of hubei, which quickly surged to potential of global threat and rapidly succeeded from china to europe and then to the united states of america in a matter of weeks was taxonomically designated as sarscov-2 and diseases named as corona virus disease (covid-19). covid-19 was declared a pandemic on the march 11, 2020 by who.[4] currently, sars-cov-2 has affected almost every country of the world with confirmed cases of 38,22,382 tolling 2,63,658 death. in nepal, as of may 10, 2020 there were 109 confirmed cases with zero mortality.[5] virus: sars-cov-2 is a single-strand rna (ssrna) corona virus similar to sars like coronavirus that had previously been reported in bats in china. the rna genome of sars-cov-2 is enclosed by spike (s), envelop (e) and membrane (m) protein. spike protein projecting from the virus membrane is the key structure for the infectivity and pathogenicity of this virus into host. the spike protein enables the attachment of the virion to the cell membrane by interacting with the host ace-2 receptor.[6] it has been found that the spike protein of sars-cov-2 has 10-20 folds increased affinity to the ace-2 receptor than sars-cov-1, making it highly contagious and infectious.[7,8] mechanism of neuro invasion: the mechanism of action for sars-cov-2 neurological invasion is not yet specified. capillary endothelium expresses ace-2 receptors which is the vulnerable site for the access of the virus into the cerebral microcirculation. the lesion in the endothelial lining as a result of subsequent budding of the viral particle favors viral access to the brain. once access into the cerebral environment, it interacts with the neuronal ace-2 receptors and could initiate viral multiplication and neuronal damage has been seen in sars-cov in past and proposed for sars-cov-2 which need approval. [9] although, low expression of ace-2 in glia and cerebral neurons is well documented, the specific site of entry of sars-cov-2 is not clearly identified.[10] one of the proposed routes of access of virus to the brain is via the cribriform plate close to the olfactory bulb. other postulations are transbishokarma s. covid-19 pandemic: a neurological perspective. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 synaptic viral transfer after initial peripheral nerve invasion. direct invasion, blood circulation pathway, neuronal pathway, hypoxia injury, immune injury/ cytokine storm syndromes have also been proposed. [11,12,13,14] manifestation of neurological involvement: covid-19 is a highly contagious disease transmitted from droplets, aerosols and contact to nasal or ocular surfaces. the incubation period is generally 3-14 days but an extended period up to 24 days has been reported. neurological symptoms vary with the level of nervous system involved. involvement of central nervous system (cns) manifests as dizziness, headache, impaired consciousness, acute cerebrovascular diseases, ataxia or seizure while peripheral nervous system (pns) involvement manifests as taste impairment, anosmia, visual impairment or neuralgia. increased severity of covid-19 increases the risk of neural involvement and complications.[15] spectrum of complication of covid-19 includes viral meningitis, encephalitis, post infectious acute disseminated encephalitis, post infectious brainstem encephalitis, guillain barre syndrome (gbs), acute necrotizing hemorrhagic encephalopathy.[2] ace-2 at the level of blood brain barrier may jeopardize the protective barrier giving way to viral encephalitis while spinal cord membrane expressing ace-2 receptor in a spinal vein may predispose to myelitis like feature. systemic homeostasis dysregulation caused by pulmonary, renal, cardiac and circulatory damage in covid-19 can result in secondary cerebral damage. however, a dominant cerebral involvement alone with the potential of causing cerebral edema in covid-19 can take heavy toll before systemic dysregulation ensues.[8] cerebrovascular events (cve) including hemorrhagic or ischemic stroke or cerebral venous sinus thrombosis could be a presenting feature of covid-19. in a study done by filatov a et al., among 221 patients, 5.88% (13 patients) had cve of which majority (11 patients) of them presented with acute ischemic stroke (4.9%) while 0.45% patients presented with hemorrhagic stroke.[3] in a retrospective study done by mao l et al., in wuhan, china among 214 patients hospitalized with laboratory confirmed diagnosis of sarscov-2 infection. seventy-eight (36.4%) patients had neurologic manifestations. more severe patients were likely to have neurologic symptoms (40 [45.5%] vs 38 [30.2%]), such as acute cerebrovascular diseases (5 [5.7%] vs 1 [0.8%]), impaired consciousness (13 [14.8%] vs 3 [2.4%]. [10] there can be multiple reasons for a patient with covid-19 to present with impaired consciousness which includes viral encephalitis, metabolic perturbation, infectious toxic encephalopathy, seizure with post ictal confusion and stroke.[15] seizure in covid-19 patients has minimal incidences as observed by mao et al.[15] association of seizure in covid-19 can be multifaceted. proposed mechanism could be due to direct viral invasion of cns, severe hypoxia induced, metabolic, septic encephalopathy, gliosis due to encephalopathy or due to fever.[16] gbs was recorded infrequently in different studies worldwide. in a very recent study done by zhao et al., five cases of gbs diagnosed among covid-19 patients, three presented as axonal variant while two cases presented as demyelinating variants.[17] rapid deteriorating respiratory function of covid-19 patients could be due to bulbar involvement by gbs and need to be accurately sought. on the basis of this observational series involving five patients, it is not possible to determine whether severe deficits and axonal involvement are typical features of covid-19 associated gbs. conclusion: sars-cov-2 can take a severe toll on the respiratory system. however, virus bears potential to infect the nervous system as well. neural access via hematogenous route or cribriform plate ensues damage of either the central or the peripheral nervous system. subtle neurological manifestation must be considered as a presenting feature of covid-19 to early detect and treat this evil. conflict of interest: author declares that no competing interest exists. funding: no funds were available for the study. references: 1. zhou f, yu t, du r, fan g, liu y, liu z et al. clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. lancet. 2020;395:1054-62. doi: https://doi.org/10.1016/ s0140-6736(20)30566-3 2. nath a. neurological complications of corona virus infection. neurology. 2020;94(19):809810. pmid: 32229625 doi: https://doi. org/10.1212/wnl.0000000000009455 3. filatov a, sharma p, hindi f, espinosa ps. neurological complications of corona virus diseases (covid-19). cureus. 2020;12:e7352. pmid: 32328364 doi: https://doi.org/10.7759/ cureus.7352 4. mahase e. covid-19: who declares pandemic because of “alarming levels” of spread, severity, and inaction. bmj 2020;368:m1036. pmid: 32165426 doi: https://doi.org/10.1136/bmj. m1036 5. mohp. nepal; 2020 may 10. available from: https://covid19.mohp.gov.np/ 6. su s, wong g, shi w, liu j, lai ack, zhou j et al. epidemiology, genetic recombination, and pathogenesis of coronaviruses. trends microbiol. 2016;24:490-502. pmid: 27012512 doi: https://doi.org/10.1016/j.tim.2016.03.003 7. wrapp d, wang n, corbett ks, goldsmith ja, hsieh cl, abiona o et al. cryo-em structure of the 2019-ncov spike in the prefusion conformation. science. 2020;367(6483):1260‐63.pmid: 32075877 doi: https://doi.org/ 10.1126/science. abb2507 8. baig am, khaleeq a, ali u, syeda h. evidence of the covid-19 virus targeting the cns: tissue distribution, host−virus interaction, and proposed neurotropic mechanisms. acs chem neurosci. 2020;11:995-8. pmid: 32167747 doi: https://doi.org/ 10.1021/acschemneuro.0c00122. 9. netland j, meyerholz dk, moore s, cassell m, perlman s. severe acute respiratory syndrome coronavirus infection causes neuronal death in the absence of encephalitis in mice transgenic for human ace2. j virol. 2008;82(15);7264-75. pmid: 18495771 doi: https://doi.org/ 10.1128/ jvi.00737-08 10. harberts e, yao k, wohler je, maric d, ohayon j, henkin r et al. human herpesvirus-6 entry into cns through the olfactory pathway. proc natl acad sci usa. 2011;108(33):13734-9. pmid: 21825120 doi: https://doi.org/ 10.1073/ pnas.1105143108 11. butowt r, bilinska k. sars-cov-2: olfaction, brain infection, and the urgent need for clinical samples allowing earlier virus detection. acs chem neurosci. 2020;11(9):1200-03. pmid: 32283006 doi: https://doi.org/10.1021/ acschemneuro.0c00172 12. li yc, bai wz, hashikawa t. the neuroinvasive potential of sars-cov-2 may play a role in the respiratory failure of covid-19 patients. j med virol; 2020; epub feb 27 2020. pmid: 32104915 doi: https://doi.org/10.1002/jmv.25728 13. wu y, xu x, chen z, duan j, hashimoto k, yang l et al. nervous system involvement after infection with covid-19 and other coronaviruses. brain behav immun. 2020;s0889-1591(20)30357-3. [epub ahead of print]. pmid: 32240762 doi: https://doi.org/10.1016/j.bbi.2020.03.031 14. poyiadji n, shahin g, noujaim d, stone m, patel s, griffith b. covid-19-associated acute hemorrhagic necrotizing encephalopathy: ct and mri features. radiology. 2020; epub march 31 2020. doi: https://doi.org/10.1148/ radiol.2020201187 15. mao l, jin h, wang m, hu y, chen s, he q, et al. neurologic manifestations of hospitalized patients with coronavirus disease 2019 in wuhan, china. jama neurol. 2020;e201127 [epub ahead of print]. pmid: 32275288 doi: https://doi.org/10.1001/jamaneurol.2020.1127 16. lahiri d. ardila a. neuro perspective: covid-19 pandemic: a neurological perspective. cureus. 2020; 12(4):e7889. doi: https://doi.org/10.7759/ cureus.7889 17. zhao h, shen d, zhou h, liu j, chen s. guillain barre syndrome associated with sars-cov-2 infection: causality or coincidence? lancet neurol. 2020;19:383-4. pmid: 32246917 doi: https://doi.org/ 10.1016/s1474-4422(20)301095. bishokarma s. covid-19 pandemic: a neurological perspective. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 17 june, 2020 accepted: 22 june, 2020 published: 26 june, 2020 a medical officer, bmetrocity hospital, pokhara, nepal. ckaski model hospital, pokhara, nepal. corresponding author: aabishkar bhattarai email: aabishkar.bhattarai@gmail.com orcid: https://orcid.org/0000-0003-3669-1707 how to cite this article: bhattarai a, karki b. covid-19 pandemic and mental health issues. journal of lumbini medical college.2020;8(1):2 pages. doi: https:// doi.org/10.22502/jlmc.v8i1.383 epub: 2020 june 26._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.383 aabishkar bhattarai,a,b bijaya karki a,c covid-19 pandemic and mental health issues in january 2020, the world health organization (who) declared the outbreak of novel coronavirus disease (covid-19), a public health emergency of international concern. who stated that there is a high risk of covid-19 spreading to countries around the world. in march 2020, who declared covid-19 as a global pandemic.[1] from december 2019 till today (18 june 2020) the total cases have approached to 8,242,999 with the death of 445,535 and the incidence is increasing day by day.[2] from the first case seen in wuhan, china the virus has been rapidly spreading to most of the countries of asia, europe and america with almost all the world population affected directly by the disease or its consequences. the physical, social, economic, psychologic and mental wellbeing of the world population have been affected with this pandemic in its peak. to control this pandemic, most of the resources and manpower are dedicated to the patients with covid-19 and the health care workers and volunteers who work in frontline. governments have implemented lockdown modalities with a hope to reduce the burden of transmission in their countries, which has surpassed more than 2-3 months in most countries. the effect of pandemic, lockdown and social isolation approach have risen concern regarding their consequences to the mental health of the general population.[3] fear, worry and stress are the normal consequences of the perceived or real threat when an individual is faced with uncertainties. this covid-19 pandemic comes with lots of uncertainties regarding management and containment approaches. many people are having fear regarding contracting the virus, worrying regarding their health and health of their beloved ones. people are having undue distress and impairment to social and occupational functioning. across the societies, a sense of loss can be felt from losing direct social and physical contact, entrapment, loss of loved ones, loss of job opportunities and employment, recreational activities, freedom, and social supports. post infectious fatigue and depression have been associated with other epidemics in past and it seems to be the same for covid-19 pandemic.[4] stresses have attributed to difficulties in concentration, changes in sleep habits and eating patterns with worsening of the pre-existing chronic health and mental problems and indulgence of the people in substance abuse, alcoholism and domestic violence. the perception of fear, anxiety, depression, obsessive compulsive disorders, self-harm and suicidality and post-traumatic stress disorder are increasing.[5] there is increased worsening of preexisting mental problems and increased incidence of treatment non-compliances and relapses in patient with mental disorders. with the implementation of lockdown, people are not able to enjoy routine health services and opds visits which have reduced the evaluation of the pre-existing mental problem as well as diagnosis and treatment of new mental health related issues. strict lockdown as a pandemic control measure disproportionately affects the most vulnerable populations e.g. those with preexisting mental and physical disorder, recovered individuals and those who become mentally unwell due to loneliness, restrictions, entrapments and anxiety. health workers who need to make a highly challenging decisions working closely with the virus and patients with covid-19 and who are exposed to the traumatic events such as death and dying are especially vulnerable to the mental health problems attributed to the stress they go through. bhattarai a, et al. covid-19 pandemic and mental health issues. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 a dual relationship exists between the covid-19 infection and mental health; infection causing mental health issues and mental health disorders on other hand being hurdle to control the pandemic. lack of cognition in respect to patient with mental health disorders, inappropriate awareness of the risk and control strategies of personal protective behaviours, lack of knowledge/cognition regarding personal protection, handwashing, not touching t-zone of the face, tissue use; physical and social distancing and confinement to the home or psychiatric wards can increase the susceptibility to the disease. also due to the prevalence of social discrimination in respect to the patients with mental health disorders, there remains a barrier to treat or transfer a psychiatric patient to the health care facilities. also due to delayed diagnosis of the covid-19 infection in such patients they can also be a contagious source of virus to the society. pandemics do not affect all the patients equally and inequalities can drive the spread of infection. so along with the patients and health care workers, attempts should be focused to the most vulnerable groups to develop a novel intervention to protect mental health and physical wellbeing. maintaining healthy life style, balanced diet, sleep and social contact, daily physical exercises to maintain body mobility, meditation and yoga, avoidance of alcohol, tobacco and illicit substances, involvement in the activities of interest to make oneself acquainted, and keeping in touch to the near and dear ones via electronic and online medium can help to reduce the stress and anxiety regarding the pandemic. social media on its dark side being the source of rapidly spreading misinformation, amplifying the perception of risk with repeated exposure to information also increases the worries, stress and impair the functioning. these uncertainties and worries draw additional media consumption and further distress creating a cycle difficult to break. so, it is healthy not to overindulge oneself continuously to the news of disease and pandemic, however one should seek information from the trusted source so that one could take practical steps to prepare plans and protect themselves and their loved ones. the current situation will not disappear overnight, so the global population should focus on long term behavioural modifications and sustainable rather than repeated short-term approach to preserve individual’s mental health and functioning. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. who director-general’s opening remarks at the media briefing on covid-19. world health organization: geneva; 11 mar 2020. https:// www.who.int/dg/speeches/detail/who-directorg e n e r a l s o p e n i n g r e m a r k s a t t h e m e d i a briefing-on-covid-19---11-march-2020 2. who coronavirus disease (covid-19) dashboard. world health organization, geveva, switzerland. 18 june 2020. available from: https://covid19.who.int/ 3. torales j, o’higgins m, castaldelli-maia jm, ventriglio a. the outbreak of covid-19 coronavirus and its impact on global mental health. int j soc psychiatry. 2020;66(4):317320. pmid: 32233719 doi: https://doi. org/10.1177/0020764020915212 4. ho cs, chee cy, ho rc. mental health strategies to combat the psychological impact of covid-19 beyond paranoia and panic. ann acad med singapore. 2020;49(3):155-160. pmid: 32200399. 5. clay ra. covid-19 and suicide. monitor on psychology. 2020;51(4). available from: https:// www.apa.org/monitor/2020/06/covid-suicide j. lumbini. med. coll. vol 9, no 1, jan-june 2021 chaudhary s, et al. vision loss following small incision cataract surgery: a case report.chaudhary s, et al. vision loss following small incision cataract surgery: a case report. jlmc.edu.np ___________________________________________________________________________________ submitted: 16 july, 2020 accepted: 20 september, 2020 published: 15 may, 2021 aoptometrist, bconsultant ophthalmologist, csagarmatha choudhary eye hospital, siraha, lahan, nepal. ddristi eye hospital, birgunj, nepal. corresponding author: sushma chaudhary e-mail: chaudharysushma169@gmail.com orcid: https://orcid.org/0000-0002-5061-652x_______________________________________________________ abstract: introduction: retro-bulbar block is still safe and widely employed anesthetic technique in large volume routine cataract surgery. nevertheless, the procedure is not free of complication. case report: a 48 years old man who had small incision cataract surgery of left eye under retro-bulbar block, had vision of hand movement close to face on his first postoperative day. he was given intracameral cefuroxime and subconjunctival gentamycin at the end of the surgery. fundoscopy of the operated eye showed marked retinal whitening with cherry red spot in the posterior pole suggestive of cilio-retinal artery occlusion. optical coherence tomography and optical coherence tomography angiography were done to support and confirm the diagnosis.conclusion: retinal artery occlusion secondary to retro-bulbar block or drug induced toxicity following routine cataract surgery is unusual and sometimes dreadful vision threatening complication can occur. keywords: optical coherence tomography angiography ; retinal artery occlusion; retrobulbar anesthesia case reporthttps://doi.org/10.22502/jlmc.v9i1.390 sushma chaudhary,a,c sharad gupta,b,c sanjaykumar singh,b,c hari sharma,b,d reenayadav,b,c vinit kumar kamble b,c vision loss following small incision cataract surgery: a case report how to cite this article:how to cite this article: chaudhary s, gupta s, singh s, sharma h, yadav r, kamble vk. chaudhary s, gupta s, singh s, sharma h, yadav r, kamble vk. vision loss following small incision cataract surgery: a case vision loss following small incision cataract surgery: a case report. journal of lumbini medical college. 2021;9(1):4 pages. report. journal of lumbini medical college. 2021;9(1):4 pages. doi: doi: https://doi.org/10.22502/jlmc.v9i1.390. epub: 2021 may 15. epub: 2021 may 15. introduction: with regard to subtenon, topical and peribulbar anesthesia, retrobulbar anesthesia is still commonly employed anesthetic technique for high volume intraocular surgery. however, the technique is not free of complications. retrobulbar injection is given at the junction of medial two-third and lateral one-third of the inferior orbital margin using a 26-gauge, 35 mm retrobulbar needle (4 ml of 2% lignocaine with adrenaline 1:100,000 dilution) into the retrobulbar space which contains vascular and neural structures.[1] few literature reported that globe perforation, retrobulbar hemorrhage, central retinal artery occlusion and combined central retinal artery occlusion with central retinal vein occlusion are some of the complications that may compromise vision.[2,3] possible mechanism for those complications would be due to direct trauma to the optic nerve along with mechanical effect of the bolus anesthetic and pharmacologically mediated changes in the vascular caliber.[4] here we report a case of cilioretinal artery occlusion following routine small incision cataract surgery under retro-bulbar anesthesia. case report: a 48 years old male presented with painless progressive diminution of vision in the left eye for last six months. his visual acuity was 6 /12 in the right eye and 6/60 in the left eye. visual acuity improved to 6/6 and 6/12 after best refractive correction. patient had cataract surgery in his right eye two years ago. pupillary reactions (direct and consensual) were normal in both eyes. on slit-lamp biomicroscopic examination anterior and posterior segment except intra-ocular lens in the right eye and nucleus sclerosis grade 2 in the left eye was licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 chaudhary s, et al. vision loss following small incision cataract surgery: a case report.chaudhary s, et al. vision loss following small incision cataract surgery: a case report. jlmc.edu.np unremarkable. intraocular pressures were 15 mmhg in the right eye and 16 mmhg in the left eye. his physical examination was normal and systemic history was not significant. a diagnosis of right eye pseudophakia and left eye nucleus sclerosis grade 2 was made. the patient was merited for left eye small incision cataract surgery. topical ciprofloxacin 0.3 % was instilled before surgery and 4 ml of 2% lignocaine in 1: 100000 adrenaline was injected via retrobulbar route (inferior approach) for anesthesia. after anesthesia the eye was usually compressed with palm for 10-15 minutes. under aseptic condition small incision cataract surgery with intraocular lens implantation in bag was done. at the end of surgery intracameral cefuroxime (1 mg/0.1 ml) along with subconjunctival injection gentamycin (20 mg in 0.5ml) and dexamethasone (0.2 mg in 0.5 ml) was given. figure 1. aleft fundus showing pale retina in the posterior pole along with cherry red spot. b-normal right fundus. figure 2. aoptical coherence tomography images of posterior segment of the left eyethe horizontal cross-sectional image demonstrates increased reflectivity and thickness of the inner retinal layers, but decreased reflectivity in the outer retinal layer. beneath the fovea, there is an area of normal reflectivity of the is/os line and rpe layer. b, c oct of posterior of the left eye showed superficial and deep plexus with loss of flow in the capillary network of the occluded area. on the first postoperative day his best corrected visual acuity in the operated eye was hand movement close to face. anterior segment examination of operated eye had clear cornea, inflammatory reaction (2-3+ cells) in the anterior chamber, intraocular lens in bag and relative afferent pupillary defect (rapd) was noted. under mydriasis, examination of the left fundus revealed whitening of the retina at the posterior pole with cherry red spot suggestive of cilioretinal artery occlusion (fig 1a) whereas fundus examination of the right eye was normal (fig 1b). intraocular pressure was 16 mmhg in each eye by noncontact air puff tonometer. no proptosis or other signs of retrobulbar hemorrhage were noted. swept source optical coherence tomography and optical coherence tomography angiography was performed to confirm the diagnosis (fig 2a and b) whereas it was normal in the right eye (fig 3a and b). he was treated with oral carbonic anhydrase inhibitors. laboratory and cardiac assessment was found to be within normal limit. patient was discharged on topical steroid and antibiotic eye drops. patient was advised for follow up after one month. figure 3. anormal oct images of posterior segment of the right eye. bnormal oct-a posterior segment of the right eye. discussion: retinal artery occlusions (rao) are most commonly a result of embolic obstruction which might be of carotid or cardiac origin, vaso-obliteration and vascular compression.[5] though retinal vascular accident secondary to retrobulbar anesj. lumbini. med. coll. vol 9, no 1, jan-june 2021 chaudhary s, et al. vision loss following small incision cataract surgery: a case report.chaudhary s, et al. vision loss following small incision cataract surgery: a case report. jlmc.edu.np thesia is rare but damage to the optic nerve, artery or vein via various mechanism (direct trauma, mechanical compression or drug toxicity) still occurs. [4] klein ml et al., and morgan cm et al., stated that the probable mechanism for crao would be direct trauma to the retinal artery along with retrobulbar hemorrhage associated with marked rise of orbital iop.[4,6] the most probable hypothesis for combined retinal vein and artery occlusion would be injection into the optic nerve sheath and optic nerve sheath hematoma.[3,6] our patient had received intracameral cefuroxime and subconjunctival gentamycin at the end of the surgery. some literatures reported that the use of intracameral cefuroxime and subconjunctival gentamycin could prevent from severe and feared complications like endophthalmitis.[7,8] but use of these drugs can also lead to blinding complications such as macular ischemia and infarction.[9,10,11,12] our patient was diagnosed as a case of cilioretinal artery occlusion based on clinical finding of fundus and confirmed by octa. in our patient the most possible hypothesis for cilioretinal artery occlusion would be mechanical effect of the volume of anesthetic agent and its vasoconstrictive properties that mediated changes in the vascular caliber. intracameral cefuroxime and subconjunctival gentamycin induced macular infarction would be another probable hypothesis. conclusion: cataract surgery is most common ocular surgery. even routine and uneventful cataract surgery is associated with severe unfavorable outcomes. retinal artery occlusion secondary to retro-bulbar block or drug induced toxicity following routine cataract surgery is unusual and sometimes dreadful vision threatening complication can occur. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. references: 1. katsev da, drews rc, rose bt. an anatomic study of retrobulbar needle path length. ophthalmology 1989;96(8):1221-4. doi: https://doi.org/10.1016/s0161-6420(89)32748-5 2. jung eh, park kh, woo sj. iatrogenic central retinal artery occlusion following retrobulbar anesthesia for intraocular surgery. korean j ophthalmol. 2015;29(4):233-40. pmid:26240507 doi: https://doi.org/10.3341/ kjo.2015.29.4.233 3. vasavada d, bhaskaran p, seema r. retinal vascular occlusion secondary to retrobulbar injection: case report and literature review. middle east afr j ophthalmol. 2017;24(1)57-60. pmid: 28546695 doi: https://doi.org/10.4103/ meajo.meajo_37_16 4. klein ml, jampol lm, condon pi, rice ta, serjeant gr. central retinal artery occlusion without retrobulbar hemorrhage after retrobulbar anesthesia. american journal of ophthalmology. 1982;93(5):573-7. doi: https://doi.org/10.1016/ s0002-9394(14)77371-4 5. körner-stiefbold u. central retinal artery occlusion (crao) etiology, clinical signs and management. therapeutic umschau. 2001;58(1):36-40. doi: https://doi. org/10.1024/0040-5930.58.1.36 6. morgan cm, schatz h, vine ak, davidorf fh, gitter ka, rudich r. ocular complications associated with retrobulbar injections. ophthalmology.1988;95(5):660-5. pmid: 3174025 doi: https://doi.org/10.1016/s01616420(88)33130-1 7. yorston d. using intracameral cefuroxime as a prophylaxis for endophthalmitis. community eye health. 2008;21(65):11. pmid: 18504469 pmcid: http://www.ncbi.nlm.nih.gov/pmc/ articles/pmc2377382/ 8. fintelmann re, naseri a. prophylaxis of postoperative endophthalmitis following cataract surgery: current status and future directions. drugs. 2010;70(11):1395409. pmid: 20614947 doi: https://doi. org/10.2165/11537950-000000000-00000 9. campochiaro pa, conway bp. aminoglycoside toxicity a survey of retinal specialists: implications for ocular use. arch j. lumbini. med. coll. vol 9, no 1, jan-june 2021 chaudhary s, et al. vision loss following small incision cataract surgery: a case report.chaudhary s, et al. vision loss following small incision cataract surgery: a case report. jlmc.edu.np ophthalmol.1991;109(7):946-50. pmid: 2064573 doi: https://doi.org/10.1001/ archopht.1991.01080070058035 10. murao f, kinoshita t, katome t, sano h, niki m, mitamura y. suspected gentamicin-induced retinal vascular occlusion after vitrectomy. case reports ophthalmology. 2020;11(2):47380. doi: https://doi.org/10.1159/000509337 11. cardascia n, boscia f, furino c, sborgia l. gentamicin-induced macular infarction in transconjunctival sutureless 25-gauge vitrectomy. int ophthalmol. 2008;28(5):383-5. pmid: 17938870 doi: https://doi.org/10.1007/ s10792-007-9148-4 12. quresh f, clark d. macular infarction after inadvertent intracameral cefuroxime. journal of cataract and refractive surgery. 2011;37(6):1168-9. doi: https://doi. org/10.1016/j.jcrs.2011.03.032 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 9 june, 2020 accepted: 13 june, 2020 published: 21 june, 2020 a consultant dermatologist, b palpa district hospital, palpa, nepal. corresponding author: alina sharma e-mail: alina.amelia@gmail.com orcid: https://orcid.org/0000-0002-7529-6630 how to cite this article: sharma a. dermatological aspects of covid-19. journal of lumbini medical college. 2020;8(1):4 pages.doi: https://doi.org/10.22502/ jlmc.v8i1.379 epub: 2020 june 21._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.379 alina sharma a,b dermatological aspects of covid-19 introduction: on 31 december 2019, wuhan, the capital city of hubei province in china reported world health organization(who) about cases of pneumonia which were caused by a severe acute respiratory syndrome coronavirus 2 (sars-cov-2)[1] currently designated coronavirus disease (covid-19).[2] the infection rapidly spread throughout the world escalating the situation and who eventually declared covid-19 as a global pandemic on 11 march 2020. [3] it has already affected almost all aspects of health and society globally. with the current pandemic, dermatologists should be aware of dermatological aspects of sars-cov-2, its skin manifestations and general skin care. cutaneous manifestations in covid-19 patients: the sars-cov-2 primarily affects the respiratory system, but currently numerous cutaneous manifestations of this viral infection are reported.[4] incidence of cutaneous manifestations among confirmed covid-19 cases was 20.4% among total 88 covid-19 patients as per an italian study conducted by recalcati et al.[4] the trunk was the main involved region, pruritus was minimal and usually lesions healed within a few days. the study reported no correlation of cutaneous manifestations with disease severity. a recent study done in spain has classified cutaneous features of covid-19 as acral areas of erythema with vesicles or pustules (pseudo‐chilblain or covid toes), vesicular eruptions, urticarial lesions, maculopapular eruptions and livedo or necrosis. a commonly observed cutaneous feature was maculopapular or morbilliform rash in 47% of cases among 375 cases.[5] the timing of eruption of skin lesion ranged from three days before covid-19 diagnosis to 13 days after diagnosis and lesion usually healed within 14 days.[6] the mechanism of cutaneous disturbances by covid-19 is not yet properly understood but some theories postulate that viral particles present in the cutaneous blood vessels in patients could lead to a lymphocytic vasculitis induced by blood immune complexes that activate cytokines. the virus does not directly target the keratinocyte, but rather immune response to infection leads to langerhans cells activation, resulting in a state of vasodilatation and spongiosis. it was also suggested that livedo reticularis could probably be due to the accumulation of micro thromboses originating in other organs.[6] in nepal, covid-19 positive cases are increasing rapidly. the dermatologists must be aware of and cautious about skin lesions and the possibility of covid-19 infection for prompt diagnosis and appropriate management. however, these rashes must be differentiated from drug rashes due to antivirals or other drugs used for the disease. it is desirable that physicians be aware of cutaneous manifestations for prevention of misdiagnosis. joob b et al. from thailand reported a case initially diagnosed as dengue based on skin rash with petechiae, which was later confirmed to be covid-19.[7] similarly, the clinical features of covid-19 in younger age group may overlap with kawasaki disease.[8] as the incubation period of covid-19 is around 14 days, during which most of the cases are asymptomatic, knowledge of cutaneous manifestations may help as an early indicator for timely diagnosis especially in countries like ours with limited available tests.[2,6] patients suffering from skin disease receiving immunosuppressive medications: in patients with no other co-morbidities, there is little specific evidence of covid-19 infection being aggravated by immunomodulators, but a sharma a. dermatological aspects of covid-19. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 precaution must be taken as any secondary bacterial infection as part of covid-19 may be aggravated by its concurrent use.[9] american academy of dermatology (aad) recommends that patients should not stop their ongoing systemic immunosuppressive therapy who have not tested positive or have no signs and symptoms of covid-19, however indication, age and other co-morbidities should be considered and risk should be outweighed. for patients who have tested positive, aad recommends to postpone or discontinue using immunosuppressive therapies. [10] british association of dermatologists (bad) has also provided guidelines for patients on immunosuppressive medications. patients at definite high risk (extremely vulnerable people), who are of old age or with other co-morbidities, having two or more immunosuppressive medications should undergo shielding with self-isolation up to 12 weeks. wellcontrolled patients with minimal disease activity and no co-morbidities who are being treated with single agent of immunosuppressant or biologics or topical treatment need to maintain social distancing.[11] in confirmed cases of covid-19 infection who are on systemic steroids for dermatological disorders, it can be continued with tapering doses.[9] the national guidelines from society of dermatologists, venereologists and leprologists of nepal (sodvelon) suggests discontinuation of immunosuppresants and immunomodulators like rituximab if viral symptoms are present, whereas discontinuation of immunomodulator like apremilast only if severe symptoms appear.[12] thus, risk versus benefit ratio must be carefully weighed having original indication, elderly people and co-morbidities in mind before prescribing any immunomodulators or immunosuppressants in this era of pandemic. if possible, lowest dose possible or alternative drugs should be preferred and patients must be properly counselled about risks and necessity of shielding or self-isolation. skin problems in healthcare professionals dealing with covid-19 patients: covid-19 is primarily transmitted by droplets however transmission through surface contact is also not denied.[13] as skin is the first line of defense, maintaining integrity of skin must be of foremost priority to prevent contact transmission. [14] in a study done in china among frontline health workers during this pandemic, occurrence of skin lesions was closely associated with the level of protection, working frequency and duration of wearing protective suits.[15] frequent hand hygiene practice and prolonged wearing of gloves can make the skin over the hands vulnerable increasing the risk of allergic and irritant contact dermatitis. aggravation of previous skin diseases has also been observed. after prolonged contact with masks and goggles, skin lesions ranging from contact and pressure urticaria to contact dermatitis have been reported.[16] the heat and high humidity in the summer season can add to the skin problems associated with personal protective equipment (ppe) use and could possibly induce miliaria.[17] for the frontline workers; fewer working hours, well fitted and comfortable ppe, prophylactic dressing, preference of soap-based cleanser over alcohol-based hand rub and frequent moisturization of skin could be helpful for maintaining skin integrity. conclusion: with covid-19 spreading rapidly in the country, all healthcare professionals need to be prepared for cases in the hospitals and community both. in our regular practice, aerosol generating procedures, cosmetic procedures and nonemergency dermatologic surgical procedures can be postponed during this period. out-patients are to be examined only after basic screening and with proper personal protective measures. as the duration of the pandemic cannot be predicted, strategies should be framed for future course of action including dermatology practice for the benefit of both patients and physicians. conflict of interest: the author declares that no competing interest exists. funding: no funds were available for the study. references: 1. world health organization. naming the coronavirus disease (covid-19) and the virus that causes it [internet]. who: geneva; 2020 [cited 2020 june 2] available from: https:// www.who.int/emergencies/diseases/novelcoronavirus-2019/technical-guidance/namingthe-coronavirus-disease-(covid-2019)-and-thevirus-that-causes-it 2. phelan al, katz r, gostin lo. the novel coronavirus originating in wuhan, china: challenges for global health governance. jama. 2020;323(8):709-10. pmid: 31999307. doi: https://doi.org/10.1001/jama.2020.1097 3. world health organization. coronavirus disease (covid-19) situation report. who: geneva; 2020. situation report no.: 51. [cited 2020 may 25] available from: https://www. who.int/docs/default-source/coronaviruse/ situation-reports/20200311-sitrep-51-covid-19. pdf?sfvrsn=1ba62e57_10 4. recalcati s. cutaneous manifestations in covid‐19: a first perspective. journal of the european academy of dermatology and venereology. 2020;34(5):e212-e213. doi: https://doi.org/10.1111/jdv.16387 5. casas cg, català a, hernández gc, rodríguezjiménez p, nieto df, lario ar, et al. classification of the cutaneous manifestations of covid-19: a rapid prospective nationwide consensus study in spain with 375 cases. british journal of dermatology. forthcoming 2020. available from: https://onlinelibrary.wiley.com/ doi/abs/10.1111/bjd.19163 6. sachdeva m, gianotti r, shah m, lucia b, tosi d, veraldi s, et al. cutaneous manifestations of covid-19: report of three cases and a review of literature. j dermatol sci. 2020;s09231811(20)30149-3. pmid: 32381430. pmcid: pmc7189855. doi: https://doi.org/10.1016/j. jdermsci.2020.04.011 7. joob b, wiwanitkit v. covid-19 can present with a rash and be mistaken for dengue. j am acad dermatol. 2020;82(5):e177. pmid: 32213305. pmcid: pmc156802. doi: https:// doi.org/10.1016/j.jaad.2020.03.036 8. morand a, urbina, d, fabre a. covid-19 and kawasaki like disease: the known-known, the unknown-known and the unknownunknown. preprints. forthcoming 2020. available from: https://www.preprints.org/ manuscript/202005.0160/v1 9. rademaker m, baker c, foley p, sullivan j, wang c. advice regarding covid-19 and use of immunomodulators, in patients with severe dermatological diseases. australas j dermatol. 2020;61(2):158-59. pmid: 32219857. pmcid: pmc7228260. doi: https://doi.org/10.1111/ ajd.13295 10. american academy of dermatology. guidance on the use of immunosuppressive agents [internet]. united states: american academy of dermatology; 2020 [cited 2020 april 14]. available from: www.aad.org/member/practice/ coronavirus/clinical-guidance/biologics 11. british association of dermatologist. dermatology advice regarding self-isolation and immunosuppressed patients: adults, paediatrics and young people [internet]. london: british association of dermatologists; 2020 [cited 2020 may 25]. available from: https:// www.bad.org.uk/healthcare-professionals/ covid-19/covid-19-%20immunosuppressedpatients. 12. consensus/policy of sodvelon on current covid-19 crisis [internet] 1st published 15th april 2020. nepal: society of dermatologists venereologist and leprologists, 2020 [cited 2020 june 9] available from: https://docs.google. com/viewerng/viewer?url=http://sodvelon. com/wp-content/uploads/2020/04/covid-19sodvelon-statement-for-dermatologicaland-cosmetic-practice-final.pdf 13. chan jf, yuan s, kok kh, to kk, chu h, yang j, et al. a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. lancet. 2020;395(10223):514-23. pmid: 31986261. pmcid: pmc7159286. doi: https://doi.org/10.1016/s0140-6736(20)301549.t 14. toncic rj, jakasa i, hadzavdic sl, goorden sm, vlugt kjg, stet fs, et al. altered levels of sphingosine, sphinganine and their ceramides j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 jlmc.edu.np sharma a. dermatological aspects of covid-19. in atopic dermatitis are related to skin barrier function, disease severity and local cytokine milieu. int j mol sci. 2020;21(6):1958. pmid: 32183011. pmcid: pmc7139865. doi: https:// doi.org/10.3390/ijms21061958 15. pei s, xue y, zhao s, alexander n, mohamad g, chen x, et al. occupational skin conditions on the frontline: a survey among 484 chinese healthcare professionals caring for covid-19 patients. j eur acad dermatol venereol. 2020; [epub ahead of print]. pmid: 32362062. pmcid: pmc7267162. doi: https://doi. org/10.1111/jdv.16570 16. lan j, song z, miao x, li h, li y, dong l, et al. skin damage among health care workers managing coronavirus disease-2019. j am acad dermatol. 2020;82(5):1215-16. pmid: 32171808. pmcid: pmc7194538. doi: https:// doi.org/10.1016/j.jaad.2020.03.014 17. jagadeesan s, sarkar r. covid-19 and the dermatologist: finding calm in the chaos. pigment int. 2020; [epub ahead of print]. doi: https://doi.org/10.4103/pigmentinternational. pigmentinternational_24_20 sharma a. dermatological aspects of covid-19. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 10 june, 2020 accepted: 13 june, 2020 published: 26 june, 2020 a clinical research fellow, department of anesthesia, critical care and pain medicine, b bidmc, harvard university, us. corresponding author: preeti upadhyay e-mail: upadhyaypreetidr123@gmail.com orcid: https://orcid.org/0000-0003-1709-8158 how to cite this article: upadhyay p. healthcare workers and burnout during covid-19 pandemic. journal of lumbini medical college. 2020;8(1):3 pages. doi: https://doi.org/10.22502/jlmc.v8i1.380 epub: 2020 june 26._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.380 preeti upadhyay a,b healthcare workers and burnout during covid-19 pandemic have you ever felt stuck? or rather unmotivated and unsatisfied at your work? maybe you do not feel like being a doctor anymore, but the fear of what will you do after; scares you more. or maybe, you do wish to continue your medical practices but feel rather tired and let down at most times. in either scenario, you are not alone.[1] several healthcare workers feel underappreciated and suffer from lack of enthusiasm for work, feelings of cynicism towards life and low sense of personal accomplishment, in short, they feel “burnt out”. burnout is on the rise in medical fraternity. established professionals, residents in training, to young medical school trainees beginning their careers in medicine, none can escape from the brunt of burnout.[2,3] long working hours and increasing burden of bureaucratic tasks make the medical profession a tedious one.[4] continued exposure to human suffering and death introduce cynicism towards life and its purpose. constant need to be compassionate to patients and their family members require immense mental and emotional fortitude. however, with an increase in violence against the medical fraternity,[5] a typical doctor begins to question the sanctity of the profession and feels unappreciated. no wonder, compassion fatigue [6] and healthcare worker migration [7] are on a rise in nepal. the pervasive spread of the corona virus disease (covid-19) pandemic has indeed made matters worse for the existing mental health challenges faced by the healthcare practitioners in nepal. for one, there is no documented data on the pre-existing prevalence of burn out in the nepalese medical fraternity.[8] to add to this, a substantial rise is noticed in incidences of depression, anxiety, and substance abuse amongst the frontline healthcare workers.[3,4,8] possible rationale for this rise in mental health conditions are attributed to one or more of the following reasons: lack of personal protective equipment (ppe), respirators, and hospital infrastructure to support the increasing hospitalizations due to covid-19 infections, moral and ethical dilemma faced by healthcare workers during decision making process. a sense of guilt and regret for the general lack of preparedness to support the patients and fear for one’s life and safety add to existing mental health challenges faced by these professionals.[9,10] any further delay in instituting measures to effectively address these issues will pave way for an ominous mental health pandemic in near future. whilst a lot is being written in the scientific community regarding burnout and mental health challenges faced by the healthcare workers during the current pandemic;[2,3,9] it is difficult to ascertain if any effort is being made to combat it. this is especially true in a resource poor setting such as nepal. work culture in nepalese medical fraternity tends to stem from a common belief that healthcare workers are bound to promote selfless service towards the society. in the pursuit of serving the needs of the sick and their kin, healthcare workers often neglect their own physical, mental, social, and emotional wellbeing. in addition, the hierarchical structure of the medical fraternity requires the subordinates to step up to the expectations of their seniors. cumulative upadhyay p. healthcare workers and burnout during covid-19 pandemic. jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 outcome of all these practices is an increased predisposition to burnout. furthermore, stressors such as a natural disaster (e.g. mega earthquake of 2015) or the current pandemic (covid-19) tend to leave a long-lasting imprint on the society suffering from them. there are several studies suggesting a surge in mental health challenges including a rise in posttraumatic stress disorder in healthcare practitioners following the 2015 earthquake.[11] simple measures such as mandated time away from work (especially for frontline healthcare workers), practicing mindfulness, and an emphasis on one’s own physical and mental health can ensure better ability to combat mental health challenges.[12] these would require a change in one’s lifestyle which is often difficult to implement and include self-driven technique to avoid burnout. however, since burnout tends to be affected by organizational behavior, a change from burnout culture to a healthier work environment is extremely urgent. this is possible only if organizational interest in combating these challenges is generated. nepal has several private healthcare organizations working in conjunction with the public organizations to provide sustainable healthcare to the entire population. in the absence of a committed national effort from the government, at least private led institutions and organizations responsible for the healthcare provision should take an interest in implementing the culture change. healthcare workers are highly skilled human resources. a predominance of burnout culture in a skilled resource will negatively impact the productivity of an organization. a culture change will prove beneficial for not just the healthcare workers but also the organizations and patients. in a country like ours, where only a small fraction amongst the 30 million population is skilled to provide healthcare services, the onus of their wellbeing lies upon the society. a strong political commitment with easy accessibility to financial aid is the need of the hour.[2] persistence of burnout culture will lead to continued migration of healthcare workers to developed countries in pursuit of better work environment. this will propagate the existing imbalance of caregivers to patient ratio, and subsequently worsen the crisis. hence, it is in the county’s best interest to remedy burnout urgently. the discussion above is not just about statistics and research into mental health issues predominant in healthcare workers, nor is it solely about the effects of covid-19 pandemic on the mental health of healthcare professionals. this is simply my attempt as an ex-professional to draw attention of all my colleagues towards a rather pertinent issue affecting all our lives as healthcare professionals: the need for some physical, mental, and emotional selfcare. conflict of interest: the author declares that no competing interest exists. funding: no funds were available for the study. references: 1. kwon s. in ‘drop out club’, desperate doctors counsel each other on quitting the field [internet]. c2020 stat [cited 2020 june 6]. available from: https://www.statnews.com/2017/05/24/doctorsburnout-online-community/ 2. dzau vj, kirch d, nasca t. preventing a parallel pandemic a national strategy to protect clinicians’ well-being. n engl j med. 2020; [epub ahead of print]. pmid: 32402153 doi: http://doi.org/10.1056/nejmp2011027 3. panchal n, kamal r, orgera k, cox c, garfield r, hamel l et al. the implications of covid-19 for mental health and substance use. [internet] c2020 kff [cited 2020 june 6]. available from: https://www.kff.org/coronavirus-covid-19/issuebrief/the-implications-of-covid-19-for-mentalhealth-and-substance-use/ 4. galea s, merchant rm, lurie n. the mental health consequences of covid-19 and physical distancing: the need for prevention and early intervention. jama intern med. 2020;180(6):817-8. pmid: 32275292 doi: http:// doi.org/10.1001/jamainternmed.2020.1562 5. mckay d, heisler m, mishori r, catton h, kloiber o. attacks against health-care personnel must stop, especially as the world fights covid-19. lancet. 2020;395(10239):1743-45. pmid: 32445692 pmcid: pmc7239629 doi: http://doi.org/10.1016/s0140-6736(20)31191-0 6. adhikari y. compassion fatigue into the nepali counselors: challenges and recommendations. moj public health. 2018;7(6):376-9. doi: http:// doi.org/10.15406/mojph.2018.07.00271 7. nair m, webster p. health professionals’ migration in emerging market economies: patterns, causes and possible solutions. journal of public health. 2012;35(1):157-63. pmid: 23097260 doi: http://doi.org/10.1093/pubmed/ fds087 8. lamichhane n. professional burnout: how caring for ourselves helps us care for others. j psychiatrists’ association of nepal. 2015;4(2):13. doi: https://doi.org/10.3126/jpan.v4i2.18315 9. li w, frank e, zhao z, chen l, wang z, burmeister m et al. mental health of young physicians in china during the novel coronavirus disease 2019 outbreak. jama netw open. 2020;3(6):e2010705. pmid: 32478846 pmcid: pmc7265093 doi: http://doi. org/10.1001/jamanetworkopen.2020.10705 10. gold j. the covid-19 crisis too few are talking about: healthcare workers’ mental health. [internet] c2020 stat [cited 2020 june 6]. available from: https://www.statnews. com/2020/04/03/the-covid-19-crisis-too-feware-talking-about-health-care-workers-mentalhealth/ 11. shrestha r. post-traumatic stress disorder among medical personnel after nepal earthquake, 2015. j nepal health res counc. 2015;13(30):144-8. pmid: 26744200 doi: https://doi.org/10.33314/ jnhrc.v0i0.639 12. linzer m, levine r, meltzer d, poplau s, warde c, west cp. 10 bold steps to prevent burnout in general internal medicine. j gen intern med. 2013, sept 4;29(1):18-20. pmid: 24002633 doi: http://doi.org/10.1007/s11606-013-2597-8 upadhyay p. healthcare workers and burnout during covid-19 pandemic. j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 jlmc.edu.np j. lumbini. med. coll. vol 9, no 2, july-dec 2021 karki s, et al. anatomical variants of portal vein branching in cect scan of abdomen: a descriptive study jlmc.edu.np ___________________________________________________________________________________ submitted: 04 april, 2021 accepted: 22 september, 2021 published: 04 october, 2021 aassociate professor, department of radio-diagnosis and imaging blecturer, department of radio-diagnosis and imaging cresident, department of radio-diagnosis and imaging dkathmandu university school of medical sciences, dhulikhel hospital, kathmandu university hospital, dhulikhel, kavre, nepal. corresponding author: subindra karki e-mail: subindrakarki@gmail.com orcid: https://orcid.org/0000-0002-3910-4523_______________________________________________________ abstract: introduction: various anatomical variants are encountered in portal venous system which are quite important while undergoing hepatobiliary surgeries and percutaneous radiological interventions. contrast enhanced computed tomography (cect) of the abdomen is considered a better imaging modality to identify these variations. methods: a descriptive prospective study was conducted in 1000 individuals undergoing cect of abdomen. triple phase cect scan of the abdomen was done and the portal vein anatomy was reconstructed and analyzed. results: normal branching pattern of the portal vein was seen in 786 (78.6%) patients. variations were seen in rest of the 214 (21.40%) patients. the most common variant was trifurcation of the portal vein seen in 113 (11.3%) patients. right posterior portal vein as the first branch of main portal portal vein was found in 72 (7.2%) patients. right anterior portal vein arising from left portal vein was seen in 29 (2.9%). sixty nine of the 567 males had trifurcation accounting for 12.1% incidence of this variation amongst males. trifurcation was seen in 44 of the 433 females resulting in an incidence of 10.1%. forty-four (7.7%) males and 28 (6.4%) females had right posterior portal vein as the first branch of main portal vein. right anterior portal vein was noted to arise from the left portal vein in 20 (3.5%) males and nine (2.07%) females. conclusion: the most common variation in portal venous system was trifurcation of portal vein followed by right posterior as first branch and right anterior branch arising from left portal vein respectively. keywords: anatomical variants; computed tomography; portal vein original research articlehttps://doi.org/10.22502/jlmc.v9i2.430 subindra karki,a,d ram chandra paudel,b,d anupam bhandari,b,d arun phuyal,c,d mohit raj dahal c,d anatomical variants of portal vein branching in cect scan of abdomen: a descriptive study how to cite this article:how to cite this article: karki s, paudel rc, bhandari a, phuyal a, dahal mr. anatomical variants of portal vein branching in cect scan of abdomen: a descriptive study. journal of lumbini medical college. 2021;9(2):5 pages. doi: https://doi.org/10.22502/jlmc.v9i2.430. epub: october 4, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: the portal vein (pv) is formed by the confluence of the splenic and superior mesenteric veins, and drains directly into the liver, contributing to approximately 75% of its blood flow.[1,2] normally the main pv divides into right and left portal veins. [1] the left portal vein (lpv) is horizontal for a short distance before it turns cranially and branches, supplying couinaud hepatic segments i, ii, iii, and iv. the right portal vein (rpv) subdivides into anterior and posterior branches; the anterior one supplying segments v and viii, and the posterior branch supplying segments vi and vii.[1,3] the anatomy of pv and its branches can be assessed by different imaging modalities like ultrasonography (usg), contrast enhanced computed tomography (cect) and magnetic resonance imaging (mri) of abdomen. delineation of anatomy from usg can be limited owing to patient and performer’s factors and mri, because of the cost and time, is seldom used for the same. thus, cect of the abdomen is considered better among these options in the evaluation of the portal venous anatomy. j. lumbini. med. coll. vol 9, no 2, july-dec 2021 karki s, et al. anatomical variants of portal vein branching in cect scan of abdomen: a descriptive study jlmc.edu.np this study aimed to evaluate different anatomical variations of the portal vein and its branches. since various hepatic interventional procedures have significantly progressed over the past years, the meticulous knowledge of anatomy of the portal venous system is a must prior to performing these procedures. methods: this was a descriptive prospective study conducted in 1000 individuals of all ages undergoing cect of abdomen in the department of radiodiagnosis and imaging at dhulikhel hospital, kavre from january 2020 to january 2021. individuals with history of major upper abdominal surgery involving liver, pancreas, biliary tree, stomach and duodenum were excluded. similarly, those with known tumors in the upper abdomen involving liver, pancreas, biliary tree, stomach and duodenum were also not enrolled. ethical approval was granted by institutional review committee (approval no. 73/20). convenience sampling technique was used. informed consent was taken from each patient. the details about objectives and protocol of the study were explained to patients. a clinical data proforma was filled up. siemens 128 slice ct scanner was used. triple phase cect scan of the abdomen was done. a non-contrast scan was then performed initially to cover the abdomen. iohexol, an iodinated low osmolar contrast media containing 350mgi/100 ml of the solution was then administered via an intravenous cannula from the ante-cubital vein using a pressure injector. the rate of injection of the contrast media ranged between 3-5ml/sec and the amount to be administered was calculated based upon the weight of individuals (1-2 ml/kg body weight). ct scanning was then done in axial sections and images were acquired after contrast administration. the parameters used were hepatic arterial, portal venous and delayed phases with enhancement threshold set at 100 hounsfield unit (hu). additional image reformation was done in sagittal and coronal sections. maximum intensity projection (mip) image demonstrating the portal vein anatomy was reconstructed in coronal section. the portal venous anatomy and variants were recorded and analyzed. type 1 categorization was done when the main portal vein divided into lpv and rpv and rpv then divided into right anterior portal vein (rapv) and right posterior portal vein (rppv). main portal vein (mpv) trifurcating into lpv, rapv, and rppv was accepted as type 2. likewise, type 3 variant was defined as rpv arising as first branch of mpv and type 4 variant as rapv arising from lpv. all the data were compiled in the excel spreadsheet and statistical analysis was done using ibm statistical program for social science (spss) software version 20. results: out of 1000 patients enrolled into the study, 567 were males (56.7%) and 433 were females (43.3%). the mean age ± sd was 33.4 ± 2.17 years (range: 1-85 years). anatomical variations in the branching of the portal vein were studied in these patients and incidence was calculated in relation to gender. type i branching pattern of the portal vein was seen in 786 (78.6%) patients (figure 1). variations were seen in rest of the 214 (21.40%) patients. the most common variant was type ii which was observed amongst 113 (11.3%) patients (figure 2). seventy-two (7.2%) patients had type iii variation (figure 3) and twentynine (2.9%) patients had type iv variation (figure 4) (table 1). fig 1. axial ct scan showing normal branching pattern of portal vein. among 786 patients who had normal branching of the portal vein, 443 were males and 343 were females. normal branching pattern of the j. lumbini. med. coll. vol 9, no 2, july-dec 2021 karki s, et al. anatomical variants of portal vein branching in cect scan of abdomen: a descriptive study jlmc.edu.np portal vein was seen in 78.1% of the males and 79.2% females. sixty nine of the 567 males had trifurcation accounting for 12.1% incidence of this variation amongst males. trifurcation was seen in 44 of the 433 females resulting in an incidence of 10.1%. forty-four (7.7%) males and 28 (6.4%) females had right posterior portal vein as the first branch of main portal vein. right anterior portal vein was noted to arise from the left portal vein in 20 (3.5%) males and nine (2.07%) females (table 2). discussion: the portal vein is a major vascular structure that needs to be evaluated in all the abdominal ct scans performed. a thorough knowledge about the normal anatomy and spectrum of congenital variations of the portal venous system is essential for hepatobiliary surgeons and interventional radiologists in order to avoid major catastrophic events during the planned procedures. awareness of portal venous branching anatomy is important in planning liver surgery so as to ensure that portal perfusion to the future liver remnant is not compromised. it is also important in liver transplantation to enable appropriate graft selection so as to avoid complex anastomosis that might compromise the graft or the residual liver. it is also crucial while performing percutaneous interventional procedures.[1,4,5,6] fig 2. axial ct scan showing trifurcation of portal vein. fig 3. axial ct scan showing rppv as first branch of portal vein. table 1. various branching patterns of the portal vein (n=1000). type branching pattern frequency (%) i normal branching pattern 786 (78.60) ii trifurcation of portal vein 113 (11.30) iii right posterior portal vein as first branch of portal vein 72 (7.20) iv right anterior portal vein arising from left portal vein 29 (2.90) fig 4. coronal-oblique maximum intensity projection image showing corresponding right anterior portal vein arising from left portal vein. table 2. branching pattern of the portal vein in relation to sex (n=1000). type branching pattern males (n=567) females (n=433) frequency (%) frequency (%) i normal branching pattern 443 (78.1) 343 (79.2) ii trifurcation of portal vein 69 (12.1) 44 (10.1) iii right posterior portal vein as first branch of portal vein 44 (7.7) 28 (6.4) iv right anterior portal vein arising from left portal vein 20 (3.5) 9 (2.07) j. lumbini. med. coll. vol 9, no 2, july-dec 2021 karki s, et al. anatomical variants of portal vein branching in cect scan of abdomen: a descriptive study jlmc.edu.np the incidence of typical branching pattern of the main pv has been reported to be 65 to 80% in previous studies.[1,3,5] in the current study also, the normal branching pattern of portal vein was seen in 78.6% patients which is similar to those studies. the variations in portal vein morphology have been documented as 20–35% by many authors. [1,2,6,7] the most common patterns reported were trifurcation of the main portal vein (7.8–10.8%), right posterior segmental branch arising from the main portal vein (4.7–5.8%), and right anterior segmental branch arising from the left portal vein (2.9–4.3%).[4,9,10] we observed anatomical variations in 21.40%. however, we report a slightly higher incidence of trifurcation of the portal vein (11.3%), right posterior portal vein arising from the first branch of main portal vein (7.2%) and right anterior portal vein arising from the left portal vein (2.9%). our observations were different from another author which showed a common rapv– lpv trunk was almost 2.5 times more common than trifurcation.[11] conclusion: the most common variation in portal venous branching pattern was trifurcation of portal vein followed by right posterior as first branch and right anterior branch arising from left portal vein respectively. meticulous knowledge of the variations in portal venous anatomy is mandatory before graft procurement during liver transplantation, placement of transjugular intrahepatic portosystemic shunts, portal venous embolization, and localization and resection of hepatic tumors. acknowledgement mr. sitaram parajuli and other technical staff of the ct scan unit. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. references: 1. carneiro c, brito j, bilreiro c, barros m, bahia c, santiago i, et al. all about portal vein: a pictorial display to anatomy, variants and physiopathology. insights imaging. 2019;10(1):38. pmid: 30900187 doi: https:// doi.org/10.1186/s13244-019-0716-8 2. corness jag, mchugh k, roebuck dj, taylor am. the portal vein in children: radiological review of congenital anomalies and acquired abnormalities. pediatr radiol. 2006;36(2):8796. pmid: 16284764 doi: https://pubmed.ncbi. nlm.nih.gov/16284764/ 3. strasberg s. hepatic, biliary and pancreatic anatomy. in: garden jo, parks rw (eds). hepatobiliary and pancreatic surgery. 5th ed. uk: elsevier; 2013. p.17-38. 4. sureka b, patidar y, bansal k, rajesh s, agrawal n, arora a. portal vein variations in 1000 patients: surgical and radiological importance. british journal of radiology. 2015;88(1055):20150326. doi: https://doi.org/10.1259/bjr.20150326 5. lee wk, chang sd, duddalwar va, comin jm, perera w, lau wfe, et al. imaging assessment of congenital and acquired abnormalities of the portal venous system. radiographics. 2011;31(4):905-26. pmid: 21768231 doi: https://doi.org/10.1148/rg.314105104 6. dighe m, vaidya s. case report. duplication of the portal vein: a rare congenital anomaly. br j radiol. 2009;82(974):e32-4. pmid: 19168687 doi: https://doi.org/10.1259/bjr/81921288 7. guerra a, de gaetano am, infante a, mele c, marini mg, rinninella e, et al. imaging assessment of portal venous system: pictorial essay of normal anatomy, anatomic variants and congenital anomalies. eur rev med pharmacol sci. 2017;21(20):4477-4486. pmid: 29131270. 8. covey am, brody la, getrajdman gi, sofocleous ct, brown kt. incidence, patterns, and clinical relevance of variant portal vein anatomy. american journal of roentgenology. 2004;183(4):1055-64. doi: https://www. ajronline.org/doi/10.2214/ajr.183.4.1831055 9. atri m, bret pm, fraser-hill ma. intrahepatic portal venous variations: prevalence with j. lumbini. med. coll. vol 9, no 2, july-dec 2021 karki s, et al. anatomical variants of portal vein branching in cect scan of abdomen: a descriptive study jlmc.edu.np us. radiology. 1992;184(1):157-8. pmid: 1609075 doi: https://doi.org/10.1148/ radiology.184.1.1609075 10. fraser-hill ma, atri m, bret pm, aldis ae, illescas ff, herschorn sd. intrahepatic portal venous system: variations demonstrated with duplex and color doppler us. radiology. 1990;177(2):523-6. pmid: 2217795 doi: https://doi.org/10.1148/radiology.177.2.2217795 11. atasoy c, ozyürek e. prevalence and types of main and right portal vein branching variations on mdct. ajr am j roentgenol. 2006;187(3):67681. pmid: 16928929 doi: https://pubmed.ncbi. nlm.nih.gov/16928929/ j. lumbini. med. coll. vol 9, no 1, jan-june 2021 thapa as, et al. pre-operative hypoglycemia in patients presenting for surgery: a hospital based cross-sectional study. jlmc.edu.np ___________________________________________________________________________________ submitted: 04 june, 2020 accepted: 18 december, 2020 published: 16 march, 2021 aassistant professor, dept. of anaesthesiology and critical care bassociate professor, dept. of anaesthesiology and critical care credisent, dept. of anaesthesiology and critical care dcollege of medical sciences, bharatpur, chitwan, nepal. corresponding author: ajay singh thapa e-mail: ajaysinghthapa567@gmail.com orcid: https://orcid.org/0000-0003-3196-9925_______________________________________________________ abstract: introduction: peri-operative glycemic control is an important factor for post-operative recovery and is well protocoled for diabetic patients in every setup. it is not always so with non-diabetic patients. this study aimed to observe the pre-operative glucose level and prevalence of hypoglycemia in patients presenting for surgery and its association with the duration of nil per oral period (npo), age and intravenous fluids used in the pre-operative period. methods: a cross-sectional study was conducted in the department of anesthesiology in a nepalese medical college including all the patients posted for elective surgery over a period of three months. socio-demographic and clinical details of the participants were collected in the operating theatre. duration of npo period and intravenous fluid prescribed in the pre-operative fasting period were recorded. a glucose strip test was performed in all the participants. results: participants were found to have fasted for an unnecessarily longer duration (12.84±2.27 hours). the incidence of hypoglycemia in patients posted for elective surgery was very high (43.3%). ringer lactate and normal saline were equally prescribed (38.4%) and dextrose-normal saline was prescribed in the rest of the participants. gender and type of intravenous fluids were positively correlated. npo period was negatively correlated in overall participants. in hypoglycemic participants, we observed that lower glucose was influenced by pre-operative fluids, age and npo duration. conclusion: pre-operative use of glucose containing fluids during npo period is an important step to prevent hypoglycemia and related consequences. keywords: hypoglycemia; intravenous fluids; pre-operative original research articlehttps://doi.org/10.22502/jlmc.v9i1.373 ajay singh thapa,a,d rajesh kumar yadav,b,d rajan basnet,c,d bijay pradhan,c,d rosee maharjan,c,d samreta chaudhary c,d pre-operative hypoglycemia in patients presenting for surgery: a hospital based crosssectional study how to cite this article:how to cite this article: thapa as, yadav rk, basnet r, pradhan b, maharjan r, chaudhary s. pre-operative hypoglycemia in patients presenting for surgery: a hospital based cross-sectional study. journal of lumbini medical college. 2021;9(1):4pages. doi: https://doi.org/10.22502/jlmc. v9i1.373. epub: march 16, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: peri-operative glucose level is known to have a significant impact on the morbidity and outcome of patients after surgical procedure. hyperglycemia increases the chance of infection and wound healing time.[1] on the other hand, hypoglycemia results in increased sympathetic activities confounding the peri-operative complications.[2] peri-operative glucose level primarily depends on the period of fasting, age of the patients, amount and type of intravenous fluids used and the use of peri-operative medications such as steroids and certain antibiotics known to cause hyperglycemia.[3,4] peri-operative glucose metabolism is essential for complication free recovery from anesthesia and surgery. pre-operative hyperglycemia is known to increase peri-operative morbidity and prolong hospital stay. similarly, pre-operative hypoglycemia is known to induce catabolic response and adversely j. lumbini. med. coll. vol 9, no 1, jan-june 2021 thapa as, et al. pre-operative hypoglycemia in patients presenting for surgery: a hospital based cross-sectional study. jlmc.edu.np affect the recovery from surgery. recently, enhanced recovery from surgery program is advocating for peri-operative glucose containing fluids to avoid development of catabolic state and insulin resistance and thus reducing overall hospital stay.[5] this study aimed to find the peri-operative glucose level and prevalence of hypoglycemia in patients presenting for surgery and its association with the duration of nil per oral (npo) period, age and intravenous fluids used in the pre-operative period. methods: this cross-sectional observational study was conducted in the department of anesthesiology, college of medical sciences, bharatpur, chitwan, nepal. ethical approval was obtained from the institutional review committee prior to enrollment of the participants. since calculated minimum sample size was 272.13, we included 302 participants over a period of three months. all the patients posted for elective surgery during the study period were included in the study. patients who were diabetic were excluded. all the personal details were recorded. after shifting to the operating table, all the participants were questioned regarding the npo period and the duration was noted. intravenous fluid transfused during the pre-operative fasting period and prescription of preoperative steroids, if any, were also noted. blood glucose level was checked with glucose strip test in all the participants and noted. hypoglycemia was defined as blood glucose level less than 70 mg/dl and managed with intravenous dextrose. all the data were compiled in the excel spreadsheet and later statistical analysis was done using statistical package for social sciences (spsstm) software version 20. patient demography was analyzed using frequency and mean (+sd). pearson correlation test was used to find the correlation between age, duration of npo and glucose level whereas eta test was used to find the correlation between gender, types of fluids used preoperatively and glucose level. a p value <0.05 was considered statistically significant. results: a total of 302 participants were included in the study out of which 58.6% were male and 41.4% were female. the average age of the participants was 40.74±19.26 years. the average npo duration was 12.84±2.27 hours and the average glucose level observed was 89.09±41.38 mg/dl. the association between gender and pre-operative glucose level was not significant (table 1). three types of intravenous fluids were used out of which normal saline (ns) and ringer lactate (rl) were common. both the fluids were equally used in 38.4%, where as 23.2% received 5% dextrose in normal saline (dns). it was observed that there was positive correlation between age and pre-operative glucose level (r=0.63). the type of intravenous fluids preoperative was found to have moderate association with the pre-operative blood glucose level (table 2). the frequency of hypoglycemia (blood glucose level less than 70 mg/dl) was 131 (43.3%). among the hypoglycemic participants, 54.2% were males and the rest were females. the mean preoperative glucose level in hypoglycemic participants was 57.02±9.97 mg/dl. the average age of the patients with hypoglycemia was 40.72±19.18 years and had positive correlation with the pre-operative glucose level. this means, among the hypoglycemics the blood glucose level was higher in older participants (table 3). we observed insignificant association between gender and pre-operative glucose level in non diabetic participants. the npo duration table 1. association between gender and glucose level in overall participants (n=302). value nominal by interval eta gender dependent 0.632 (eta square = 0.39) glucose level dependent 0.047 table 2. association between ivf and glucose level in overall participants (n=302). value nominal by interval eta ivf dependent 0.578 (eta square= 0.32) glucose level dependent 0.056 j. lumbini. med. coll. vol 9, no 1, jan-june 2021 thapa as, et al. pre-operative hypoglycemia in patients presenting for surgery: a hospital based cross-sectional study. jlmc.edu.np was13.37±2.39 hours in the hypoglycemic group and was positively correlated with glucose level which means though hypoglycemic, blood glucose level was higher in patients with longer duration of nil per oral duration which may be due to metabolic compensation. among the hypoglycemic patients 37.4%, 41.2% and 21.4%t had received ns, rl and dns respectively in the pre-operative fasting period. it was observed that there was moderate association between ivf and pre-operative glucose level (table 4). discussion: pre-operative fasting induced hypoglycemia is very common. it is regarded as high as 23.3% of the population posted for surgery.[6] depending on the presence or absence of symptoms and glucose monitoring results, hypoglycemia may be classified as biochemical, symptomatic or both.[7] the severity of hypoglycemia is taken as one of the predictors of mortality in patients and it is more significant with diabetic patients.[8,9,10] symptoms of hypoglycemia are often masked during surgical procedures due to blunting by anesthetic agents while under general anesthesia.[11] the anesthesiologists often delay or infrequently monitor blood glucose levels due to added responsibilities or concurrent multiple tasks during surgical procedures.[12] poor communication during patient hand-over from ward and intensive care unit to operation theatre is the prime vulnerable periods for occurrence of hypoglycemia. hong m et al. observed that glucose level decreases with increase in fasting period in elderly patients posted for surgery.[13] similarly, shah m et al. observed that blood glucose level decreases with prolonged fasting period in pediatric patients. [14] in our study, we observed that glucose level increases with age though it was not statistically significant. according to roberts et al. male gender is an independent predictor for elevated fasting blood glucose level.[15] we observed insignificant association between gender and pre-operative glucose level in nondiabetic participants. unnecessary prolongation of pre-operative fasting was observed by pattajoshi et al.[5] we had almost similar observation. we observed that pre-operative fasting was unnecessary increased to 12.84±2.27 hours. we observed that npo period was negatively correlated with pre-operative glucose level in overall population i.e. blood glucose level decreases with increase in npo duration whereas in hypoglycemic participants it had positive correlation i.e. though hypoglycemic blood glucose was higher in patients with longer npo duration which may be due to metabolic compensation such as decrease in insulin secretion and hepatic and renal gluconeogenesis.[16] blood glucose level is higher in patients receiving hydroxyethyl starch (hes), blood transfusion and dextrose containing fluids as compared to non dextrose fluids.[5] in our study, we observed that three types of fluids were used. the commonly prescribed pre-operative fluids in the preoperative period were dns (21.4%), ns (37.4%) and rl (41.2%) in increasing order. we observed that pre-operative glucose level had moderate association with types of fluids prescribed during the fasting period. pattajoshi claimed that incidence of hypoglycemia is as 23.3%.[5] we observed the incidence to be 43.3% which was found to be influenced by pre-operative ivf, age and npo duration. table 3. correlation between age, npo duration and pre-operative blood glucose level in hypoglycemic population (n=131). age (years) npo duration (hours) glucose level (mg/dl) mean + sd 40.72+19.18 13.37+2.40 57.02+9.98 pearson correlation (r) 1 0.334 pearson correlation (r) 1 0.059 table 4. association between intravenous fluids and glucose in hypoglycemic participants. value nominal by interval eta ivf dependent 0.580 (eta square =0.33) glucose dependent 0.218 j. lumbini. med. coll. vol 9, no 1, jan-june 2021 thapa as, et al. pre-operative hypoglycemia in patients presenting for surgery: a hospital based cross-sectional study. jlmc.edu.np conclusion: though the result of our study in overall participants was different from the usual understanding that prolonged fasting increases the incidence of preoperative hypoglycemia which could be due to metabolic compensation, we conclude that use of pre-operative glucose containing fluids during the fasting period decreases the incidence of preoperative hypoglycemia to some extent, if not overall elimination.thus we suggest using pre-operative glucose containing fluids in nondiabetic patients during the fasting period. acknowledgment: we are thankful to all the participants and colleagues for the help and trust during the study. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available for the study. references: 1. takesue y, tsuchida t. strict glycemic control to prevent surgical site infections in gastroenterological surgery. ann gastroenterol surg. 2017;1(1):52-9. doi: https://dx.doi. org/10.1002/ags3.12006 2. amiel sa, gale e. physiological responses to hypoglycemia. counter regulation and cognitive function. diabetes care. 1993; 16 (suppl 3):4855. doi: https://doi.org/10.2337/diacare.16.3.48 3. ko gtc, wai hps, tang jsf. effects of age on plasma glucose levels in non-diabetic hong kong chinese. croat med j. 2006;47(5):709-13. pmid: 17042062 4. fathallah n, slim r, larif s, hmouda h, ben salem c. drug induced hyperglycemia and diabetes. drug saf. 2015;38(12):1153-68. doi: https://doi.org/10.1007/s40264-015-0339-z 5. duggan ew, carlson k, umpierrez ge. perioperative hyperglycemia management: an update. anesthesiology. 2017;126(3):547-560. doi: https://doi.org/10.1097/aln.0000000000001515 6. pattajoshi s, nerurkar aa, tendolkar ba. a cross sectional observational analysis of preoperative blood glucose levels in nondiabetic patients presenting for surgery. res inno in anesth. 2017;2(2):29-33. [link] 7. workgroup on hypoglycemia, american diabetes association. defining and reporting hypoglycemia in diabetes: a report from the american diabetes association workgroup on hypoglycemia. diabetes care. 2005;28:1245– 9. doi: https://doi.org/10.2337/diacare.28.5.1245 8. graham bb, keniston a, gajic o, trillo alvarez ca, medvedev s, douglas is. diabetes mellitus does not adversely affect outcomes from a critical illness. crit care med. 2010;38:16–24. doi: https://doi.org/10.1097/ccm.0b013e3181b9eaa5 9. krinsley js, grover a. severe hypoglycemia in critically ill patients: risk factors and outcomes. crit care med. 2007;35:2262– 7. doi: https://doi.org/10.1097/01. ccm.0000282073.98414.4b 10. hermanides j, bosman rj, vriesendorp tm, dotsch r, rosendaal fr, zandstra df, et al. hypoglycemia is associated with intensive care unit mortality. crit care med. 2010;38:1430– 4. doi: https://doi.org/10.1097/ ccm.0b013e3181de562c 11. leese gp, savage mw, chattington pd, vora jp. the diabetic patient with hypertension. postgrad med j. 1996;72:263–8. doi: https://doi. org/10.1136/pgmj.72.847.263 12. rice mj, pitkin ad, coursin db. review article: glucose measurement in the operating room: more complicated than it seems. anesth analg. 2010;110:1056–65. doi: https://doi. org/10.1213/ane.0b013e3181cc07de 13. hong m, yon h. influence of pre-operative fasting time in blood glucose in older patients. k korean acad nurs. 2011;41(2):157-64. doi: https://doi.org/10.4040/jkan.2011.41.2.157. 14. shah m, mazoorullah haq tu, akhtar t. the effect of preanesthetic fasting on blood glucose in children undergoing surgery. j pak med assoc. 1990;40(10)243-5). pmid: 2123262 15. d roberts, t meakem, c dalton, d haverstick, c lynch iii. prevalence of hyperglycemia in a pre-surgical population. the internet journal of anesthesiology. 2006;12(1). [link] 16. sprague je, arbeláez am. glucose counterregulatory responses to hypoglycemia. pediatr endocrinol rev. 2011; 9(1): 463–475. pmid: 22783644 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 ___________________________________________________________________________________ submitted: 24 may, 2020 accepted: 28 may, 2020 published: 30 may, 2020 aconsultant gynecologic oncologist, bkathmandu cancer center, nepal korea friendship municipality hospital, nepal. corresponding author: suresh kayastha email: drsureshkayastha@gmail.com orcid: https://orcid.org/0000-0002-6257-7476 how to cite this article: kayastha s. gynecological oncology surgery during covid-19 pandemic: what we should know. journal of lumbini medical college.2020;8(1):3 pages. doi: https://doi.org/10.22502/jlmc. v8i1.357 epub: 2020 may 30._______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v8i1.357 suresh kayastha a,b gynecological oncology surgery during covid-19 pandemic: what we should know severe acute respiratory syndrome coronavirus-2 (sars-cov-2) that causes corona virus disease -19 (covid-19) is a novel virus and hence humans do not have any prior immunity to it.[1] every human being is susceptible to this viral infection and rapid spread worldwide made who declare it as a global pandemic.[2] cancer patients are even more vulnerable not only because they are immunocompromised by the disease process itself, but also due to potential effect of chemotherapy, radiotherapy along with substantial effect on their timing of treatment. patients older than 65 years, and those with preexisting co-morbidities are considered more at risk.[3,4,5] considering the increased chances of intensive care unit admission, need of mechanical ventilation and possible mortality, all cancer patients should be educated about preventive measures, personal protection, social distancing and isolation. [6] another possible impact of covid-19 could be delays in initial evaluation, diagnosis and initiation of actual treatment which are independent risk factors for cancer related mortality.[6] this is due to limited services provided at the health care facilities, lockdown effects, fear of being infected and economic crisis. implementation of preoperative screening for covid-19 before initiating treatment for gynecologic cancer is still a debate. most of the patients are asymptomatic and available polymerase chain reaction (pcr) testing from naso-pharyngeal swab has false negative rate of around 30%.[7] in this pandemic, all cases can be considered positive unless proven otherwise and every possible precaution and protective measure should be taken in the operation theatre to protect the health care workers as well as other patients. pcr should be done at least a week prior to the surgery.[7] as false negative rate is high, checking for symptoms like fever, cough, tiredness, difficulty in breathing, sore throats or flu-like symptoms should be done at the time of admission and preventive and full protective measures should also be taken even if pcr is negative. another recommendation for the pcr negative cases is to perform low-dose chest computed tomography (ldct) scan 48 hours before surgery for characteristic covid-19 lung changes. [7] there are many guidelines with alternative management options to help clinicians decide the management of gynecologic cancer during this pandemic.[8,9,10] european society for medical oncology (esmo) has prioritized patients as high priority, medium priority and low priority for outpatient visits, imaging, surgical oncology, medical oncology and for radiation oncology.[3,4,5] this has been formulated considering emergency conditions associated with cancer patients, clinical or radiological stage, histological variant and grade, ongoing or scheduled chemotherapy or radiation, and patients on trials and palliative therapy. the details are made available in esmo website for different gynecologic malignancies like ovarian, endometrial and cervical cancer.[3,4,5] kayastha s. gynecological oncology surgery during covid-19 pandemic: what we should know jlmc.edu.npj. lumbini. med. coll. vol 8, no 1, jan-jun 2020 patients with gynecologic malignancy should be triaged for observation or intervention. basic principle is to prioritize intervention for oncologic emergencies and initiate treatment for aggressive or advanced stage disease and reasonably postpone intervention for benign or pre-invasive or early stage low grade malignancy after informed consent.[6] a simple categorization can be category 1 or low acuity surgery that are not life threatening and can be postponed for few weeks or months.[6] this includes management of pre-invasive lesion of cervix or endometrium. category 2 or intermediate acuity surgery includes those conditions that are not life threatening but with potential future morbidity or mortality.[6] low risk cancer like early cervical cancer and well differentiated endometrial cancers with co-morbidities are some of the examples for which surgery can be postponed for reasonable period after informed decision making and in case surgery is done, they should be considered for early discharge post operatively.[6] category 3 or high acuity surgery includes life threatening conditions like bowel obstruction, highly symptomatic patients, type ii endometrial cancers, ovarian cancer, interval debulking surgery after 3–4 cycles of chemotherapy, uterine sarcoma, those in need of emergency procedures, excision of malignant recurrences and gestational trophoblastic neoplasm.[6] surgery should not be postponed if covid-19 census is low and resources permit. only life saving procedure should be done when there is high burden of covid-19 cases and with limited resource supply and rest should be closely observed. selected cases should be subjected to neo-adjuvant therapy after informed consent.[6] when surgery is planned, laparoscopic procedures are preferably avoided.[6] after surgery also, enhance recovery after surgery (eras) protocol may be implemented for rapid recovery, early discharge and to decrease chance of being infected.[11] the key components of eras protocol in the preoperative setting is to avoid mechanical bowel preparation, provide light meal up until six hours, and consume clear fluids including oral carbohydrate drinks up until two hours before initiation of anesthesia and encourage use of premedications (acetaminophen, non-steroidal antiinflammatory drugs, anti-emetics). similarly, intraoperative measures include maintenance of normothermia and euvolemia, avoidance of surgical drains and nasogastric tubes and infiltration of wound with local anesthetic agents. post-operative measures are to prevent nausea and vomiting using ≥2 antiemetics (multimodal approach), early introduction of solid diet post-operatively (day 0–1), multimodal narcotic-sparing post-operative analgesia (use of scheduled non-narcotic medications with oral narcotic medications only as needed), peripheral lock intravenous when patient has 600 ml oral intake, remove urinary catheter on post-operative day one in the absence of contraindications and active mobilization.[11] telemedicine is a useful tool for followup of patients.[7] but it is limited by the inability to perform physical examination. considering the covid-19 pandemic, remote consultation should be preferred rather than face to face visits and patient should be called for evaluation based on reported symptoms.[7] in conclusion, every case of gynecologic malignancies needs to be considered as covid19positive cases and adequate precautions should be taken. they should be triaged for immediate intervention or reasonably rescheduled for treatment after informed consent based on their clinical profile. conflict of interest: the author declares that no competing interest exists. funding: no funds were available for the study. references: 1. biswas a, bhattacharjee u, chakrabarti ak, tewari dn, banu h, dutta s. emergence of novel coronavirus and covid-19: whether to stay or die out? crit rev microbiol. 2020;46(2):182193. pmid: 32282268 doi: https://doi.org.10.1 080/1040841x.2020.1739001 2. world health organization. who announces covid-19 outbreak a pandemic. 2020 mar 12. available from: http://www.euro.who.int/en/ health-topics/health-emergencies/coronaviruscovid-19/news/news/2020/3/who-announcescovid-19-outbreak-a-pandemic 3. esmo guidelines, cancer patient management during the covid-19 pandemic, esmo management and treatment adapted recommendations in the covid-19 era: endometrial cancer. available from: https:// www.esmo.org/guidelines/cancer-patientmanagement-during-the-covid-19-pandemic/ gynaecological-malignancies-endometrialcancer-in-the-covid-19-era. 4. esmo guidelines, cancer patient management during the covid-19 pandemic, esmo management and treatment adapted recommendations in the covid-19 era: cervical cancer. available from: https://www.esmo. org/guidelines/cancer-patient-managementduring-the-covid-19-pandemic/gynaecologicalmalignancies-cervical-cancer-in-the-covid-19era 5. esmo guidelines, cancer patient management during the covid-19 pandemic, esmo management and treatment adapted recommendations in the covid-19 era: ovarian cancer. available from: https://www.esmo. org/guidelines/cancer-patient-managementduring-the-covid-19-pandemic/gynaecologicalmalignancies-epithelial-ovarian-cancer-in-thecovid-19-era. 6. bhatla n, singhal s. the covid-19 pandemic and implications for gynaecologic cancer care. indian j gynecol oncolog. 2020;18(2):48. doi: https://doi.org/10.1007/s40944-020-00395-7 7. lavoué v, akladios c, gladieff l, classe jm, lécuru f, collinet p. onco-gynecologic surgery in the covid-19 era: risks and precautions-a position paper from francogyn, scgp, sfco, and sfog. j gynecol obstet hum reprod. 2020;101787 [epub ahead of print]. pmid: 32407899 doi: https://doi.org/10.1016/j. jogoh.2020.101787 8. ramirez pt, chiva l, eriksson agz, frumovitz m, fagotti a, martin ag,et al.covid-19 global pandemic: options for management of gynecologic cancers. international journal of gynecologic cancer. 2020; [epub ahead of print]. doi: https://doi.org/10.1136/ijgc-2020001419 9. british gynecological cancer society. bgcs framework for care of patients with gynaecological cancer during the covid-19 pandemic. available from: https://www.bgcs. org.uk/wp-content/uploads/2020/03/bgcscovid-guidance-v1.-22.03.2020.pdf 10. society of gynecologic oncology. gynecologic oncology considerations during the covid-19 pandemic. available from: https://www.sgo. org/clinical-practice/management/covid-19resources-for-health-care-practitioners/gyn-oncconsiderations-during-covid-19/ 11. thomakos n, pandraklakis a, bisch sp, rodolakis a, nelson g, et al. eras protocols in gynecologic oncology during covid-19 pandemic. international journal of gynecologic cancer. 2020; [epub ahead pf print]. doi: https:// doi.org/10.1136/ijgc-2020-001439 j. lumbini. med. coll. vol 8, no 1, jan-jun 2020 jlmc.edu.np kayastha s. gynecological oncology surgery during covid-19 pandemic: what we should know j. lumbini. med. coll. vol 8, no 2, july-dec 2020 kc s, et al. nairobi eye: a clinico-epidemiological study from a tertiary care center of central nepal. 190 jlmc.edu.np ___________________________________________________________________________________ submitted: 02 june, 2020 accepted: 02 august, 2020 published: 16 august, 2020 a lecturer, department of dermatology, b resident, department of dermatology, c professor, department of dermatology, d dhulikhel hospital kathmandu university hospital, nepal. corresponding author: sekhar kc e-mail: drshekharkc@gmail.com orcid: https://orcid.org/0000-0002-7891-7252_______________________________________________________ abstract: introduction: periocular paederus dermatitis (nairobi eye) is characterized by erythematous vesiculobullous linear plaque with stinging sensation. it commonly occurs during rainy season. it has been described in people living near agricultural fields due to the potential toxin pederin. this study aims to evaluate the demographic profile and clinical presentation of patients with periocular paederus dermatitis in a tertiary care center. methods: this was a descriptive, cross-sectional study evaluating patients attending dermatology and/or ophthalmology department with features consistent with paederus dermatitis involving periocular area from june to august, 2019. relevant demographic and clinical data were obtained; clinical photographs were taken and histopathology performed among selected patients. results: a total of 24 (14.8%) patients had features of nairobi eye among 162 patients of paederus dermatitis. majority of the patients were males (1.4:1) with mean age 29.08±13.38 years. the peak time of presentation was the first week of july (37.5%). mean time period between onset of symptoms and presentation was 3.41±2.01 days. the lesions were unilateral in all cases, with predominant involvement of the right eye (62%). burning sensation (80%) and itching (60%) were the predominant symptoms while conjunctival hyperemia (41.6%), seropurulent discharge (20.8%) and chemosis (16.6%) were the ocular findings. most of the patients (n=17, 70.8%) noticed the lesion while waking up in the morning. conclusion: the finding of the present study has shown that nairobi eye is a common presentation during rainy season. periocular findings with significant intraocular signs were documented to be presenting features among patients with periocular paederus dermatitis. keywords: dermatology, nairobi eye, paederus dermatitis, pederin original research articlehttps://doi.org/10.22502/jlmc.v8i2.370 shekhar kc,a,d aditi mishra,a,d dhiraj kc,b,d dharmendra karn c,d nairobi eye: a clinico-epidemiological study from a tertiary care center of central nepal how to cite this article:how to cite this article: kc s, mishra a, kc d, karn d. nairobi eye: a clinico-kc s, mishra a, kc d, karn d. nairobi eye: a clinicoepidemiological study from a tertiary care center of central nepal. epidemiological study from a tertiary care center of central nepal. journal of lumbini medical college. 2020;8(2):190-194. doi: journal of lumbini medical college. 2020;8(2):190-194. doi: https://doi.org/10.22502/jlmc.v8i2.370. epub: 2020 august 16. epub: 2020 august 16. introduction paederus dermatitis (pd),also known as “rove beetle dermatitis”, “dermatitis linearis” or “whiplash dermatitis” is an acute irritant contact dermatitis to a toxin called pederin found in the insects of family paederus.[1,2] it presents with linear erythematous, vesiculo-bullous lesions involving the exposed areas with stinging or burning sensation.[3] one of its common presentations is periorbital dermatitis or related ocular findings; also known as “nairobi eye”.[4] there are more than 600 species of paederus beetle worldwide.[5] these insects commonly live in agricultural fields and grow in wet rotting leaves so that its population increases more during rainy and harvesting seasons. they are attracted to artificial lights which bring them to household.[6,7] humans are exposed to toxin pederin when beetle are crushed or smeared across the skin.[8] secondary lesions on eyes are usually produced by the individual touching these areas after crushing the insect.[5,9] pd involving periorbital region (nairobi licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 kc s, et al. nairobi eye: a clinico-epidemiological study from a tertiary care center of central nepal. 191 jlmc.edu.np eye) is fairly common in subtropical region like ours. there are limited data regarding periocular-pd or its clinical patterns from nepal. the objective of this study was to evaluate the demographic profile and various clinical presentations of pd involving the periocular region. methods: this was a descriptive, cross-sectional study involving the patients presenting with clinical findings suggestive of periorbital pd attending the department of dermatology and/or ophthalmology of dhulikhel hospital kathmandu university hospital, from june to august 2019. a total of 162 patients with clinical features of pd including 24 patients of periocular pd was included in the study using purposive sampling method. patients with chronic history of allergy/atopic eczema with periocular involvement were excluded from the study. after approval from the institutional review board (irb: 43/19) and with informed consent from patients or their guardian, demographic data were recorded. detailed cutaneous and ophthalmological examinations were done and clinical photographs were documented. furthermore, selected cases of pd providing consent for biopsy were subjected to biopsy from trunk area (extraocular pd lesions) and histopathological evaluation was performed for academic interest. for all statistical analyses, the statistical package for social sciences (spsstm) version 20.0 statistical software package (spss inc, chicago, il, usa) was used. results: during the study period, a total of 162 patients presented with clinical features suggestive of pd. a total of 24 (14.81%) patients clinically diagnosed with pd had periocular features. regarding periocular pd, majority of patients were male (1.4:1). the age range was 12-59 years with mean age of presentation 29.08±13.38 years (figure 1). most of the patients were students (42%) followed by farmers (25%) and servicemen (17%). the peak time of presentation between the time period of june to august was the first week of july (37.5%). the mean time period between onset of symptoms and presentation was 3.41±2.01 days (range: 1-7 days). seventeen patients (70.8%) noticed the lesion involving periocular area while waking up in the morning (figure 2). figure 1: age distribution of patients with periocular paederus dermatitis. figure 2: time of noticing skin lesions. in the present study, lesions of periocular pd were unilateral in all cases, predominantly involving the right eye (62%). burning sensation (83.3%), itching (58.3%) and foreign body sensation in eye (33.3%) were the predominant symptoms (figure3). figure 3: frequency of symptoms of periocular paederus dermatitis (multiple response). common periocular examination findings were linear erythematous plaques with eyelid swelling (66%), vesicles (50%) and pustules (41.6%) (figure-4). table 1 represents the variety of periocular clinical findings. on intraocular examination, ten patients (41.6%) had conjunctival j. lumbini. med. coll. vol 8, no 2, july-dec 2020 kc s, et al. nairobi eye: a clinico-epidemiological study from a tertiary care center of central nepal. 192 jlmc.edu.np hyperemia, five (20.8%) had discharge and four (16.6%) had conjunctival chemosis (table 2). a total of 20 (83.33%) patients had significant intraocular signs. figure 4: clinical images of patients with nairobi eye, showing linear erythematous papulovesicular plaques. table 1. periocular clinical features and their frequency (n=24) (multiple response). periocular clinical features frequency (%) erythema 22(91.6%) lid swelling 16(66%) vesicles 12(50%) crusts 11(45.8%) pustules 10(41.6%) skin erosion 8(33.3%) matting of eye-lashes 6(25%) table 2.intraocular findings and their frequency (n=24). intraocular findings frequency (%) conjunctival hyperemia 10 (41.6%) discharge 5 (20.8%) conjunctival chemosis 4 (16.6%) corneal epithelial defect 1 (4.1%) anterior chamber reaction 0 (0%) biopsy was performed from a clinical lesion of pd from the interscapular area which showed non-specific findings of spongiosis, foci of vacuolar degeneration of basal layer, exocytosis of neutrophils in epidermis with dense perivascular neutrophilic and lymphocytic infiltrate with inflammation in the interstitium (figure 5). species identification of the beetle could not be done. discussion: the clinical presentation of pd usually depends on the area of residence as proximity of nearby farming areas. it also depends on the health care seeking behavior of the patients. it can affect population of any age group. the present study has shown slight male predominance. similar to the study by prasher p et al., all of the cases in this study presented during the monsoon season, during which the beetle gets dispersed from agricultural fields. [8]the beetles are then attracted by the fluorescent light inside the houses and patients wake up at night with unexplained lesion when the beetles are crushed reflexly during the sleep or position change as they come in contact with its toxic hemolymph. figure 5: histopathological images showing orthokeratotis, mild spongiosis, follicular plugging, foci of vacuolar degeneration of basal layer, exocytosis of neutrophil in epidermis with dense perivascular neutrophilicand lymphocytic infiltrate with inflammation in the interstitium (hematoxylin and eosin staining; figure 5a: 10x magnification, figure 5b: 40x magnification). j. lumbini. med. coll. vol 8, no 2, july-dec 2020 kc s, et al. nairobi eye: a clinico-epidemiological study from a tertiary care center of central nepal. 193 jlmc.edu.np [10] moisture during rainy season remains a key factor for the survival of the beetle and poses significant threat to farm related occupations.[11] possibly for this reason, 71% of the patients in the present study noticed the periocular findings during the morning time. for this reason it is also known with eponymous names like “wake and see disease”, “rove beetle blistering” and “night burn”.[2,10] characteristic clinical manifestation is linear erythematous plaque with overlying papulovesicular eruptions associated with itching and burning sensation frequently involving the exposed part of the body.[12,13,14] most of the patients in the current study presented with similar findings involving the periorbital area. as periorbital area is a common exposed part during sleep and has multiple rugosities, it is a common area for deposition of the toxin, pederin.[8] in a case report from nepal, one of the authors deliberately rubbed the paederus beetle into his forearm and observed series of changes ranging from erythematous papule with slight itching after 12 hours later progressing to form vesicle on the third day and subsequently pustule on the fourth day.[14] concomitant similar lesions on other body parts, linear vesicles containing pus or affected family members of same duration could support the diagnosis of pd.[15] ocular involvement in nairobi eye occurs due to transfer of toxin pederin to eyes and may mimic preseptal cellulitis.[16] it commonly causes keratoconjunctivitis with unilateral involvement and presents frequently with redness, eyelid swelling, discharge, foreign body sensation and watering. [8,16] the toxin pederin cannot penetrate cornea and conjunctiva hence the damage is limited to these structures only.[12] the most frequent findings in this study were conjunctival hyperemia, eyelid swelling and discharge which were consistent with the findings of study by prasher p et al.[8] the diagnosis of nairobi eye is straightforward due to its typical presentation. however in some cases it may be confused with various other dermatological conditions like herpes zoster and simplex, phytophotodermatitis, impetigo, millipede dermatitis, dermatitis artefacta, preseptal cellulitis or infective conjunctivitis.[5,9,12] histopathology is performed less frequently due to typical clinical presentation and involvement of site of cosmetic concern but in the cases of diagnostic confusion, it can aid in the diagnosis. typically described histopathological findings include spongiosis with neutrophilic infiltrate progressing to confluent necrosis of epidermis and dermal perivascular infiltrates consisting mainly mononuclear cells.[9,12] a single center study for a limited period of time are possible limitations of this study. further, observer bias could have been a confounding factor. conclusion: periocular findings were documented to be a significant presenting feature among patients with paederus dermatitis. significant intraocular findings were also documented among this subset of patients. complications and improper management may ultimately lead to blindness. thus awareness among health care professionals especially ophthalmologists and dermatologists may lead to timely diagnosis, screening of complications and effective management. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available for the study. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 kc s, et al. nairobi eye: a clinico-epidemiological study from a tertiary care center of central nepal. 194 jlmc.edu.np references: 1. karthikeyan k, kumar a. paederus dermatitis. indian j dermatol venereol leprol. 2017;83(4):424-431. doi: https://doi. org/10.4103/0378-6323.198441. pmid: 28584222. 2. narasimhalu cr, murali a, kannan r, srinivasan n. blister beetle dermatitis. j indian med assoc. 2010;108(11):781-2. pmid: 21510580. 3. fakoorziba mr, eghbal f, azizi k, moemenbellah-fard md. treatment outcome of paederus dermatitis due to rove beetles (coleoptera: staphylinidae) on guinea pigs. trop biomed. 2011;28(2):418-24. pmid: 22041764. 4. mbonile l. acute haemorrhagic conjunctivitis epidemics and outbreaks of paederus spp. keratoconjunctivitis (‘nairobi red eyes’) and dermatitis. s afr med j. 2011;101(8):541-3. pmid: 21920128. 5. beaulieu ba, irish sr. literature review of the causes, treatment, and prevention of dermatitis linearis. j travel med. 2016;23(4):taw032. doi: https://doi.org/10.1093/jtm/taw032. 6. schunkert em, aschoff ns, grimmer f, wiemann c, zillikens d. paederus dermatitis touched by champion flies three clinical manifestations of pederin toxin-inflicted dermatitis. int j dermatol. 2018;57(8):989-991. doi: https://doi.org/10.1111/ijd.13968. pmid: 29603192. 7. maryam s, fadzly n, zuharah wf. the effects of light and height of building in attracting paederusfuscipes curtis to disperse towards human residential areas. trop life sci res. 2016;27(supp1):95-101. doi: https://doi. org/10.21315/tlsr2016.27.3.13. pmid: 27965746. 8. prasher p, kaur m, singh s, kaur h, bala m, sachdeva s. ophthalmic manifestations of paederus dermatitis. int ophthalmol. 2017;37(4):885‐891. doi: https://doi.org/10.1007/ s10792-016-0352-y. pmid: 27628585. 9. srihari s, kombettu ap, rudrappa kg, betkerur j. paederus dermatitis: a case series. indian dermatol online j. 2017;8(5):361-364. doi: https://doi.org/10.4103/idoj.idoj_238_16. pmid: 28979873. 10. bong lj, neoh kb, jaal z, lee cy. life table of paederus fuscipes (coleoptera: staphylinidae). j med entomol. 2012;49(3):451-60. doi: https:// doi.org/10.1603/me11163. pmid: 22679850. 11. uzunoğlu e, oguz id, kir b, akdemir c. clinical and epidemiological features of paederus dermatitis among nut farm workers in turkey. am j trop med hyg. 2017;96(2):483487. doi: https://doi.org/10.4269/ajtmh.16-0582. pmid: 27879459. pmcid: pmc5303057. 12. assaf m, nofal e, nofal a, assar o, azmy a. paederus dermatitis in egypt: a clinicopathological and ultrastructural study. j eur acad dermatol venereol. 2010;24(10):1197201. doi: https://doi.org/10.1111/j.14683083.2010.03621.x. pmid: 20236196. 13. cressey bd, paniz-mondolfi ae, rodríguezmorales aj, ayala jm, de ascenção da silva aa. dermatitis linearis: vesicatingdermatosis caused by paederus species (coleoptera: staphylinidae). case series and review. wilderness environ med. 2013;24(2):124-31. doi: https://doi.org/10.1016/j. wem.2012.11.005. pmid: 23352312. 14. panta yr, poudyal y. a case report of a selfreproduced case of paederus dermatitis. journal of universal college of medical sciences. 2013;1(4):48-52. doi: https://doi.org/10.3126/ jucms.v1i4.9575. 15. canan h, altan-yaycioglu r, durdu m. periocularpaederus dermatitis mimicking preseptal cellulitis. can j ophthalmol. 2013;48(2):121-5. doi: https://doi.org/10.1016/j. jcjo.2012.10.004. pmid: 23561606. 16. verma s, gupta s. ocular manifestations due to econda (paederussabaeus). med j armed forces india. 2012;68(3):245-8. doi: https:// doi.org/10.1016/j.mjafi.2011.11.006. pmid: 24532878. original research article jlmc.edu.np —–————————————————————————————————————————— abstract: background: in most children proximal humeral fractures are treated non-operatively with generally good results. the aim of the study was to evaluate the clinical outcome of closed/open reduction in children with severely displaced proximal humeral fractures. materials and methods: the charts of 15 patients (8 girls and 7 boys; mean age: 9.4 years) with proximal humeral fractures who were managed at our institution were reviewed from october 2011 to december 2013. results: there were 7 metaphyseal fractures and 8 physeal injuries which were angulated according to neer-horowitz score as grade ii (n=2), grade iii(n=4) and grade iv(n=9). associated lesions comprised open fracture with head trauma in a 2 year old female child which was operated on primarily and the 14 others by secondary intention. all patients were treated surgically with either closed (n = 5) or open (n=10) reduction and internal fixation with kirschner wire or titanium elastic nails (tens). they were assessed for clinical and radiological healing at a mean follow up of 1.25 years ranging from 0.5 to 2.0 years. conclusion: surgical option is indicated for severely displaced and unstable fractures in older children and adolescents. in addition to the periosteum , long head of the biceps, deltoid muscle, and bone fragments in combination can prevent fracture reduction. key words: proximal humerus fracture, children, open reduction, operative. —–————————————————————————————————————————— 71j. lumbini. med. coll. vol 1, issue 2, july-dec 2013 ___________________________________________________________________________________ a lecturer, b associate professor, c professor and head, d department of orthopaedic surgery & traumatology, lumbini medical college teaching hospital(lmcth), palpa, nepal. corresponding author: dr. ruban raj joshi, e-mail: dr_rubanjoshi@yahoo.com how to cite: joshi rr, narang s, sundararaj gd. fractures of the proximal humerus in children and adolescents. j lumbini med coll, 2013;1(2):71-75. doi: ___________________________________________________________________________________ joshi rra,d, narang sb,d, sundararaj gdc,d fractures of the proximal humerus in children and adolescents fact, approximately 80% of the longitudinal growth of the humerus comes from the proximal humeral physis.4 the concern for disruption of the bone growth and remodelling leads surgeons to choose non-operative treatment regardless of the degree of displacement, angulation, rotation or translation. however, immobilization by a cast is lengthy, uncomfortable and hard for children to tolerate. the residual deformities after non-operative treatment, such as upper limb length discrepancy, humerus varus or humerus valgus, can lead to cosmetic problems due to the decreasing ability of remodelling in older children.5 therefore, some surgeons in recent years have recommended closed or open reduction and internal fixation for proximal humerus fractures in children, especially in teenagers.6,7 introduction proximal humeral fractures account for only 1% of all fractures in children and 3 to 6% of all epiphyseal injuries.1 the majority of proximal humeral fractures are either undisplaced or minimally displaced (neer horowitz grade i–ii) and can be managed non-operatively with a satisfactory outcome.2,3 however, in cases of severe humeral fractures with significant bone displacement (neerhorowitz grade iii–iv), especially in teenagers, non-operative treatment is controversial. an important concern of surgeons while dealing with paediatric proximal humeral fracturesis the growth of the bone and the resulting remodelling potential. in fig 1: sex distribution j. lumbini. med. coll. vol 1, issue 2, july-dec 2013 jlmc.edu.np joshi rr et. al. fractures of the proximal humerus in children and adolescents. 72 the methods of internal fracture fixation include percutaneous k-wires, staples, screws or plates.8–10 however, complications such as pin tract infection, pin migration, osteomyelitis and loss of reduction have been reported using these modes of fracture fixation.8-11 methods: this was a retrospective study of patients treated for proximal humeral fractures at the department of orthopedic surgery, lumbini medical college and teaching hospital, palpa, from october 2011 to december 2013. there were 15 patients, 8 girls and 7 boys (fig 1); their mean age was 9.4 years. all patients were skeletally immature as defined by open proximal humeral growth plates on the injured side at the time of injury based on plain radiographs. the most common cause was tumbling during play or sports, followed by traffic accidents. none of the fractures was pathological. there were no associated neurovascular injuries in the arms there were 7 metaphyseal fractures and 8 epiphyseal fractures (two cases of type i and six cases of type ii according to the salter-harris classification) (fig 2 & 3). according to neer-horowitz classification, there were two cases of type 2, four were type 3 and nine were type 4 (fig 4). there was a 2 years girl (fig 8) with an open proximal humerus fracture (gustilo type iiia) due to fall from height and was accompanied by head injury. indications for surgery in all the patients were irreducibility in nine cases and re-displacement in six. all the children were treated with either closed or open reduction with k wires or tens for severely displaced proximal humeral fractures. open reduction via deltopectoral approach & internal fixation with k wires was required in nine cases & one case (fig 8; 9a,b) with an open fracture(gustilo iiia) was operated emergently with debridement & k wire fixation. the remaining three patient had closed reduction internal fixation with k wires. two patients were managed by closed reduction and tens were inserted by retrograde route (fig 11). outcome assessment: we undertook a retrospective review to evaluate outcomes including, clinical results, complications related to treatment and radiological assessments. patients were assessed clinically and radiographically at 6 weeks. 3 months, 6 months and annually and were examined for fracture healing, angulation at the fracture site, premature closure of the growth plate and shortening of the humerus. radiological evaluations were carried out using anteriorposterior and lateral views of the humerus we adjudged the result excellent if shoulder function was similar to the normal side, good if the function was normal with radiologic imperfections and fair when both were abnormal. the potential complications related to treatment include neurovascular injury, fig 2: type of fxs (mf: metaphyseal fracture; pf: physeal fractures) fig 3: salter harris type fig 4: neer horowitz grade fig 5: clinical picture of 11 years old boy with left proximal humerus fracture j. lumbini. med. coll. vol 1, issue 2, july-dec 2013 joshi rr et. al. fractures of the proximal humerus in children and adolescents. jlmc.edu.np73 deep infection, pin tract infection, pin migration, loss of reduction and skin irritation. the evaluation of the clinical outcomes was both objective and subjective. results : patient presented to us at mean of 2 days following injury & surgery was carried out at a mean of 4 days after their initial injury. a total of 5 fractures were reduced by closed reduction, while 10 patients underwent open reduction (table 2), including one case with an open fractures (fig 8) ; in seven cases it was found that the fracture site was interposed with periosteum, and in the other two cases the fracture site was interposed with the long head of the biceps & bone fragment. k-wire fixation was most commonly used (85.7%), followed by retrograde elastic stable intramedullary nailing (14.28 %)(table 1). the surgical approach utilized included a formal delto-pectoral approach in the majority of cases, in three cases, an oblique incision was made over the metaphysis anterolaterally in order to obtain access to an interposed bony fragment. postoperatively, all patients who were treated with k wire fixation were immobilised using a u splint until radiological union, at which time pins were removed. the follow up period averaged 1.25 years (range = 0.5 to 2.0 years). radiological healing duration averaged 34 days (range = 28 40 days). at follow up, excellent and good results (table 3) were achieved in all the patients and had non-painful shoulder range of motion and normal rotator cuff strength (comparable to the opposite side) and returned to activities at a mean of 2.3. months from the time of the surgery. implant removal was performed after a duration of 6 to 10 weeks for k wires and after 6 months for tens fixation. one girl developed marked keloids and two patients had minor valgus deformity with of no clinical significance. neither physeal arrest nor implants n percent k wires 13 86.7 esin 2 13.3 total 15 100.0 table 1: type of implants treatment n percent crif 5 33.3 orif 10 66.7 total 15 100.0 table 2: treatment (crif: closed reduction internal fiixation; orif: open reduction internal fixation) fig 7(a & b): immediate postoperative radiographs after k-wire fixation fig 6(a &b): pre-operative anteroposterior (ap) radiograph, salter-harris type ii fracture of the proximal humerus fracture figure 8: 2 years old child with open proximal right humerus fracture sustained from a fall while playing figure: 9(a) injury film; (b)immediate post op radiographs after k-wire fixation j. lumbini. med. coll. vol 1, issue 2, july-dec 2013 jlmc.edu.np joshi rr et. al. fractures of the proximal humerus in children and adolescents. 74 avascular necrosis was observed. major complications, such as deep infections, neurovascular injuries, loss of reduction and nail migration, were not observed. skin irritation relating to prominent hardware occurred in three cases, and resolved following implant removal. discussion: traditionally, proximal humerus fractures in skeletally immature patients have been treated non-operatively due to the tremendous potential for remodeling and the wide functional arc of motion of the shoulder. as a result, even significantly angulated and displaced fractures have achieved union in positions that have allowed for normal or near-normal functional outcome. in children up to 10 years of age, axial malalignment of the proximal humerus of as much as 600 in varus, anteversion, or retroversion can be corrected by remodeling; however, beyond 10 years of age, the remodeling potential is not as high and correction can be expected only with axial deformities of up to 20–300. pahlavan et al.,15 in a systematic review of 569 proximal humerus fractures treated in the literature from 1960 to 2010, found that patients below the age of 10 and above the age of 13 years should be treated as distinct patient populations. through a review of patient outcomes in their review, the authors found that children less than 10 years of age should be treated non-operatively due to their tremendous remodeling potential, whereas patients above the age of 13 years are candidates for open reduction and fixation due to a much more limited remodeling potential. furthermore, dameron and reibel evaluated 46 skeletally immature patients with proximal humerus fractures and found that, in their patients above the age of 14 years, poor outcomes were noted due to loss of reduction.5 kohler and trillaud 13 reported their proximal humeral fracture experience and noted that, in their subset of older patients, operative intervention was warranted, as irreducible fractures could not remodel. in regards to severe displacement, neer and horwitz found that patients with severe displaceresults n percent exellent 8 53.3 good 7 46.7 total 15 100.0 table 3: outcome fig 11: (a)13 years old boy with proximal metadiaphyseal humeus fracture.(b) post op reduction radiographs with a single retrograde ten. fig 10: (a) 3 months followup showing good function with complete union(b) fig 12: (a&b) monthsl followup with excellent function fig 13: (a) 7 months post-operative ap radiographs showing complete healing prior to flexible nail removal; (b) after implant removal j. lumbini. med. coll. vol 1, issue 2, july-dec 2013 joshi rr et. al. fractures of the proximal humerus in children and adolescents. jlmc.edu.np75 ment (greater than 2/3rds of the humeral shaft) had persistent deformity and arm shortening compared to the contralateral side.2 in addition, schwendenwein et al.14 examined 16 patients with significantly displaced proximal humeral fractures who underwent operative intervention with excellent results, recommending operative treatment in displaced fractures. due to the results of studies such as those mentioned above, operative indications for proximal humerus fractures are expanding, particularly in adolescent patients with displaced fractures.2,17 as in our nine patients with age of ten or more, operative intervention can lead to good results. with an understanding of the indications for operative intervention (i.e., increased age, displacement, and angulation) which can lead to excellent results. within our cohort of nine patients, all patients failed attempts at closed reduction either in the emergency room and/ or the operating room. not surprisingly, at the time of open reduction, all of them were found to have anatomical structures blocking reduction. traditionally, the long head of the biceps and/or periosteum has been reported to prevent the reduction of proximal humerus fractures in a closed fashion.2,12,14 bahrs et al.7 examined 43 patients with proximal humerus fractures (33 treated operatively), in which 17 could not be closed reduced under general anesthesia. in seven cases, the biceps was entrapped, and in two cases, periosteum was entrapped. yet, in our study, we found not only the periosteum and long head of the biceps entrapped within the fracture site, but also deltoid muscle , as well as bony fragment. as a result, it would be quite difficult to achieve a reduction via closed means with these multiple structures within the fracture site. a myriad of open approaches can be utilized, although formal delto-pectoral approaches were most commonly used. with knowledge of the appropriate indications for operative treatment and the need for a formal open approach to adequately address all interposed structures, it is critical to understand the different fixation methods at the disposal of the treating surgeon. in our series, 85.7 % of patients underwent k-wire fixation, 14.28 % with flexible nails. all of our patients achieved excellent functional and radiographic outcomes, regardless of the implant utilized. burgos-flores et al.6 noted excellent results in 22 patients with displaced proximal humerus fractures treated with k-wire fixation at a mean of 6.8 years after surgery. disadvantages of k-wire fixation include non-rigid fixation necessitating cumbersome post-operative immobilization, pin tract infections, and the need for secondary procedures to remove hardware. in addition, there is a risk for hardware breakage. in conclusion, operative treatment of proximal humerus fractures, particularly in adolescents with severe displacement/angulation and failure of closed methods, is increasingly being seen as an acceptable modality of management. in addition to the long head of the biceps, periosteum, deltoid muscle, and bone fragments in combination can prevent fracture reduction. surgeon preference and skill should dictate implant choice, as patients achieved excellent functional and radiographic outcomes at the final follow-up with the use of k-wires, flexible nails, or cannulated screws. the risk of physeal damage with these implants is low. further randomized, controlled studies are necessary so as to examine the operative treatment of proximal humeral fractures in the adolescent population. 1. bishop jy, flatow el (2005) pediatric shoulder trauma. clin orthop relat res 432:41–48 2. neer cs, horowitz bs (1965) fractures of the proximal humeral epiphyseal plate. clin orthop relat res 41:24–31 3. larsen cf, kiaer t, lindequist s (1990) fractures of the proximal humerus in children. nine-year follow-up of 64 unoperated on cases. acta orthop scand 61:255– 257 4. pritchett jw (1988) growth and prediction of growth in the upper extremity. j bone joint surg am 70:520–525 5. dameron tb jr, reibel db (1969) fractures involving the proximal humeral epiphyseal plate. j bone joint surg am 51:289–297 6. burgos-flores j, gonzalez-herranz p, lopez-mondejar ja et al (1993) fractures of the proximal humeral epiphysis. int orthop 17: 16–19 7. bahrs c, zipplies s,ochs bget al (2009) proximal humeral fractures in children and adolescents. j pediatr orthop 29:238–242 8. herscovici d jr, saunders dt, johnsonmp et al (2000) percutaneous fixation of proximal humeral fractures. clin orthop relat res 375: 97–104 9. vander have k, herrera j, kohen r et al (2008) the use of locked plating in skeletally immature patients. j am acad orthop surg 16: 436–441 10. watford ke, jazrawi lm, eglseder wa jr (2009) percutaneous fixation of unstable proximal humeral fractures with cannulated screws. orthopedics 32:166 11. hutchinson ph, bae ds, waters pm (2011) intramedullary nailing versus percutaneous pin fixation of pediatric proximal humerus fractures: a comparison of complications and early radiographic results. j pediatr orthop 31:617–622 12. pahlavan s, baldwin kd, pandya nk, namdari s, hosalkar h (2011) proximal humerus fractures in the pediatric population: a systematic review. j child orthop 5:187–194 13. kohler r, trillaud jm (1983) fracture and fracture separation of the proximal humerus in children: report of 136 cases. j pediatr orthop 3:326–332 14. schwendenwein e, hajdu s, gaebler c, stengg k, ve´csei v (2004) displaced fractures of the proximal humerus in children require open/closed reduction and internal fixation. eur j pediatr surg 14:51–55 15. baxter mp, wiley jj (1986) fractures of the proximal humeral epiphysis. their influence on humeral growth. j bone joint surg br 68:570–573. references: j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 08 march, 2020 accepted: 25 may, 2020 published: 17 june, 2020 aassociate professor, bassistant professor, clecturer, dresearch assistant, edepartment of anatomy, kathmandu university school of medical sciences, dhulikhel, nepal. fdepartment of radio-diagnosis, dhulikhel hospital/kathmandu university hospital, dhulikhel, nepal. corresponding author: dil islam mansur e-mail: dilislam@kusms.edu.np orcid: https://orcid.org/0000-0001-5958-0423_______________________________________________________ abstract introduction: the radiological space between two vertebrae is known as intervertebral space (height) which corresponds to the thickness of the intervertebral disc. lumbar intervertebral disc is the most important structure which maintains the spinal function. an early diagnosis of pathological changes in disc has clinical significance. hence the study aimed to determine normal height of the intervertebral disc space and effect of aging. methods: it was a cross-sectional analytical study performed on 106 images of mri scans of lumbar region. dimensions of lumbar intervertebral spaces (discs) such as the anterior, middle, posterior intervertebral space height were measured in millimeter. results: the mean anterior intervertebral space height was gradually increased from l1-l2 level (6.91 mm) to l5-s1 level (13.55 mm). the middle intervertebral space height increased from l1-l2 level (7.89 mm) to l4-l5 level (11.96 mm) whereas at l5-s1 level, there was a decrease (11.10 mm). similarly, the posterior intervertebral space height showed an increment from l1-l2 level (5.52 mm) to l4-l5 level (8.09 mm) except at l5-s1 level, where it was decreased (6.94 mm). all mean values were found to be higher in males than in females except posterior intervertebral space height. the height of disc was increased up to third or fourth decade followed by a decrease. conclusion: knowing the normal lumbar intervertebral space height could be helpful for clinicians to diagnose and plan for proper treatment. it may also help to generate baseline data and to produce proper devices for nepalese population. keywords: intervertebral disc, lumbar vertebrae, mri scan original research articlehttps://doi.org/10.22502/jlmc.v8i1.320 dil islam mansur,a,e pragya shrestha,b,e sunima maskey,c,e kalpana sharma,b,e subindra karki,a,f trishna kisiju d,e morphometric study of lumbar intervertebral spaces (discs) by using mri. how to cite this article:how to cite this article: mansur di, shrestha p, maskey s, sharma k, karki s, kisiju t. mansur di, shrestha p, maskey s, sharma k, karki s, kisiju t. morphometric study of lumbar intervertebral spaces (discs) by morphometric study of lumbar intervertebral spaces (discs) by using mri. journal of lumbini medical college. 2020;8(1): 7 pages. using mri. journal of lumbini medical college. 2020;8(1): 7 pages. doi: doi: https://doi.org/10.22502/jlmc.v8i1.320320 epub: 2020 june 17. epub: 2020 june 17. introduction: the intervertebral space (height) is the typically radiological space between adjacent vertebrae which corresponds to the thickness of the intervertebral disc. it is a vital and dynamic structure which lies between the vertebrae and consists of annulus fibrosus, nucleus pulposus and end plates.[1] it enables vertebral column to develop compound movement which has the structure that can most perfectly move and withstand the axial load.[2] lumbar region is the most vulnerable area for the common symptom of backache.[3] it is strongly associated with degeneration of the intervertebral disc.[4] the disc degeneration is a natural aging process characterized by cellular changes in the disc which leads to decrease in the disc height.[5] however, a study suggested that average height of the disc increases with advance ageing in some discs individually.[6] artificial disc replacement is recently being introduced to restore the intervertebral space that maintaining spinal alignment and facilitating range j. lumbini. med. coll. vol 8, no 1, jan-june 2020 mansur di, et al. morphometric study of lumbar intervertebral spaces (discs) by using mri. jlmc.edu.np of movement.[7] therefore, if the size of lumbar intervertebral disc for nepalese population is known, it may help the clinicians for proper evaluation and treatment plan. hence, the aim of this study was to evaluate normal height of the intervertebral disc and effect of aging on the height of the disc by using magnetic resonance image (mri) scan. methods: this was a descriptive cross-sectional study conducted in the department of anatomy and the images were collected from the department of radio-diagnosis, dhulikhel hospital/kathmandu university school of medical sciences (kusms), dhulikhel, nepal. approval from institutional review committee (irc-109/19) was taken prior to the beginning of study. a total of 106 mri scans (56 males and 50 females) of the lumbar region of vertebral column were included for this study. the participants had undergone mri scan for abdominal and genitourinary complaints during the period of may to december, 2019. the participants between the ages of 20 to 69 years old as well as lumbar spine appearing normal on mri images were included in this study. mri image of individual with congenital vertebral abnormalities, lumbar spine pathology, previous spinal surgery, screw fixed lumbar vertebrae and unclear images were excluded from the study. the mri scanner used for the study was a 1.5 tesla ingenia mri scanner. measurements were done at the midsagittal t2-weighted images. the intervertebral space heights between l1-l2, l2-l3, l3-l4, l4-l5 and l5-s1 were measured in millimeter (mm) by using computerized digital caliper in both genders separately. anterior intervertebral space height (aivsh) was taken as the distance between the extreme anterior margins of the two adjacent vertebral endplates measured in mm as shown in fig. 1a. middle intervertebral space height (mivsh) was taken as the distance between the midpoints of the two adjacent vertebral endplates measured in mm as shown in fig. 1b. posterior intervertebral space height (pivsh) was measured as the distance between the extreme posterior margins of the two adjacent vertebral endplates measured in mm as shown in fig. 1c. the obtained data were studied under different age groups of the participants. the age group was categorized in every 10 years.[8] the observed data were tabulated in microsoft office excel 2007. the tabulated data were analyzed using statistical package for social sciences (spsstm) software version 23.0) for descriptive statistical analysis. independent sample student’s t test was done. p-value p<0.05 was considered statistically significant and the confidence interval was taken as 95%. results: a total of 106 mri scans, 56 (52.8%) males and 50 (47.2%) females were included in the study. the mean age (+sd) of the studied population was 37.44±11.80 years. the mean age (+sd) of males was 37.5±11.69 years whereas 37.38±12.04 years was in females. the mean aivsh has cephalo-caudal gradient of increase from l1-l2 to l5-s1. there was increase in mivsh and pivsh from l1-l2 to l4-l5 but there was decrease in height at the level of l5-s1. [table 1] fig. 1. blue arrow marks showing intervertebral space heightsa; aivsh (anterior intervertebral space height–red line), b; mivsh (middle intervertebral space height–red line) and c; pivsh (posterior intervertebral space height–red line). j. lumbini. med. coll. vol 8, no 1, jan-june 2020 mansur di, et al. morphometric study of lumbar intervertebral spaces (discs) by using mri. jlmc.edu.np table 1. intervertebral space height at various vertebral levels (mean±sd) in mm. l1-l2 l2-l3 l3-l4 l4-l5 l5-s1 aivsh 8.12± 1.28 9.53±1.42 11.15±1.60 12.92±2.03 13.55±2.47 mivsh 8.87± 1.25 10.32±1.28 11.36±1.55 11.96±1.75 11.10±1.87 pivsh 6.36±1.11 7.11±1.20 7.66±1.25 8.09±1.49 6.94+±1.35 table 2. gender-wise comparison of intervertebral space heights (mm) at various vertebral level. vertebral level males (n=56) females (n=50) statistics l1-l2 aivsh 8.60±1. 17 7.58±1.19 t(104,106)=4.283, p<0.05 mivsh 9.03±1.15 8.69±1.34 t(104,106)=0.304, p>0.05 pivsh 6.25±1.10 6.49±1.11 t(104,106)=-0.936, p>0.05 l2-l3 aivsh 10.00±1.33 9.00±1.34 t(104,106)=3.866, p<0.05 mivsh 10.63±1.34 9.97±1.13 t(104,106)=2.577, p>0.05 pivsh 7.23±1.21 6.97±1.19 t(104,106)=1.553, p>0.05 l3-l4 aivsh 11.46±1.41 10.81±1.75 t(104,106)=2.103, p<0.05 mivsh 11.58±1.71 11.12±1.33 t(104,106)=1.567, p>0.05 pivsh 7.81±1.23 7.49±1.27 t(104,106)=1.715, p>0.05 l4-l5 aivsh 13.25±1.61 12.54±2.38 t(104,106)=1.602, p>0.05 mivsh 11.90±1.66 12.03±1.86 t(104,106)=-0.538, p>0.05 pivsh 8.30±1.38 7.85+±1.58 t(104,106)=1.537, p>0.05 l5-s1 aivsh 13.86±2.20 13.20±2.73 t(104,106)=1.473, p>0.05 mivsh 11.18±1.66 11.01±2.10 t(104,106)=0.561, p>0.05 pivsh 7.04±1.20 6.83±1.51 t(104,106)=0.960, p>0.05 table 3. comparison of the mean values of the intervertebral space height among different age groups. vertebral level parameters age groups (years) 20-29 30-39 40-49 50-59 60-69 l1-l2 aivsh 8.64±1.84 8.13±1.33 8.44±1.16 7.72±0.73 7.35±1.07 mivsh 8.71±1.01 8.69±1.22 9.02±1.29 9.62±1.29 8.37±0.61 pivsh 7.02±1.29 6.281.09 6.39±0.95 6.72±1.17 6. 42±1.82 l2-l3 aivsh 9.44±1.97 9.63±1.47 9.85±1.01 8.93±1.21 9.08±1.26 mivsh 9.40±1.33 10.24±1.36 10.55±1.30 10.62±1.12 10.41±0.18 pivsh 7.22±1.68 7.10±1.26 7.06±1.08 7.23±1.86 6.79±1.38 l3-l4 aivsh 10.29±2.011 11.44±1.59 11.00±1.28 10.65±1.84 10.91±1.21 mivsh 10.86±2.10 11.30±1.16 11.46±1.45 11.65±1.08 11.82±1.15 pivsh 7.40±1.76 7.85±1.06 7.63±1.49 7.17±1.00 7.55±1.15 l4-l5 aivsh 11.77±2.65 13.18±1.99 13.07±2.10 12.53±1.46 11.59±2.35 mivsh 11.27±2.40 11.93±1.66 11.97±1.800 12.80±1.22 10.72±2.62 pivsh 8.11±1.97 8.30±1.41 7.86±1.96 7.87±1.05 7.36±1.61 l5-s1 aivsh 13.16±2.84 13.24±2.61 13.75±1.67 14.20±2.19 14.04±2.41 mivsh 10.55±2.03 10.80±1.59 11.25±2.14 11.57±2.21 13.40±1.81 pivsh 7.29±1.33 6.89±1.33 6.93±1.87 6.74±1.46 8.38±0.79 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 mansur di, et al. morphometric study of lumbar intervertebral spaces (discs) by using mri. jlmc.edu.np aivsh increased from the level of l1-l2 to l5-s1 for both sexes whereas mivsh and pivsh increased from the level of l1-l2 to l4-l5 and decreased at the level of l5-s1 for both sexes. there was statistically significant difference in aivsh of male and female in the region of l1-l2, l2-l3 and l3-l4 (p<0.05). however, there was no statistically significant difference in mivsh and pivsh of male and female (p>0.05) [table 2]. this study presented that there was steady increase in aivsh up to 49 years followed by decrease after 50 years. pivsh at the level of l1-l2, l2-l3 and l4-l5 increased up to 59 years followed by decrease after 60 years. pivsh at the level of l3-l4 showed increase up to 49 years followed by decrease at 50 years. at the level of l5-s1 there was as continuous increase in aivsh and pivsh with the age [table 3]. discussion: the intervertebral disc connects the vertebral bodies to each other and enables them to produce compound movement. it has the structures that transmit the axial load.[2] accurate anatomical knowledge of the disc is essential for the clinicians for diagnostic interpretation. it is not only important for the understanding of biomechanics of lumbar spine but also for various interventions such as stabilization and correction of deformities.[9] a study observed that the mean values for anterior intervertebral space height gradually increased from l1-l2 to l5-s1 levels whereas there was increment in middle intervertebral space height and posterior intervertebral space height from l1-l2 to l4-l5 but decrease in height at the level of l5s1 disc among the egyptian[8] and the iranian[10] populations which is similar to the findings of the present study. another study done in korea claimed a typical cephalo-caudal gradient of increment in anterior, middle and posterior heights of disc from the level of l1-l2 to l4-l5 followed by a decline at the level of l5-s1.[9] in the present study, it was also reported that the mean values for disc heights were higher among males than females which is also supported by an another study.[2] as there is difference in stature of males and females, the difference in disc height is also anticipated.[5] however, a study claimed that there was no sexual dimorphism in anterior disc height[11] which is in contrast to this study. moreover, the mean disc height was larger in males than female subjects at all level except at l5-s1 disc at which, the disc height was slightly larger in females.[12] similarly, a study reported that the l4l5 disc was found to be the thickest which may be due to greater mobility at that level of spine. [13] a recent study also revealed that disc was found greater among the long-distance runners at the lower lumbar vertebral levels l3-l4 to l5-s1. this may be due the strongest anabolic stimulus and hypertrophic response for adaptation in the human intervertebral disc with exercise.[14] on the other hand, a study quoted that the disc height was progressively increased from l1-l2 to l5-s1 disc in both genders[11] which are in accordance with the present study except anterior disc height. however, a study also claimed that the height of l5-s1 disc was to some extent changeable: in some individuals it was small and in others it was the largest one.[12] a study quoted that there is a continuous development and remodeling of vertebrae which may be due to the changing demands of the body. [13] in fact, in the intervertebral disc receiving continuous stress for a long period, a process of the decomposition and regenesis should be available to sustain its func tion.[6] it is know that there is a tendency for the general population to become taller, due to factors still under study. anthropometric analysis shows that humans get taller as they reach adult years and consequently the intervertebral discs height are also raised.[5] as there is alteration in thickness of intervertebral disc with ages, it is essential for the age particular computation of the disc.[11] there was an increment in disc height up to the third or fourth decade followed by a decrease in height. but at the level of l5-s1 there was steady increase in height of the disc with the increasing age in the present study. however, a study reported that a cephalo-caudal gradient of in crease was observed in the lumbar disc heights and di ameters from the level of l1-l2 to l4-l5 discs followed by a decline at lumbo-sacral disc (l5-s1) especially in 5th and 6th decades. in a study, the disc heights appeared to have gained an increase in 6th decade when compared to 3rd decade with significant differences in both males and females at different segmental levels.[8] j. lumbini. med. coll. vol 8, no 1, jan-june 2020 mansur di, et al. morphometric study of lumbar intervertebral spaces (discs) by using mri. jlmc.edu.np lumbar region is the most common site for causing low back pain due to heavy mechanical pressure on this region as compared to any other part of spine, it is more prone to be affected by degenerative changes.[15] a study claimed that lumbar degenerative disc which is age related disease is one of the causes of low back pain[16] whereas a study reported that disc herniation and nerve root compression were common in patients who presented with back pain.[15] they also reported that the most common cause of back pain is degenerative disc disease and the most common age group is in the fourth decade of life. in their findings, the degenerative discs of the lumbar spine occur most commonly at l4-5 and l5-s1. it may be happening due to the highest mechanical stress at these levels.[17,18] an another study quoted that that the most affected by degenerative diseases are the discs l5-s1, l4-l5, followed by the l3-l4.[5] it was also important to distinguish the space height between males and females and to understand changes in height as age increases. if the height of disc is too high, then it may induce facet joint pain and if it is low, it induces early degeneration change of the facet joint.[2] the restoration of the appropriate intervertebral disc space is an important factor[2] for some therapeutic procedures like spine fusion or artificial disc replacement.[10] the mean values of the present study were higher than that of the korean population [2] and lower than that of the iranian population.[10] hence, it was indicated that variations in the measurements were found in different populations and ethnic groups. therefore, it is important to pay attention during spine procedures, taking into account that there may be a inconsistency in size (height) between device, level, gender and the population being treated.[5] total disc replacement is a pioneering procedure that has gained traction in spine surgery. the objective behind it is that the removing the pain causing disc and restoring painless movement of the spinal column.[7] if there is mismatched between the device height and the disc space height that may produce neurological complications and failure of disc replacement in some sequences. few of the complications will be permanent and require reoperations at the operated level and also in adjacent vertebrae [19,20]. hence, knowing the disc height is mandatory for proper selection of intervertebral devices.[5] conclusion: the present study showed that the anterior space height gradually increased cephalo-caudally whereas middle and posterior space heights increased cephalo-caudally upto l4-l5 level followed by decreased at l5-s1 level. all measurements were found to be smaller in females than males. the l3-l4 and l4-l5 discs present greater anterior height than posterior and this difference tends to decrease with aging. a good knowledge on lumbar vertebral space heights is essential for radiologists and clinicians during their routine practices, and to select the appropriate size of the artificial disc inserted in the intervertebral space. this study was only conducted in the middle region of nepal, therefore, the results might not be generalized. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 mansur di, et al. morphometric study of lumbar intervertebral spaces (discs) by using mri. jlmc.edu.np references: 1. standring s. gray’s anatomy the anatomical basis of clinical practice. 40th ed. churchilllivingstone: elsevier; c2008. chapter 5, the back; p. 712-23. available from: https:// w w w. e l s e v i e r. c o m / b o o k s / g r a y s a n a t o m y / standring/978-0-443-06684-9 2. hong ch, park js, jung kj, kim wj. measurement of the normal lumbar intervertebral disc space using magnetic resonance imaging. asian spine j. 2010;4(1):1-6. pmid: 20622948. doi: https://doi.org/10.4184/asj.2010.4.1.1 3. chaudhary s, sarvesh, batra aps, gupta r, swami s. a radiographic study of interpedicular distance of the lumbar vertebrae measured in plain antero-posterior radiographs. international journal of advanced research. 2015;3(8):336. available from: http://www.journalijar.com/ uploads/684_ijar-4961.pdf 4. allaire bt, kaluza mcd, bruno ag, samelson ej, kiel dp, anderson de, et al. evaluation of a new approach to compute intervertebral disc height measurements from lateral radiographic views of the spine. euro spine j. 2017;26(1):167-72. pmid: 27757680. doi: https://doi.org/10.1007/s00586-016-4817-5 5. onishi fj, de paiva neto ma, cavalheiro s, centeno rs. morphometric analysis of 900 lumbar intervertebral discs: anterior and posterior height analysis and their ratio. interdisciplinary neurosurgery. 2019;18(0):100523. doi: https:// doi.org/10.1016/j.inat.2019.100523 6. malkoc i, aydinlioglu sa, alper f, kaciroglu f, yuksel y, yuksel r, et al. age related changes in height and shape of the lumbar intervertebral discus. european journal of basic medical science. 2012;2(3):68-73. available from: https:// www.researchgate.net/publication/330834477 7. othman ya, verma r, qureshi sa. artificial disc replacement in spine surgery. ann transl med. 2019;7(suppl 5):s170. pmid: 31624736. doi: https://doi.org/10.21037/atm.2019.08.26 8. fetouh fa. age and gender related changes in midsagittal dimensions of the lumbar spine in normal egyptians: mri study. international journal of current research and review. 2015;7(2):21-40. available from: https://www. ijcrr.com/past-articles.php?issueid=89 9. alam mm, waqas m, shallwani h, javed g. lumbar morphometry: a study of lumbar vertebrae from a pakistani population using computed tomography scans. asian spine j. 2014;8(4):421-6. pmid: 25187858. doi: https:// dx.doi.org/10.4184%2fasj.2014.8.4.421 10. mirab smh, barbarestani m, tabatabei sm, sahsavari s, zangi mbm. measuring dimensions of lumbar intervertebral discs in normal subjects. anatomical sciences journal. 2017;14(1):3-8. available from: http://anatomyjournal.ir/article1-197-en.pdf 11. gocmen-mas n, karabekir h, ertekin t, edizer m, canan y, duyar i. evaluation of lumbar vertebral body and disc: a stereological morphometric study. international journal of morphology. 2010;28(3):841-7. available from: https://scielo.conicyt.cl/pdf/ijmorphol/v28n3/ art28.pdf 12. shukri ig, mahmood ka, abdulrahman sa. a morphomet ric study of the lumbar spine in a symptomatic subjects in sulaimani city by magnetic resonance imaging. journal of sulaimani medical college. 2013;3(1):21-31. doi: https://doi.org/10.17656/jsmc.10028 13. demir m, atay e, seringeç n, yoldafl a, çiçek m, ertoğrul r, et al. intervertebral disc heights and concavity index of the lumbar spine in young healthy adults. anatomy. 2018;12(1):33-7. available from: h t t p s : / / p d f s . s e m a n t i c s c h o l a r. o r g / 9 d d b / a02e2c2d6cae428cc44ebc9e7ab901b1bbe6.pdf 14. belavy dl, quittner mj, ridgers n, ling y, connell d, rantalainen t. running exercise strengthens the intervertebral disc. scientific reports. 2017;7(0):45975. available from: https://www.nature.com/articles/srep45975.pdf 15. mallikarjun md, chetan m, patil s. evaluation of degenerative lumbosacral diseases and common location of disc herniations causing radiculopathy. international journal of anatomy, radiology and surgery. 2017;6(3):ro22-ro27. available from: https://pdfs.semanticscholar.org/4792/ 5b5e163c16340ffd8271bc9d7e67520cb353.pdf 16. ran b, li q, yu b, chen x, guo k. morphometry of lumbar spinous process via three dimensional ct reconstructions in a chinese population. int j clin exp. 2015;8(1):1129-36. pmid: 25785103. 17. bakhsh a. long-term outcome of lumbar disc j. lumbini. med. coll. vol 8, no 1, jan-june 2020 mansur di, et al. morphometric study of lumbar intervertebral spaces (discs) by using mri. jlmc.edu.np surgery: an experience from pakistan. j neurosurg spine. 2010;12(6):666-70. pmid: 20515353. doi: https://doi.org/10.3171/2009.10. spine09142 18. david g, ciurea av, iencean sm, mohan a. angiogenesis in the degeneration of the lumbar intervertebral disc. j med life. 2010;3(2):15461. pmid: 20968201. 19. rao pj, phan k, giang g, maharaj mm, phan s, mobbs rj. subsidence following anterior lumbar interbody fusion (alif): a prospective study. j spine surg. 2017;3(2):168-75. pmid: 28744497. doi: https://doi.org/10.21037/jss.2017.05.03 20. bocahut n, audureau e, poignard a, delambre j, queinnec s, lachaniette chf, et al. incidence and impact of implant subsidence after standalone lateral lumbar interbody fusion. orthop traumatol surg res. 2018;104(3):40510. pmid: 29292121. doi: https://doi. org/10.1016/j.otsr.2017.11.018 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha s, et al. sex determination from radiological assessment of the sacrum in nepalese population: a cross-sectional study. 259 jlmc.edu.np ___________________________________________________________________________________ submitted: 28 july, 2020 accepted: 9 december, 2020 published: 22 december, 2020 alecturer, department of anatomy, bassistant professor, department of radiodiagnosis, clumbini medical college, palpa, nepal. dnepalese army institute of health sciences, kathmandu, nepal. corresponding author: subina shrestha e-mail: ssubina8@gmail.com orcid: https://orcid.org/0000-0002-0006-4974_______________________________________________________ abstract: introduction: human skeleton shows variable degree of sexual dimorphism, but definitive inference can be obtained from only a few bones, sacrum being one of them. the morphometric differences of the bone will be helpful to obstetricians, as it shows special adaptations in females for child bearing. it is also important for physical anthropologists and forensic scientists for sex determination. the aim of this study was to find out whether sex could be determined by using sacral parameters from x-ray images of pelvis. methods: the study included antero-posterior x-ray images of pelvis with clearly visible 680 sacra (311 of males and 369 of females) obtained by computer generated random numbers from records in the department of radiodiagnosis of a medical college in nepal. x-ray images with the sacrum suspected for fractures and pathological diseases were excluded. inbuilt software “cr konica minolta aero dr/cr cs7” was used for measurements. results: the mean sacral length and mean transverse diameter of s1 vertebra were higher in males; whereas, mean sacral breadth, mean left ala length, mean right ala length, mean ala length, mean sacral index and mean alar index were higher in females. these differences in sacral parameters between the two sexes were statistically significant (p<0.05). the percentage of bones identified by demarking points of sacral index was 15.17% and 0.32% respectively in the males and the females. conclusion: the result of the present study supported determination of sex of an individual from radiological assessment of sacrum. keywords: anthropology, radiology, sacrum, sex original research articlehttps://doi.org/10.22502/jlmc.v8i2.393 subina shrestha,a,c sudikshya kc,a,d sumnima acharyab,c sex determination from radiological assessment of the sacrum in nepalese population: a crosssectional study how to cite this article:how to cite this article: shrestha s, kc s, acharya s. sex determination from radiological assessment of the sacrum in nepalese population: a cross-sectional study. journal of lumbini medical college. 2020;8(2):259-263. doi: https://doi.org/10.22502/jlmc.v8i2.393 epub: 2020 december 22. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: determination of sex, age, height and ethnic background of an individual contributes to identification of the individual. all elements of human skeleton show variable degree of sexual dimorphism, but definitive inference can be obtained from only a few bones, sacrum being one of them.[1] sacrum is a large single triangular irregular bone made up of five rudimentary vertebrae. it is the wedge between two hip bones and forms the posterior superior wall of pelvic cavity. sacrum also shows special adaptations in females for child bearing, thus its morphometric features form important obstetric landmarks.[2] to the best of our knowledge, determination of sex from sacrum using radiographs in nepalese population has not been carried out till date. the aim of the present study was to study the morphometric differences of sacral parameters as determinant of sexual dimorphism using antero-posterior x-ray images of pelvis. this study will be helpful to obstetricians, physical anthropologists and forensic scientists. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha s, et al. sex determination from radiological assessment of the sacrum in nepalese population: a cross-sectional study. 260 jlmc.edu.np methods: this was a cross-sectional study conducted in june and july 2020 in the department of radiodiagnosis, lumbini medical college and teaching hospital (lmcth), nepal. the ethical clearance was obtained from institutional review committee (irc-lmc12-cd/020). sample size was calculated by using the formula, sample size 2 2 2 )( d z n σα = where, n= desired sample size z= 1.96 (standard value at 95% confidence interval) d= 0.05 (margin of error), α=level of significance σ = 0.66[3] thus, the required sample size was 680. this study included the records of anteroposterior (ap) x-ray images of pelvis with clearly visible 680 (311 of males and 369 of females) sacra of nepalese people. first, all the available x-ray images that fulfilled inclusion criteria were identified and serial numbers were given; then the sample was chosen by computer generated random numbers. x-ray images with the sacrum suspected for fractures and pathological diseases were excluded. the radiographs had been taken by “allengers x ray machine” and further developed by cr systemkonica minolta. inbuilt software “cr konica minolta aero dr/cr cs7” was used for the measurements. following measurements (in millimeters) were taken as shown in figure 1. • length of the sacrum (i to j): this measurement was taken from midpoint of sacral promontory to anterior inferior margin of the 5th sacral vertebra. • breadth of sacrum (e to h): it was measured by taking two points, each at the lateralmost part of each ala on anterior aspect of the sacrum. • transverse diameter of the body of the first sacral vertebra (s1) (f to g): this was measured by taking the lateralmost point on each side of the superior surface of the body of s1 vertebrae. • length of the right ala (e to f): this was measured from the most right lateral point on the superior surface of the body of s1 vertebra to the most lateral point of right ala of sacrum. • length of the left ala (g to h): this was measured from the most left lateral point on the superior surface of the body of s1 vertebra to the most lateral point of left ala of sacrum. • mean alar length = (length of the left ala + length of the right ala)/2 figure 1. measurement of sacral parameters (i to j: sacral length, e to h: sacral breadth, f to g: transverse diameter of s1, e to f: right alar length and g to h: left alar length) for sex determination, following indices were calculated; • sacral index = (sacral breadth/sacral length) x 100 • alar index = (length of ala/transverse diameter of body of s1 vertebra) x 100 • mean and standard deviations were calculated for sacral and alar indices of males and females. using these values ‘calculated range’ was derived by the formula ‘mean ± 3sd’.[4] for males, if the calculated range was ‘a to b’ and for females, if the calculated range was ‘x to y’ (the ranges expectedly overlap each other partly with averages higher in females), then the upper limit of the range for males (b) was chosen as the ‘demarking point’ (dp) for females. meaning by, values above ‘b’ would be accurately identified as belonging to females in cases of uncertainty. following the same logic, the lower limit of the range for females (x) would be chosen as the dp for identifying males. hence, the values less than ‘x’ would be identified as males. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha s, et al. sex determination from radiological assessment of the sacrum in nepalese population: a cross-sectional study. 261 jlmc.edu.np statistical analysis was done by using statistical package for social sciences (spsstm) version 20. basic descriptive statistics namely standard deviation, mean and range were obtained. independent sample two tail t-test was used for testing the significance of the differences in the means of the various parameters in males and females. p value <0.05 was considered to be statistically significant. results: a total of 680 ap pelvic x-ray images were measured. among them 311 x-ray images were of males and 369 were of females. observed values of studied parameters are shown in table 1. the mean sacral length and mean transverse diameter of s1 vertebra were greater in males (108.04 ± 12.19 mm and 37.94 ± 4.4 mm respectively), when compared with females (94.66 ± 11.87 mm and 36.79 ± 6.623 mm respectively). whereas, mean sacral breadth, mean left alar length, mean right alar length and mean alar length were higher in females when compared with males. the differences were statistically significant (p<0.05). the mean sacral index, mean left ala index, mean right ala index and mean ala index were found to be greater in females as shown in table 2. dp of sacral index for males was 70.26 and for females it was 131.13. the present study found that the number of bones identified by dp in males and females were 1 (0.32%) and 56 (15.17%) respectively. similarly, dp of alar index for males was 49.51 and for females it was 134.45. the present study found that the number of bones identified by using dp of alar index in males and females were 0 and 9 (2.4%) respectively. table 1: comparison of male and female sacral parameters. parameters sex range (mm) mean (mm) sd statistics sacral length male 75-143 108.04 12.19 t (678) = 14.460, p<0.001 female 62-135 94.66 11.87 sacral breadth male 76-131 102.71 12.38 t (678) = -7.788, p<0.001 female 75-139 110.29 12.86 transverse diameter of s1 male 27-59 37.94 4.41 t (678) = 2.710, p =0.007 female 22-67 36.79 6.623 left alar length male 26-50 36.34 4.90 t (678) = -2.667, p=0.008 female 22-57 37.31 4.52 right alar length male 20-50 32.66 6.49 t (678) = -2.268, p=0.024 female 20-54 33.78 6.30 mean alar length male 26.0-48.5 34.50 4.53 t (678) = -3.155, p=0.002 female 23.5-46.0 35.53 4.06 table 2: calculation of demarking points of sacral and alar indices. parameters sex range mean 3sd mean ±3 sd demarking point number of bones identified by dp value (%) sacral index male 66.40-147.50 95.67 35.46 60.20-131.13 <70.26 1 (0.32) female 75.70-189.55 117.63 47.37 70.26-165 >131.13 56 (15.17) right alar index male 42.86-142.86 87.05 57.45 29.6-144.5 <34.39 0 female 35.71-154.55 93.22 58.83 34.39-152.05 >144.5 7 (1.89) left alar index male 56.52-141.94 96.59 43.11 53.48-139.7 <46.99 0 female 33.67-166.67 103.48 56.49 46.99-159.97 >139.7 15 (4.07) mean alar index male 57.14-137.10 91.82 42.63 49.19-134.45 <49.51 0 female 34.69-151.92 98.35 48.84 49.51-147.19 >134.45 9 (2.4) j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha s, et al. sex determination from radiological assessment of the sacrum in nepalese population: a cross-sectional study. 262 jlmc.edu.np discussion: the morphometric differences of sacrum are found to be an important parameter for determination of sex, thus useful in forensic and archaeological settings.[4] in the present study, mean sacral lengths of males and females were respectively (108.04 ± 12.19 mm) and (94.66 ± 11.87 mm) and sacral breadth in male and female were respectively (102.71 ± 12.38 mm) and (110.29 ± 12.86 mm) which were higher than those found in the study conducted by yadav n et al.[5] their observations of male and female sacral lengths were 104.73 ± 5.94 mm and 92.64 ± 6.10 mm respectively. similarly, sacral breadth in males and females were 102.93 ± 4.83 mm and 104.77 ± 6.48 mm respectively. their finding of demarking point of sacral index for males was<96.4 and for females >112.51 whereas the present study established <70.26 and >131.13 in males and females respectively. this shows that mean sacral breadth and mean sacral length in nepalese population were comparatively higher than those in maharastrian population, whereas sacral index was lower in nepalese population.[5] the present study showed the mean sacral indices to be 96.67 ± 11.82 and 117.63 ± 15.79 respectively in males and females. the calculated mean male sacral index was almost similar to the study done by ravichandran et al., whereas mean sacral index of females was greater in the present study.[6] the present study observed that the mean sacral breadth was higher in females than that in the males but the mean sacral length was higher in males. this result was similar to the studies conducted by arora et al., and dubey et al.,[4, 7] but the study done by janipati et al.,[1] reported that both mean sacral length and mean sacral breadth were higher in females than in males. similarly, the study conducted by masih et al., found that of both mean sacral length and breadth were higher in males.[8] in the present study, the percentage of bones identified by demarking point of sacral index was 15.17% and 0.32% respectively in males and females whereas the study conducted by joshi et al. found it to be 12.5% in males and 18.84% in females.[9] the present study calculated mean right alar index and mean left alar index in the males as 87.05 ± 19.15 and 96.59 ± 14.37 respectively and in females those values were 93.22 ± 19.16 and 103.48 ± 18.83 respectively. all these results were higher than the study conducted by patel et al.[10] our results showed that mean ala length was greater in females (35.54 ± 4.06 mm) than males (34.50 ± 4.53 mm) which was similar to the study performed by kamal et al.[11] the differences in result of present study compared with other studies may be due to the racial and environmental factors. further, the present study was conducted in x-ray images while other studies were performed in dry bones. there are certain limitations of this study. it was conducted in one of the medical colleges of nepal in a small population. the result obtained from this study might not represent whole population of nepal. further studies have to be carried out to find number of bones identified by demarking point for the nepalese population with larger sample size. conclusion: the sacral and alar indices were found to be greater in females. demarking points of sacral index for the males and the females have been obtained in the nepalese context and can be helpful in sex determination. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available for the study. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha s, et al. sex determination from radiological assessment of the sacrum in nepalese population: a cross-sectional study. 263 jlmc.edu.np references: 1. janipati p, kothapalli j, rao s. study of sacral index: comparison between different regional population of india and abroad. international journal of anatomy and research. 2014;2(4):640-44. available from: https://www.ijmhr.org/ijar.2.4/ ijar.2014.504.pdf 2. snell rs. clinical anatomy by regions. 9th ed. west camden street baltimore: lippincott william &wilkin, 2012. available from: https:// www.abebooks.com/clinical-anatomy-regions-ninth-edition-richard/10132537687/ bd#&gid=1&pid=1 3. ogbogbo m. gender determination from radiological assessment of the sacrum in urhobo people of nigeria. ec clinical experimental anatomy. 2019;2(8):385-90. available from: https://www.ecronicon.com/eccea/pdf/eccea-02-00077.pdf 4. arora ak, gupta p, mahajan s, kapoor ss. significance of sacral index in estmation of sex in sacra in cadavers in punjab. journal of indian academy of forensic medicine. 2010;32(2):1047. available from: https://www.researchgate.net/ publication/277214299 5. yadav n, saini k, patil k. determination of sex using dry adult human sacruma morphometric study. international journal of current research and review. 2015;7(3):22-8. available from: https://www.ijcrr.com/article_html.php?did=630&issueno=0 6. ravichandran d, shanthi kc, shankar k, chandra h. a study on sacral index in tamil nadu and andhra pradesh population of southern india. 2013;7(9):1833-4. pmid: 24179874. doi: https://doi.org/10.7860/jcdr/2013/6494.3326 7. dubey a, roy ss, verma s. significance of sacral index in sex determination and its comparative study in different races. international journal of anatomy and research. 2016;4(1):2096-8. doi: http://dx.doi.org/10.16965/ijar.2016.153 8. masih wf, singh ap, rathore kb. significance of sacral index in estimation of sex of sacrum inhadoti rajasthan. acta scientific dental sci. 2017;1(4):02-05. available from: https://actascientific.com/asds/pdf/asds-01-0035.pdf 9. joshi uu, puranik m. various sacral indices: role in study of sexual dimorphism. international journal of research in medical sciences. 2016;4(3):841-6. doi: https://dx.doi. org/10.18203/2320-6012.ijrms20160529 10. patel mm, gupta bd, singel tc. sexing of sacrum by sacral index and kimura’s base wing index. journal of the indian academy of forensic medicine. 2005;27(1):5-9. available from: https://www.indianjournals.com/ijor.aspx?target=ijor:jiafm&volume=27&issue=1&article=001 11. kamal a, ara s, begum s, hoque mm, khatun k. sexual dimorphism in alar length and auricular index of sacrum. bangladesh journal of anatomy. 2014;12(1):17-21. doi: https://doi. org/10.3329/bja.v12i1.22613 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha a, et al. the role of aspartate aminotransferase to platelet ratio index as a non-invasive predictor of variceal etiology of upper gastrointestinal bleeding 206 jlmc.edu.np ___________________________________________________________________________________ submitted: 08 june, 2020 accepted: 04 september, 2020 published: 20 september, 2020 alecturer, department of internal medicine, bbsc nurse, department of internal medicine, cassociate professor, department of internal medicine, ddhulikhel hospital kathmandu university hospital, nepal. corresponding author: ashish shrestha e-mail: ashish@kusms.edu.np orcid: https://orcid.org/0000-0002-6065-5119_______________________________________________________ abstract: introduction: non-invasive strategies to predict variceal from non-variceal bleeding will be highly beneficial for preemptive management of upper gastrointestinal bleeding (ugib). this study aimed to assess the role of aspartate aminotransferase (ast) to platelet ratio index (apri) as a non-invasive predictor of variceal etiology of ugib. methods: this was a retrospective descriptive study conducted at endoscopy department of dhulikhel hospital between january 2017 and december 2019 in patients presenting with acute ugib. we assessed the diagnostic utility of the apri score relative to other objective measures by area under the receiver operating characteristic (auroc) curve analysis. results: a total of 158 patients with history of ugib were included in the study. there were total 123 males (77.8%) and the mean age of the patients was 50.3±16.1 years. the apri score performed well in predicting a variceal etiology of acute ugib, with auroc 0.9. when apri was used at cut-off of 1.3, it had a sensitivity of 84.1% and specificity of 76.8%, a positive predictive value of 70.7% and a negative predictive value of 89.9% while predicting variceal etiology of ugib at presentation. the relative risk of varices at an apri cut-off of 1.3 is 17.5 with a p-value of <0.0001. conclusion: the present study highlighted that apri score can be used as an objective metric that helps to predict a variceal etiology of acute ugib. keywords: aspartate aminotransferase, gastrointestinal bleeding, platelets, variceal bleeding original research articlehttps://doi.org/10.22502/jlmc.v8i2.376 ashish shrestha,a,d pasanda sharma,a,d anjila lama,b,d ram bahadur gurung c,d the role of aspartate aminotransferase to platelet ratio index as a non-invasive predictor of variceal etiology of upper gastrointestinal bleeding how to cite this article:how to cite this article: shrestha a, sharma p, lama a, gurung rb. the role of aspartate aminotransferase to platelet ratio index as a non-invasive predictor of variceal etiology of upper gastrointestinal bleeding. journal of lumbini medical college. 2020;8(2):206-211. doi: https://doi. org/10.22502/jlmc.v8i2.376 epub: 2020 september 20. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: cirrhosis is characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules.[1] the prevalence of esophageal varices (ev) in cirrhotics is between 60 and 80%.[2] mortality rate due to variceal bleeding episode is about 10-20% and the life expectancy is around 63%.[3,4] till date proton pump inhibitor remains the mainstay of treatment for non-variceal bleeding. [5] in contrast, for variceal hemorrhage, medical management mainly involves intravenous vasoactive therapy (octreotide and terlipressin), intravenous antibiotics (third generation cephalosporins) and guarded blood transfusion.[6] evidence also supports benefits of early endoscopy for variceal bleed but not as much for non-variceal bleed.[7,8] aspartate aminotransferase to platelet ratio index (apri), was initially introduced as a measure to quantify fibrosis of the liver in patients with hepatitis c, however today it has been established j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha a, et al. the role of aspartate aminotransferase to platelet ratio index as a non-invasive predictor of variceal etiology of upper gastrointestinal bleeding 207 jlmc.edu.np as a marker of cirrhosis and portal hypertension in many studies.[9,10] apri can hence also act as a good non-invasive method for the screening of variceal bleeding in acute setting of upper gastrointestinal bleeding (ugib) and direct us towards early management before definite diagnosis is established with endoscopy. methods: this was a hospital based retrospective descriptive study conducted from january 2017 to december 2019. all patients presenting with features suggestive of ugib in the out-patient and emergency department (ed) were included in the study. the patients with no documented complaints of overt gastrointestinal (gi) bleeding, in whom endoscopy was not performed during admission, and with incomplete medical records were excluded from the study. questionnaire included variables such as age, gender, ethnicity, history of malena, hematemesis, hematochezia, cirrhosis / portal hypertension, endoscopic diagnosis, biochemical levels of aspartate aminotransferase (ast) , alanine aminotransferase (alt) and platelet count. patients who presented with repeated ugib due to the same underlying etiology were included only once. prior ethical approval was taken from institutional review committee (irc) of dhulikhel hospital, kathmandu university hospital (irb: 291/19). apri was calculated using first available ed data as following: [9] apri = [ast level / ast-upper limit x platelet count (109/l)] x 100 statistical analysis was performed using statistical package for the social sciences (spsstm) 20.0 software for windows. we used area under the receiver operating characteristics curve (auroc) as the measure of relative diagnostic accuracy in comparing tests. deviations from the null hypothesis with a probability of p<0.05 were considered significant. results: there were 283 presentations with ugib out of which 158 cases met the inclusion criteria and were included in the study. the mean age of the study population was 50.3±16.1 years, with a range of 4-86 years. the age group 40-60 years included 76 (47.8%) patients. there was a male predominance with 123 (77.8%) patients. the predominant ethnic groups included tamang (n=44, 27.4%), newar (n=42, 26.6%) and brahmin/chettri (n=37, 23.4%). table 1. clinical variables of the study population (n=158). clinical variables category frequency (%) malena absent 50 (31.6) present 108 (68.4) hematemesis present 133 (84.2) absent 25 (15.8) hematochezia absent 151 (95.6) present 7 (4.4) history of cirrhosis / portal hypertension absent 108 (68.4) present 50 (31.6) endoscopic diagnosis variceal 63 (39.9) non-variceal 95 (60.1) alt (iu/l) ≤56 101 (63.9) >56 57 (36.1) ast (iu/l) ≤40 55 (34.8) >40 103 (65.2) platelets / cumm ≤150000 68 (43) 150000450000 88 (55.7) >4500000 2 (1.3) table 2. causes of non variceal bleeding (n=95). causes frequency (%) gastric ulcer 22 (23.2) duodenal ulcer 21 (21.1) gastroduodenitis 19 (20) malory weiss tear 13 (13.7) esophagitis/esophageal ulcer 8 (8.4) gastric carcinoma 4 (4.2) gave (gastric antral vascular ectasia) 3 (3.2) polyp bleed 3 (3.2) deulafoy’s lesion 2 (2.1) total 95 (100) j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha a, et al. the role of aspartate aminotransferase to platelet ratio index as a non-invasive predictor of variceal etiology of upper gastrointestinal bleeding 208 jlmc.edu.np table 1 represents the clinical variables among the study population. upon review of all available data including endoscopy reports, we classified 63 (39.9%) cases as variceal ugib and 95 (60.1%) as non-variceal ugib. of the patients with clinical features of chronic liver disease (cld), 40 (80%) had variceal bleeding, nine (18%) had non-variceal bleeding, and one (2%) had unknown source of bleed. in contrast, among patients without clinical features of cld 23 (21.3%) had variceal bleeding, 79 (73.1%) had non-variceal bleeding, and six (5.6%) had unknown source of bleed. table 2 represents the causes of non-variceal bleeding. we plotted sensitivity versus specificity over a range of possible cut-off values for each score to generate a receiver operating characteristic (roc) curves comparing the performance of apri score (table 3). when apri was used at cut-off of 1.3, it had a sensitivity of 84.1% and specificity of 76.8%, a positive predictive value (ppv) of 70.7% and a negative predictive value (npv) of 89.9% while predicting variceal etiology of ugib at presentation. the relative risk of varices at an apri cut-off of 1.3 is 17.5 with a p-value of <0.0001 (table 4). table 4. relative risk at apri score of 1.3. cutoff endoscopic findings rr p value variceal non variceal >1.2 53 22 17.5 <0.0001 <=1.2 10 73 figure 1. roc curve (auc=0.90). other cutoff points were also tested, but none of them could reach a significantly better positive and negative predictive value. considering all patients presenting with apparent ugib, we found that apri had good performance in discriminating between variceal versus non-variceal ugib with auroc of 0.9 (figure 1). an ideal test is associated with auroc of 1.0 and with an auroc of 0.9 the apri score would be considered to have very good to excellent performance.[11] discussion: variceal bleeding is one of the most dramatic and fatal complications of cirrhosis. the prevalence of esophageal varices (ev) in cirrhotics is highly table 3. sensitivity, specificity, ppv and npv of apri score at different cut offs levels (* fn = false negative; tn = true negative; tp = true positive; fp = false positive). apri cut-off levels endoscopic finding sensitivity specificity ppv npv variceal non-variceal <=0.5 >0.5 1(fn) 55 (tn) 98.5 57 60.7 98.2 62 (tp) 40 (fp) <=1 >1 9 71 85.70% 74.7 69.2 88.8 54 24 <=1.1 >1.1 10 71 84.1 74.7 68.8 87.7 53 24 <=1.2 >1.2 10 73 84.1 76.8 70.7 89.9 53 22 <=1.3 >1.3 12 74 80.9 77.9 70.8 86.0 51 21 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha a, et al. the role of aspartate aminotransferase to platelet ratio index as a non-invasive predictor of variceal etiology of upper gastrointestinal bleeding 209 jlmc.edu.np variable.[2] even in known cirrhotic patients presenting with ugib, non variceal etiology of bleeding has to be ruled out because of difference in their management. for variceal bleeding evidence suggests early endoscopy along with intravenous vasoactive drugs, antibiotics and guarded blood transfusion.[6,7,8] whereas proton pump inhibitors remain the mainstay of treatment for non-variceal bleeding.[5] hence, the prediction of variceal bleeding in the emergency department (ed) will help in the management of patients with ugib before the definite diagnostic and therapeutic endoscopy is performed. the apri score is easily calculated from routinely collected laboratory data available early in the ed setting. shaheen et. al. reported that in patients with chronic hepatitis c, apri score < 0.5 had a negative predictive value (npv) of 72%, while the apri score >1.5 had a positive predictive value (ppv) of 87% for prediction of fibrosis.[12]wai ct et al. in their study had a conclusion that apri score can predict accurately significant fibrosis and cirrhosis in 51% and 81% respectively, potentially avoiding the need for liver biopsies in patients.[9] the first authors to raise the hypothesis that apri could be related to the presence of ev were sanyal et al.[13] they examined 1,016 patients with compensated liver cirrhosis and reported a correlation between apri score and the presence of esophageal varices (p=0.01). later castéra, et al. proposed the cutoff of 1.3 for apri as a predictor of ev.[14] while plotting the sensitivity, specificity, ppv and npv of apri score at different cut off levels, we also found that cut-off at 1.3 had a very good npv. (table 3) for a non-invasive test like apri to be considered helpful in the studied context, it should have a great negative predictive value, as misdiagnosing variceal bleeding as not having ev is a risk for major complication. the mortality of variceal bleeding in different studies is around 15%.[15] clinical signs and symptoms of cirrhosis prompting suspicion for a variceal etiology can be unreliable.[16] in this study, we found that the apri score performed well as measured by roc analysis with an auroc of 0.9 in predicting a variceal etiology of acute ugib. thus, the apri score represents an objective measure that could be used to guide early management decisions for ugib patients while awaiting endoscopy. a study by civan et al., concluded that a clinical decision rule based on apri improves adherence to published guidelines on the management of acute variceal bleeding using the prophylactic antibiotics and somatostatin analogues.[17] the apri cutoff value of 0.4 was used in their clinical decision rule which is lower than the cutoffs reported in other studies. the reason for low cut-off value of apri used in this study according to the authors was their reflection of their prioritization of sensitivity over specificity, and led them to design a clinical decision rule with a positive predictive value of 0.33 and negative predictive value of 0.98. in this study, at apri cut-off of 0.4 we had ppv of 0.61 and npv of 0.98 that is an increased npv compared to apri cut-off at 1.3. low ppv will increase the number of patients without varices receiving antibiotics and somatostatin analogues. octreotide is very well tolerated and a brief course in patients without varices will not cause increased morbidity.[18] unnecessary courses of antibiotics however might cause an increase in clostridium difficile infection. both these factors also will increase the cost of treatment which has to be taken into account especially in developing country like ours. at apri cut-off of 1.3 however there is a good sensitivity and specificity without significantly compromising either of the ppv and npv values (table 3). conclusion: the present study found that the apri score could serve as a useful objective measure to identify variceal etiology of bleeding in ugib patients. patients presenting with apparent acute ugib with apri score of more than or equal to 1.3 can be managed in the line of variceal bleed before definite endoscopic diagnosis. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha a, et al. the role of aspartate aminotransferase to platelet ratio index as a non-invasive predictor of variceal etiology of upper gastrointestinal bleeding 210 jlmc.edu.np references: 1. williams r. sherlock’s disease of the liver and biliary systems. clin med (lond). 2011;11(5):506. doi: https://dx.doi. org/10.7861%2fclinmedicine.11-5-506 2. giannini e, botta f, borro p, risso d, romagnoli p, fasoli a, et al. platelet count/spleen diameter ratio: proposal and validation of a non-invasive parameter to predict the presence of oesophageal varices in patients with liver cirrhosis. gut. 2003;52(8):1200-5. pmid: 12865282. doi: https://doi.org/10.1136/gut.52.8.1200 3. d’amico g, criscuoli v, fili d, mocciaro f, pagliaro l. meta-analysis of trials for variceal bleeding. hepatology. 2002;36(4 pt 1):1023-4; author reply 1024-5. pmid: 12297857. doi: https://doi.org/10.1053/jhep.2002.34737 4. carbonell n, pauwels a, serfaty l, fourdan o, lévy vg, poupon r. improved survival after variceal bleeding in patients with cirrhosis over the past two decades. hepatology. 2004;40(3):652-9. pmid: 15349904. doi: https://doi.org/10.1002/hep.20339 5. laine l, jensen dm. management of patients with ulcer bleeding. am j gastroenterol. 2012;107(3):345-60. pmid: 22310222. doi: https://doi.org/10.1038/ajg.2011.480 6. garcia-tsao g, sanyal aj, grace nd, carey w; practice guidelines committee of the american association for the study of liver diseases; practice parameters committee of the american college of gastroenterology. prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. hepatology. 2007;46(3):922-38. pmid: 17879356. doi: https://doi.org/10.1002/hep.21907 7. bjorkman dj, zaman a, fennerty mb, lieberman d, disario ja, guest-warnick g. urgent vs. elective endoscopy for acute nonvariceal upper-gi bleeding: an effectiveness study. gastrointest endosc. 2004;60(1):1-8. pmid: 15229417. doi: https://doi.org/10.1016/ s0016-5107(04)01287-8 8. lee jg, turnipseed s, romano ps, vigil h, azari r, melnikoff n, et al. endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper gi bleeding: a randomized controlled trial. gastrointest endosc. 1999;50(6):755-61. pmid: 10570332. doi: https://doi.org/10.1016/s00165107(99)70154-9 9. wai ct, greenson jk, fontana rj, kalbfleisch jd, marrero ja, conjeevaram hs, et al. a simple noninvasive index can predict both significant fibrosis and cirrhosis in patients with chronic hepatitis c. hepatology. 2003;38(2):518-26. pmid: 12883497. doi: https://doi.org/10.1053/ jhep.2003.50346 10. pissaia a jr, borderie d, bernard d, scatton o, calmus y, conti f. apri and fib-4 scores are useful after liver transplantation independently of etiology. transplant proc. 2009;41(2):679-81. pmid: 19328955. doi: https://doi.org/10.1016/j. transproceed.2008.12.014 11. eng j. receiver operating characteristic analysis: a primer. acad radiol. 2005;12(7):90916. pmid: 16039544. doi: https://doi. org/10.1016/j.acra.2005.04.005 12. shaheen aa, myers rp. systematic review and meta-analysis of the diagnostic accuracy of fibrosis marker panels in patients with hiv/hepatitis c coinfection. hiv clin trials. 2008;9(1):43-51. pmid: 18215981. doi: https://doi.org/10.1310/hct0901-43 13. sanyal aj, fontana rj, di bisceglie am, everhart je, doherty mc, everson gt, et al. the prevalence and risk factors associated with esophageal varices in subjects with hepatitis c and advanced fibrosis. gastrointest endosc. 2006;64(6):855-64. pmid: 17140886. doi: https://doi.org/10.1016/j.gie.2006.03.007 14. castera l. non-invasive assessment of liver fibrosis in chronic hepatitis c. hepatol int. 2011;5(2):625-34. pmid: 21484142. doi: https://doi.org/10.1007/s12072-010-9240-0 15. carbonell n, pauwels a, serfaty l, fourdan o, lévy vg, poupon r. improved survival after variceal bleeding in patients with cirrhosis over the past two decades. hepatology. 2004;40(3):652-9. pmid: 15349904. doi: https://doi.org/10.1002/hep.20339 16. de bruyn g, graviss ea. a systematic review of j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha a, et al. the role of aspartate aminotransferase to platelet ratio index as a non-invasive predictor of variceal etiology of upper gastrointestinal bleeding 211 jlmc.edu.np the diagnostic accuracy of physical examination for the detection of cirrhosis. bmc med inform decis mak. 2001;1(0):6. pmid: 11806763. doi: https://doi.org/10.1186/1472-6947-1-6 17. civan jm, lindenmeyer cc, whitsett m, herrine sk. a clinical decision rule based on the ast-to-platelet ratio index improves adherence to published guidelines on the management of acute variceal bleeding. j clin gastroenterol. 2015;49(7):599-606. pmid: 26167719. doi: https://doi.org/10.1097/ mcg.0000000000000173 18. vlachogiannakos j, kougioumtzian a, triantos c, viazis n, sgouros s, manolakopoulos s, et al. clinical trial: the effect of somatostatin vs octreotide in preventing post-endoscopic increase in hepatic venous pressure gradient in cirrhotics with bleeding varices. aliment pharmacol ther. 2007;26(11-12):1479-87. pmid: 17919272. doi: https://doi.org/10.1111/ j.1365-2036.2007.03539.x j. lumbini. med. coll. vol 8, no 1, jan-june 2020 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 22 april, 2020 accepted: 25 may, 2020 published: 15 june, 2020 alecturer, department of oral medicine and radiology, bassociate professor, department of oral and maxillofacial surgery, cassistant professor, department of periodontology and oral implantology, dlecturer, department of community dentistry, electurer, department of conservative dentistry and endodontics, fassociate professor, department of prosthodontics, g-dhulikhel hospital, kusms, nepal h-universal college of medical sciences-college of dental surgery, bhairhawa, nepal. i-b.p. koirala institute of health sciences, dharan, nepal. corresponding author: harleen bali e-mail: harleenbali.hb@gmail.com orcid: https://orcid.org/0000-0001-8647-9582 _______________________________________________________ abstract introduction: third molar extractions are one of the most common reasons of injury to mandibular nerve and post-operative complications. pre-operative assessment of pending doom is a must. in order to study the relations between change in inferior alveolar canal (iac) and type, class, and level of impaction with radiographic root change of impacted third mandibular molar, we designed a study to assess the relationship of the mandibular canal to the roots of impacted third molar in reference to changes in roots and factors affecting it. methods: this was a retrospective cross-sectional study where in the panoramic radiographic records of subjects with impacted third molar were assessed for change in root and its correlation with change in iac, type, class and level of impacted mandibular third molar. results: roots of impacted third molar when in contact with iac presented most often in our study subjects with the darkening of roots in both sides {right side (16.79%) and left side (11.29%)} and both genders {males (right-14.29%, left-8.75%) and females (right-19.39%, left-13.94%)}. they were statistically significantly associated with interruption of white line of iac, vertically impacted third molars and pell and gregory class ii, level a of impaction. conclusion: there is a need to properly identify radiographic risk predictor signs to avoid any surprises at the time of extraction and post-operative complications following it. keywords: impacted tooth, mandibular nerve, panoramic radiography original research articlehttps://doi.org/10.22502/jlmc.v8i1.303 harleen bali,a,g deepak yadav,b,h khushbu adhikari,c,i swagat kumar mahanta,d,g rupam tripathi,e,h binam sapkota f,g the relationship of the mandibular canal to the roots of impacted third molarsthe root factor: a panoramic radiographic study. how to cite this article:how to cite this article: bali h, yadav d, adhikari k, mahanta sk, tripathi r, sapkota b. the relationship of the mandibular canal to the roots of impacted third molars the root factor: a panoramic radiographic study. journal of lumbini medical college. 2020;8(1):8 pages doi: https:// doi.org/10.22502/jlmc.v8i1.303 epub: 2020 june 15. introduction: impacted teeth have been associated with pathologies such as cysts, tumors, infections, inflammations of jaws as well as displacement and resorption of adjacent teeth. the mandibular third molars are among the most frequent to be impacted.[1] their extraction can cause direct injury to inferior alveolar nerve (ian) or hematoma formation following extraction putting pressure over the nerve leading to neurosensory disturbances.[2,3] studies have reported that the prevalence of ian paraesthesia following third molar surgery ranges approximately from 0.4% to 8.4%.[4] in order to avoid such untoward incidents pre-operative investigations are required to plan the protocol best suiting the scenario. among 2d imaging, surgeons prefer panoramic radiographs than intraoral periapical radiographs for planning third molar extraction. though 3d imaging modalities promise clearer picture, their reduced accessibility and high cost have restricted their use j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bali h et al. the relationship of the mandibular canal to the roots of impacted third molars the root factor: a panoramic radiographic study. jlmc.edu.np in developing countries. studies are available on prevalence of root changes[5] seen in mandibular third molar when in contact with inferior alveolar canal (iac) but the relation of change in root with factors like change in iac, type, level and class of impaction is less explored and none so in nepal to the best of our knowledge. therefore, the aim of our study was to assess the root changes seen in mandibular third molar when in contact with iac and factors affecting it. methods: this descriptive cross-sectional study was conducted in universal college of medical sciencescollege of dental surgery, bhairahawa. the radiographic records of patients with impacted third molar were selected in a retrospective manner. the records from january 2016 were selected as starting point and all preoperative orthopentomograms (opgs) till february 2018 were selected for the present study. ethical clearance was obtained from the institutional ethical committee prior to conducting the study. more than 2000 panoramic radiographs were scanned, of which 673 were included in this study. all radiographs had been taken using vatech digital x-ray system, model: pch-2500 (power input: ac 100-120/200-240 v, 50/60 hz, 2.0 kva max. 170 va normal; output90 kv, 10 ma and focal spot 0.5x0.5 mm). all opgs were shot at 73kvp, 10.0ma and scan time13.5 seconds in standard mode. the inclusion criterion was individuals’ opg presenting with bilateral impacted mandibular third molars with root completion and presence of mandibular second molars. the exclusion criteria were individuals with: (1) trauma/surgery to the mandibular site of study, (2) developmental anomalies affecting the jaws, and (3) radiographic evidence of pathologies of the impacted mandibular third molar teeth of mandible which could obscure the visualization of the periapical region or iac. the radiographs were observed and read by an oral and maxillofacial surgeon, well trained and experienced in reading radiographs. the type of impaction of mandibular third molars was identified by the method adapted by winter.[6] subsequently, they were categorized as mesioangular, distoangular, vertical or horizontal impactions. the pell–gregory classification[7] in relation to ramus of the mandible (class i, ii and iii) and pell–gregory classification[7] in relation to depth/level of mandibular third molar in relation to occlusal surface of second molar (a, b and c) was also identified and recorded. digital panoramic radiographs were then interpreted cautiously for the following: the presence of each of the following sign in root of mandibular third molar and inferior alveolar canal changes (rood and shehab).[5] changes in root: a. darkening of the root: loss of root density in a tooth that is impinged upon by the canal. b. deflection of the root: an abrupt deviation of roots near the canal. c. dark and bifid root apex: a loss of root density in a tooth that is impinged upon by the canal with bifid apex of the root. d. narrowing of the root: narrowing of the tooth roots where the canal crosses. changes in iac: a. interruption of the white line: discontinuity of the superior radio-opaque line that constitutes the superior border of the inferior alveolar canal. b. diversion of the canal: a change in the direction of the canal while crossing the mandibular third molar. c. narrowing of the canal: an abrupt decrease in the width of the canal while it crosses the root apices. data was entered in ms excel sheet and analyzed using statistical package for social sciences (spsstm) software version 20. statistical analysis was done to evaluate the change in roots of impacted third molar caused by contact/superimposition of iac a. with respect to right or left side of mandible b. with respect to gender c. its relation to the type of impaction, pell– j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bali h et al. the relationship of the mandibular canal to the roots of impacted third molars the root factor: a panoramic radiographic study. jlmc.edu.np gregory class and level of impaction of mandibular third molar. descriptive statistics and chi-square, post hoc test was done. p value <0.01 was considered significant. results: the tabulated results were analyzed. of the selected 673 radiographs, 330 (49.03%) were of females and 343 (50.96%) were of males. the age group ranged from 21 to 65 years (mean+ sd=31.63+11.98). radiographic risk predictor signs in roots of impacted mandibular third molar were seen in 176 (26.15%) subjects on the right side and 133(19.76%) on the left side (figure 1). fig. 1. overall change in roots in our study. roots of impacted third molar when in contact with iac presented most often in our study subjects with the darkening of roots in both sides {figure1-right side (16.79%) and left side (11.29%)} and both genders {table 1: males (right-14.29%, left8.75%) and females (right-19.39%, left-13.94%)}. darkening along with other changes was also seen and grouped under others. change in roots of impacted third molar when correlated with changes noticed in iac, showed interruption of white line (table 2a: right side-55.90%, left side-56.98%) as the most common effect. the results were statistically highly significant (p<0.001). post hoc test after chi square was done to know which group was statistically significant among them. it showed that interruption of white line (right and left side of mandible), while diversion of iac on left side were statistically highly significant (see table 2b). an analysis of winter’s classification of type of impaction correlation with darkening of roots revealed vertical impaction (table 3: right side-62.99%, left side-52.33%), followed by mesioangular impaction (right side-27.56%, left side36.05%). the results were statistically significant (p<0.01) on right side and statistically highly significant (p<0.001) on left side. pell and gregory category for depth/level of mandibular third molar impaction when correlated with the change in roots i.e. darkening of roots showed position a (table 4: right side-58.27%, left side-47.67%) followed by position b (right side-26.77%, left side30.23%) as most related. fig. 2. no. of roots of mandibular third molar with respect to right and left side. pell and gregory class defining space table 1. change in root of mandibular third molar as per gender. change in root male (frequency, %) female (frequency, %) right left right left no change 266 (77.55%) 288(83.97%) 231 (70.00%) 252 (76.36%) darkening of root 49 (14.29%) 30 (8.75%) 64 (19.39%) 46 (13.94%) deflected 17 (4.96%) 19 (5.54%) 20 (6.06%) 23 (6.97%) dark and bifid 1 (0.29%) 1 (0.29%) 2 (0.61%) 0 (0.0%) narrowing of roots 2 (0.58%) 1 (0.29%) 7 (2.12%) 3 (0.91%) others 8 (2.33%) 4 (1.16%) 6 (1.82%) 6 (1.82%) total 343 343 330 330 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bali h et al. the relationship of the mandibular canal to the roots of impacted third molars the root factor: a panoramic radiographic study. jlmc.edu.np table 2a. darkening of roots of mandibular third molar on right and left side of mandible with respect to change in iac seen on the same side. change in iac right left no change 41 (32.28%) x2 (6,127)= 165.116, p value < 0.001* 21 (24.42%) x2(6, 86)=134.185, p value < 0.001*interruption of white line 71 (55.90%) 49 (56.98%) diversion of iac 5 (3.94%) 6 (6.98%) narrowing of iac 5 (3.94%) 5 (5.81%) others 5 (3.94%) 5 (5.81%) total 127 86 table 2b. darkening of roots of mandibular third molar on right and left side of mandible with respect to change in iac seen on the same side. change in iac p-value right side left side right side left side no change 41 21 <0.001 < 0.001 interruption of white line 71 49 <0.001 <0.001 diversion of iac 5 6 .10358 .00065 narrowing of iac 5 5 .2096 .5407 others 5 5 .011 <0.001 table 3: darkening of roots in respect to winter’s classification of type of impaction of mandibular third molar. winter’s classification right left mesioangular 35 (27.56%) x2(3, 127)=13.490, p value < 0.01* 31 (36.05%) x2 (4,86)=24.347, p value< 0.001*distoangular 5 (3.94%) 5 (5.81%) vertical 80 (62.99%) 45 (52.33%) horizontal 7 (5.51%) 5 (5.81%) total 127 86 table 4: darkening of roots in respect to pell and gregory depth/level of impaction of mandibular third molar. pell and gregory level of impaction right left a 74 (58.27%) x2 (3, 127)=27.426 p value <0.001* 41 (47.67%) x2 (3,86)=46.638 p value <0.001*b 34 (26.77%) 26 (30.23%) c 19 (14.96%) 19 (22.1%) total 127 86 table 5: darkening of roots in respect to pell and gregory class of impaction of mandibular third molar. pell and gregory class of impaction right left i 52 (40.94%) x2 (3, 127)=33.175, p value <0.001* 27 (31.4%) x2 (3, 86)=38.6 p value <0.001*ii 61 (48.03%) 48 (55.81%) iii 14 (11.02%) 11 (12.79%) total 127 86 * denotes satistitically significant. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bali h et al. the relationship of the mandibular canal to the roots of impacted third molars the root factor: a panoramic radiographic study. jlmc.edu.np available between the anterior border of the ascending ramus and the distal aspect of the second molar when correlated with the darkening of roots showed class ii (table 5: right side-48.03%, left side-55.81%) followed by class i (right side-40.94%, left side31.4%) as most related. the results were statistically highly significant (p<0.001). discussion: one of the complications of extraction of impacted mandibular third molars is dysaesthesia due to injury to the ian either directly or following hematoma formation. rood and shebab[5] studied and recognized various radiographic risk predictor signs. with the coming of new and advanced 3 d imaging modalities, investigations for pre-operative decision making have become an indispensable tool. still panoramic radiographs hold their own significance when coming to pre-operative investigation for impacted tooth extraction as they are easily accessible and more affordable for the patients in developing countries. males constituted more than females in our study sample in accordance with gupta et al.,[8] and deshpande.[1] in contrast, studies by jerjes,[3] knutsson et al.,[9] and szalma et al.,[10] observed a female preponderance. previous studies on panoramic radiograph reported that the darkening of the third molar root was strongly suggestive of an intimate relationship between the root and nerve, or nerve injury following third molar extraction.[4,5,11,12,13,14,15,16,17,18] our study showed that darkening of roots was most common phenomenon (with respect to gender and right and left side; table 1 and graph 1) noted on panoramic radiograph under change in roots of mandibular third molars when in contact/ superimposed by iac and that it was associated with interruption of white line of iac in majority of cases (table 2). this could be attributed to the researches reporting that darkening or dark band across the roots when in contact with the iac is due to loss of dentine caused by grooving of the root by the canal[14,19,20] or that darkening of the root may indicate thinning of the cortical plate rather than grooving of the root as observed by mahasantipiya et al.[21] our study findings were in accordance with peker et al.,[22] who reported a significant correlation between darkening of the roots and interruption of the white line on panoramic radiography and the presence of contact on cone beam computed tomography (cbct) images. study by neves et al.,[23] also concluded that darkening of roots and interruption of white line observed on panoramic radiographs, both as isolated findings and in association, were effective in determining the risk relationship between the tooth roots and the iac. our study reported that darkening of roots was most frequently associated with vertical impactions, followed by mesioangular impactions among our subjects (table 3). this was in contrast with miloro and dabell[24] who reported that mesioangular impactions followed by vertical impactions were closer to the inferior alveolar canal. deshpande et al.,[1] also reported mesioangular impactions to be associated with radiographic risk predictor signs followed by horizontal impactions, but stated it to be statistically insignificant similar to study concluded by blaeser et al.[25] monaco g et al.,[12], hashemipour ma et al.[26] and obiechina ae et al.[27] reported that the level of impaction assessed based on the pell and gregory classification showed that level a of impaction was the most common when considering both upper and lower third molars. in our study level a of impaction for mandibular third molars was most associated with darkening of roots (table 4). haung et al.,[28] in their study found that majority of impacted mandibular third molars were in pell and gregory class ii. our results showed impaction was in class ii in majority cases in respect to darkening of roots (table 5). our study was limited to the use of panoramic radiograph whereas more sophisticated imaging modalities such as cbct are available today. panoramic radiograph can be used as preliminary investigation to assess the relationship of iac and mandibular third molars. if it shows proximity between the two structures further investigations using 3 d imaging, though expensive and not as accessible as panoramic, should be considered. though this was a panoramic study, metaanalysis by atieh in 2010,[29] done to determine the diagnostic accuracy of panoramic radiographic markers in detecting the relationship between j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bali h et al. the relationship of the mandibular canal to the roots of impacted third molars the root factor: a panoramic radiographic study. jlmc.edu.np impacted mandibular third molar roots and the inferior alveolar canal suggested a reasonable diagnostic accuracy for panoramic radiography for the same. conclusion: our study showed darkening of root as the most common radiographic risk predictor sign seen on panoramic radiographs when change in roots of mandibular third molar was studied. they were statistically significantly associated with interruption of white line of iac, vertically impacted third molars and pell and gregory class ii, level a of impaction. we conclude that there is a need to properly identify radiographic risk predictor signs to avoid any surprises at the time of extraction and post operation complications following it. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available for the study. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bali h et al. the 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haiterneto f, freitas dq, bóscolo fn. correlation of panoramic radiography and cone beam ct findings in the assessment of the relationship between impacted mandibular third molars and the mandibular canal. dentomaxillofac radiol. 2012;41(7):553-7. pmid: 22282507. doi: https:// dx.doi.org/10.1259%2fdmfr%2f22263461 24. miloro m, dabell j. radiographic proximity of the mandibular third molar to the inferior alveolar canal. oral surg oral med oral pathol oral radiol endod. 2005;100(5):545-9. pmid: 16243238. doi https://doi.org/10.1016/j. tripleo.2005.03.009 25. blaeser bf, august ma, donoff rb, kaban lb, dodson tb. panoramic radiographic risk factors for inferior alveolar nerve injury after third molar extraction. j oral maxillofac surg. 2003;61(4):417-21. pmid: 12684956. doi: https://doi.org/10.1053/joms.2003.50088 26. hashemipour ma, tahmasbi-arashlow m, fahimi-hanzaei f. incidence of impacted mandibular and maxillary third molars: a radiographic study in a southeast iran population. med oral patol oral cir bucal. 2013;18(1):e140-e145. pmid: 23229243. doi: https://dx.doi.org/10.4317%2fmedoral.18028 27. obiechina ae, arotiba jt, fasola ao. third molar impaction: evaluation of the symptoms and pattern of impaction of mandibular third molar teeth in nigerians. odontostomatol trop. 2001;24(93):22-5. pmid: 11484653. 28. huang ck, lui mt, cheng dh. use of panoramic radiography to predict postsurgical sensory impairment following extraction of impacted mandibular third molars. j chin med assoc. 2015;78(10):617-22. pmid: 26041067. doi: https://doi.org/10.1016/j.jcma.2015.01.009 29. atieh ma. diagnostic accuracy of panoramic radiography in determining relationship between inferior alveolar nerve and mandibular third molar. j oral maxillofac surg. 2010;68(1):7482. pmid: 20006158. doi: https://doi. org/10.1016/j.joms.2009.04.074 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha jtm, et al. medication adherence pattern for benign prostatic hyperplasia: a cross-sectional study. 225 jlmc.edu.np ___________________________________________________________________________________ submitted: 28 june, 2020 accepted: 14 october, 2020 published: 30 october, 2020 aassociate professor, department of pharmacology, bassociate professor, department of urology, cresearch assistant, department of pharmacology, dkathmandu university school of medical sciences, dhulikhel, nepal. corresponding author: jyoti tara manandhar shrestha e-mail: jyoti777@gmail.com orcid: https://orcid.org/0000-0001-7403-3874_______________________________________________________ abstract: introduction: benign prostate hyperplasia is one of the most common diseases and a common cause of lower urinary tract symptoms in aging men. various disease management approaches to optimize the patient’s long life and efficient status where patient adherence to the prescribed treatment plays a vital role. this study evaluated the medication adherence pattern of the patients to obtain successful treatment outcomes. methods: a cross-sectional study was conducted in out-patient department of urology in a tertiary care hospital. patients diagnosed with benign prostate hyperplasia were interviewed using a structured questionnaire. results: the high expenses of medicine, fear of medication, lack of symptomatic relief were factors that showed statistically significant (p < 0.05) difference between adherent and non-adherent group. similarly, the duration of diagnosis of the adherent group was significantly less than the non-adherent group including the pattern of physical activities (p < 0.05). adherent group also had more participants working in business and services occupation compared to the non-adherent group. conclusion: the general attitude (such as fear of medication and lack of symptomatic relief) is seen as major factors that affect adherent pattern in benign prostate hyperplasia patients. these issues can be solved using proper guidance. however, the cost of medicines also posts an immense issue for the non-adherent group. keywords: adherence, benign prostate hyperplasia, lower urinary tract symptoms, non-adherence original research articlehttps://doi.org/10.22502/jlmc.v8i2.386 jyoti tara manandhar shrestha,a,d hem nath joshi,b,d prabin neupane c,d medication adherence pattern for benign prostatic hyperplasia: a cross-sectional study how to cite this article:how to cite this article: shrestha jtm, joshi hn, neupane p. medication adherence pattern for benign prostatic hyperplasia: a cross-sectional study. journal of lumbini medical college. 2020;8(2):225-232. doi: https://doi. org/10.22502/jlmc.v8i2.386 epub: 2020 october 30. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: benign prostatic hyperplasia (bph) is a proliferation of prostatic stromal cells leading to prostatic enlargement and bladder outlet obstruction, increasing bladder pressure, and reducing urine flow.[1] it is the most common disease in older age men (approximately 80% after 80 years of age).[2,3] lower urinary tract symptoms (luts) is highly prevalent among patients with bph.[2] these symptoms negatively impact men’s quality of life leading to sleep disturbances, sexual dysfunction, and reduced sexual satisfaction.[4] pharmacological drugs such as alphablockers and 5α reductase inhibitors (5-ari), antimuscarinics, phosphodiesterase-5 inhibitors (pde-5) are used for long term treatment of luts. [5,6,7] despite the effectiveness of the drugs, adherence to the treatment is also vital to treatment of this disease. poor adherence attenuates optimum clinical benefits and therefore reduces the overall effectiveness of health systems.[8,9] however, this still remains a challenge due to different factors.[5] in nepal, there is a lack of studies measuring adherence to this medication. in this study, we measured the factors affecting adherence for luts medication among bph patients attending dhulikhel hospital. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha jtm, et al. medication adherence pattern for benign prostatic hyperplasia: a cross-sectional study. 226 jlmc.edu.np methods: a cross-sectional study was carried out in the department of urology, kathmandu university hospital, dhulikhel hospital, kavre from june 2018 to december 2018 for a duration of six months after obtaining ethical clearance from institutional review committee, kathmandu university school of medical sciences (irc approval no. 49/18). an approval, to conduct study, was also taken from the urology department. the inclusion criteria for participants were their attendance to out-patient department in the department of urology, dhulikhel hospital. they had to be diagnosed with bph for a duration of greater than or equal to six months. they also needed to agree for participation in the study by giving written consent. participants were excluded if they refused to participate or were newly diagnosed with bph or under medications for less than six months duration. using the cia factbook, the male population within vulnerable age group (>24 years) for bph was found to be 20%.[11] with this, confidence level of 95% and margin of error 8.5% was used to calculate the sample size of 86. random days of the week were selected in the study period to collect the data. urology outpatient department (opd) provided treatment for three days in a week i.e. on monday, wednesday and friday. initial two random days of the week were selected to collect the data; the random days being monday and wednesday. these two days were the same throughout the study period. the participants were chosen by using convenient sampling technique on those random days of the week. a pilot study of the questionnaire was done for 10 participants for possible modifications to make questionnaire understandable, convenient to ask to patients and reduce bias in answers. these 10 participants were also selected on same random days of the week and by using convenient sampling technique. however, no modification was required and those 10 participants were also included in the final analysis. the structured questionnaire consisted of general information and factors related to adherence. general information of patients included age, marital status, literacy, ethnicity and occupation along with their lifestyle choices such as alcohol consumption, smoking, physical activities and duration of diagnosis. factors such as perception about medication, belief about their illness, reasons for doses missed, and their knowledge about disease and medication were asked concerning to adherence. during study, the confidentiality of patients was maintained. based on the reported age, the study participants were categorized into six groups in 10-year increments. the data was tabulated in msexcel and was analyzed by statistical package for social science (spsstm) software version 16. continuous variables were expressed in terms of mean ± standard deviation (sd), while categorical variables were expressed in terms of frequency and percentages. association between the variables and factors affecting adherence was calculated using the chi-square test or fisher-exact test whichever was applicable. p value less than 0.05 was considered as statistically significant. results: a total of 91 patients were included for the study that met the inclusion criteria. the mean ± sd age of the study population was 66.4±19.9 years. table 1 lists demographic characteristics of the participants with the chi-square test comparing each feature between adherent and non-adherent groups. among the participants who missed their medicine, reasons mentioned were medicine finished (38.6%), carelessness (38.6%), expenses (11.4%), forgot (9.1%) and travel (2.3%). the chi-square test comparing the adherent and non-adherent pattern in participants with different occupation (table 1 ) showed that the frequency of adherent group doing business and services related work was statistically significant (p=0.013). table 2 shows the lifestyle choices and patient history with chi-square test compared between adherent and non-adherent groups. although 76.9% (n=70) of the participants were not doing regular physical activities, the adherent group had significantly higher participants doing physical activities than the non-adherent group (p=0.039). when comparing the duration of diagnosis of disease, the adherent group consisted of statistically significant participants with newly diagnosed cases (p=0.017). j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha jtm, et al. medication adherence pattern for benign prostatic hyperplasia: a cross-sectional study. 227 jlmc.edu.np chi-square test comparing different factors affecting adherence is shown in table 3. the higher proportion of participants (n=20) from the non-adherent group said they would stop taking medicine if they feel better (p=0.047) compared to the adherent group. the same group also said they have not received symptomatic relief compared to the adherent group (p=0.003). the adherent group posed that they have no fear related to medication compared to non-adherent group (p=0.001). a higher proportion of non-adherent patients said that medicines were not affordable when compared with the adherent group and the difference was statistically significant (p=0.047). patients were also asked if they had any adverse effects with the medication. drowsiness (n=8), dizziness (n=8) and running nose (n=3) were reported by the patients. however, adverse effects did not separate between the adherent and non-adherent group (p=0.512). discussion: in this study, we aimed to measure the factors affecting adherence for luts medication among bph patients. the study showed majority of individuals belonged to age group above 50 years. this finding is consistent with another study conducted in italy in which majority of individuals belonged to age group 55-85 years.[11] our study also found the prevalence of bph in the age group below 50 years. the onset of bph in this age group may be associated with the use of gonadotropin supplement therapy for undescended testes and the mother’s utilization of a human chorionic gonadotropin-containing agent during pregnancy to prevent spontaneous abortion.[12] adherence to prescribed medication is crucial in the management of patients suffering from bph. it is, therefore, important to understand the table 1. demographic characteristics and adherence to treatment (n = 91) variables frequency (%) adherent non-adherent statistics age group (years) 30-40 2 (2.1) 1 1 x2 =2.068, df = 5, p = 0.840 41-50 6 (6.6) 4 2 51-60 19 (20.9) 11 8 61-70 29 (31.9) 16 13 71-80 28 (30.8) 12 16 81-90 7 (7.7) 3 4 marital status married 88 (96.7) 47 41 x2 =3.31, df = 1, p = 0.068 unmarried 2 (3.3) 0 3 literacy literate 61 (67) 34 27 x2 = 1.239, df = 1, p = 0.265 illiterate 30 (33) 13 17 ethnicity brahmin 33 (36.2) 16 17 x2 =1.844, df = 4, p = 0.764 chhetri 28 (30.8) 16 12 newar 17 (18.7) 10 7 mongolian 6 (6.6) 2 4 others 7 (7.7) 3 4 occupation farmer 29 (31.9) 10 19 x2 = 10.7, df = 3, p = 0.013* business 24 (26.4) 16 8 services 21 (23.0) 15 6 unemployed 17 (18.7) 6 11 * statistically significant (p < 0.05) j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha jtm, et al. medication adherence pattern for benign prostatic hyperplasia: a cross-sectional study. 228 jlmc.edu.np table 2. lifestyle variables and adherence to treatment (n = 91). n (%) adherent non adherent statistics alcohol x2 = 0.020, df = 2, p = 0.990yes 21 (23.1) 11 10 occasionally 19 (20.9) 10 9 no 51 (56.0) 26 25 smoking x2 = 1.386, df = 5, p = 0.5current 15 (16.5) 6 9 ex-smoker 29 (31.9) 17 12 never 47 (51.6) 24 23 physical activities x2 = 4.277, df = 1, p = 0.039*yes 21 (23.1) 15 6 no 70 (76.9) 32 38 duration of diagnosis x2 = 10.255, df = 3, p = 0.017*<1 year 46 (50.5) 31 15 1 – 5 year 36 (39.6) 14 22 5 – 10 year 6 (6.6) 1 5 >10 year 3 (3.3) 1 2 * statistically significant (p < 0.05) determinants of poor adherence which is a must to obtain successful treatment outcomes.[2] although adherent patient have higher literacy number this was not statistically significant. higher adherence among the patients in particular occupation group suggests that the occupation might be an important factor for adherence. this study found that majority of patients did not consume alcohol. this finding may account for the fact that moderate alcohol consumption decrease the risk of bph as suggested by study of parson et al., in older men with bph.[13] the current study found that there was no clear idea of cigarette smoking as modifiable factors. there are conflicting data on the effect of cigarette smoking on serum levels of various sex hormones. some studies suggested that cigarette smoking produces an antiestrogenic effect. [14] the majority of the patients in this study were not involved in any types of physical activities. this finding is consistent with different other studies demonstrating that the bph is associated with modifiable risk factors of cardiovascular disease and suggest that increased physical activity may prevent or attenuate the conditions.[16,17] this could be that the newly diagnosed participants are more likely to follow the prescription. smoking may also affect the metabolism of other sex steroids such as testosterone and adrenal hormones, and thereby influence the incidence of benign and malignant growth of prostate.[15] absence or reduction of symptoms of the illness contribute significantly to non-adherence to medication.[9] in contrast to this, in our study, a majority of patients continued taking medication despite reduction of symptoms. there is significant association observed between symptomatic relief and adherence to medication. the findings of current study also suggested higher non-adherence to medication in those patients who think the medication is not helping in the reduction of symptoms. the possible explanation might be that patients failed to realise or were not informed about the longer time taken for improvement in the symptoms. patient’s perception about the nature and severity of disease influences the adherence.[18] in the current study, it was found that the majority of patients perceived that the disease can only be managed symptomatically but still they were nonadherent to medication. however, some patients also perceived the disease as curable. furthermore, the current study has shown that the majority of patient continued medication despite the reduction of symptoms which is different from the results of other j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha jtm, et al. medication adherence pattern for benign prostatic hyperplasia: a cross-sectional study. 229 jlmc.edu.np table 3. factors affecting adherence to treatment (n = 91) n (%) adherent non-adherent statistics knowledge about medication x2 = 1.682, df =1, p = 0.194 yes 77 (84.6) 42 35 no 14 (15.4) 5 9 difficulty in taking medication x2 = 0.207, df = 1, p = 0.648 yes 9 (9.8) 4 5 no 82 (90.2) 43 39 patient’s perception about disease x2 = 4.52, df = 2, p = 0.104 curable 30 (33.0) 20 10 incurable 21 (23.1) 8 13 can be only managed symptomatically 40 (43.9) 19 21 stop taking medicine when feeling better x2 = 3.95, df = 1, p = 0.047* yes 32 (35.2) 12 20 no 59 (64.8) 35 24 adverse effects x2=0.431, df =1, p = 0.512 yes 17 (18.7) 10 7 no 74 (81.3) 37 37 symptomatic relief x2 = 8.910, df = 1, p = 0.003* yes 65 (71.4) 40 25 no 26 (28.6) 7 19 knowledge about effect if patient does not take medicine x2 = 0.775, df = 1, p = 0.379 yes 60 (65.9) 29 31 no 31 (34.1) 18 13 risk/fear regarding medication x2 = 11.61, df = 1, p = 0.001* yes 21 (23.1) 4 17 no 70 (76.9) 43 27 self-administration x2 = 0.610, df = 1, p = 0.425 yes 10 (11.0) 4 6 no 81 (89.0) 43 38 medicine affordability x2 = 3.930, df = 1, p = 0.047* yes 79 (86.8) 44 35 no 12 (13.2) 3 9 medicine availability x2 = 3.014, df = 1, p = 0.083 yes 73 (80.2) 41 32 no 18 (19.8) 6 12 follow up x2 = 3.463, df = 1, p = 0.063 yes 82 (90.1) 45 37 no 9 (9.9) 2 7 special attention from doctor x2 = 0.594, df = 1, p = 0.441 yes 78 (85.7) 39 39 no 13 (14.3) 5 8 * statistically significant (p < 0.05) j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha jtm, et al. medication adherence pattern for benign prostatic hyperplasia: a cross-sectional study. 230 jlmc.edu.np studies on medication adherence on various chronic diseases.[19] lack of clinical symptoms might often be interpreted as disease free by patients resulting on tendency to discontinue the daily medications as suggested by various studies.[19] risk/fear regarding the medication also greatly influences the adherence to the medication. [4] in this study, the majority of patients did not have risk/fear regarding medication. comparing to the non-adherent group, there was less risk/ fear regarding medication in the adherent group. this relation was statistically significant. while in patients who did not have such risk/fear regarding the medication might have helped them to achieve better adherence to medication. in this study, adverse effects were reported by only 18.68% of patients. the most common side effects experienced by patients were drowsiness, dizziness and nasal congestion. it has been found that ejaculatory dysfunctions are more common among uroselective anatogonists (tamsulosin) due to their concentrated action in the lower urinary tract.[5] but in this study such adverse effects were not reported by the patients. similarly, side effects of finasteride like loss of libido, erectile dysfunction, ejaculatory dysfunctions (less common), breast engorgement and gynecomastia were also not reported by the patients. [20,21] this finding supports the idea that the patients might have hesitated to report these adverse effects as it is related to sexual dysfunction. however, there was no significant association found between adverse effects and the adherence to medication. in contrast, non-adherence to medication due to occurrences of adverse effects have been observed in patients with type ii diabetes mellitus.[22] in this study, the majority of the adherent patients reported that the medicines were affordable. taking medicines on their own might have led to good adherence among those patients though there was no significant association found between them. in contrast, the findings from previous studies have shown that patients who received support from their family members in the course of therapy had better adherence to medication.[23] several studies have shown that patients tend to skip doses, reduce doses because they cannot afford to pay for medications. [24] the present study has showed that majority of the non-adherent patients could not afford the prescribed medicines. although, unaffordability of medicines might have led to non-adherences to medication, no significant association was found. among the non-adherence patients, the majority of them had missed doses due to lack of affordability of medicine. in our study there were some limitations as the study was cross-sectional and limited to only one center. a multi-centered follow-up study might provide a better scenario of adherence. improving on the margin of error with higher sample size could help interpret the data better. conclusion: we found that symptomatic relief, risk/ fear of taking medicine, stopping taking medicine when feeling better and affordability of medicine were primary reasons affecting adherence to the treatment. adherence to medication is crucial to treat bph. poor adherence to medication regimen and to other non-drug therapy possess significant barrier to optimum management of bph. this study provides knowledge about the adherence pattern of pharmacological therapy of bph and various factors regarding adherence pattern influencing in bph treatment. acknowledgement: our sincere thanks to department of urology of dhulikhel hospital, mr. aman maharjan, mr. himal shrestha and dr. pratigya bhattarai. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available for the study. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 shrestha jtm, et al. medication adherence pattern for benign prostatic hyperplasia: a cross-sectional study. 231 jlmc.edu.np references: 1. kapoor a. benign prostatic hyperplasia (bph) management in the primary care setting. can j urol. 2012;19 suppl 1:10-7. pmid: 23089343 2. raza i, hassan n, jafri a, gul p. relationship between benign prostatic hyperplasia and international prostatic symptom score. british journal of medicine & medical research. 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pmid: 22879203. doi: https://doi.org/10.1158/1055-9965.epi-12-0695 21. liu l, zhao s, li f, li e, kang r, luo l, et al. effect of 5α-reductase inhibitors on sexual function: a meta-analysis and systematic review of randomized controlled trials. j sex med. 2016;13(9):1297-1310. pmid: 27475241. doi: https://doi.org/10.1016/j.jsxm.2016.07.006 22. sweileh wm, zyoud sh, abu nab’a rj, deleq mi, enaia mi, nassar sm, et al. influence of patients’ disease knowledge and beliefs about medicines on medication adherence: findings from a cross-sectional survey among patients with type 2 diabetes mellitus in palestine. bmc public health. 2014;14:94. pmid: 24479638. doi: https://doi.org/10.1186/1471-2458-14-94 23. miller ta, dimatteo r. importance of family/ social support and impact on adherence to diabetic therapy. diabetes metab syndr obes. 2013;6(0)421-6. pmid: 24232691. doi: https:// doi.org/10.2147/dmso.s36368 24. de nunzio c, presicce f, lombardo r, trucchi a, bellangino m, tubaro a, et al. patient centred care for the medical treatment of lower urinary tract symptoms in patients with benign prostatic obstruction: a key point to improve patients’ care – a systematic review. bmc urol. 2018;18(1):62. pmid: 29940928. doi: https://doi.org/10.1186/ s12894-018-0376-x j. lumbini. med. coll. vol 8, no 2, july-dec 2020 maharjan n, et al. bacteriological profile of wound infection and antibiotic susceptibility pattern of various isolates in a tertiary care center. 218 jlmc.edu.np ___________________________________________________________________________________ submitted: 02 june, 2020 accepted: 14 october, 2020 published: 29 october, 2020 alecturer, department of microbiology, bprofessor and head, department of microbiology, clumbini medical college and teaching hospital, palpa, nepal. corresponding author: nabina maharjan e-mail: nabinamaharjan75@gmail.com orcid: https://orcid.org/0000-0003-1873-4646_______________________________________________________ abstract: introduction: wound infection due to various pathogenic microorganisms and the development of resistance to antibiotics is one of the major problems in medical sector. this study aimed to identify the etiological agents of wound infection along with their antibiotic susceptibility. methods: a total of 400 wound swab specimens were collected from the patients visiting a tertiary center in western nepal over a period of six months. thus, collected specimens were processed in microbiology laboratory for isolation of causative agents. antibiotic susceptibility test was performed for entire isolates by kirby baur disc diffusion method. methicillin-resistant staphylococcus aureus was detected by cefoxitin disc diffusion test and extended-spectrum beta-lactamases producing enterobacteriaeae by phenotypic confirmatory disc diffusion test as recommended by clinical and laboratory standards institute. results: two hundred and fifty-nine (64.7%) of specimens were infected, giving rise to 269 different isolates. among these, 163 (60.6%) were gram positive and 104 (38.6%) were gram negative. staphylococcus aureus (n = 130, 48.3%) was the most predominant bacteria followed by escherichia coli (n=44, 16.3%), and klebsiella pneumoniae (n=23, 8.5%). gentamicin followed by co-trimoxazole was the most effective among the tested antibiotics for staphylococcus aureus. gentamicin and ciprofloxacin were shown effective for isolated gram-negative bacteria. conclusion: fifty-eight (44.6%) of total staphylococcus aureus were methicillin-resistant staphylococcus aureus positive and 16 (20.7%) of total enterobacteriaceae were extended-spectrum beta-lactamases producers. the increased prevalence of methicillin-resistant staphylococcus aureus and extended-spectrum beta-lactamase suggest rational use of antibiotics on the basis of antibiotic sensitivity results. keywords: antibiotic susceptibility test, extended-spectrum beta-lactamases, methicillin-resistant staphylococcus aureus original research articlehttps://doi.org/10.22502/jlmc.v8i2.367 nabina maharjan,a,c bs mahawal b,c bacteriological profile of wound infection and antibiotic susceptibility pattern of various isolates in a tertiary care center how to cite this article:how to cite this article: maharjan n, mahawal bs. bacteriological profile of wound infection and antibiotic susceptibility pattern of various isolates in a tertiary care center. journal of lumbini medical college. 2020;8(2):218-224. doi: https://doi.org/10.22502/jlmc.v8i2.367 epub: 2020 october 29. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: a wound is any breach or damage in skin due to trauma, accident, surgical operation or burn providing route of entry for bacteria causing infection. wound infection is the result of successful invasion and proliferation by one or more species of microorganisms, sometimes resulting in pus formation.[1] skin is colonized by transient as well as resident commensal floras.[2] these floras will remain commensal until skin remains intact. any abrasion in skin surface provides an open door for bacterial invasion leading to infection.[3] both aerobic and anaerobic bacteria often join to form synergistic infections like gangrene, necrotizing fasciitis, and cellulitis of skin and soft tissue.[2] wound infection can be due to variety of microorganisms ranging from bacteria, fungi, parasites and virus.[4] the common responsible bacterial pathogens are staphylococcus aureus, j. lumbini. med. coll. vol 8, no 2, july-dec 2020 maharjan n, et al. bacteriological profile of wound infection and antibiotic susceptibility pattern of various isolates in a tertiary care center. 219 jlmc.edu.np pseudomonas aeruginosa, acinetobacter spp. and bacteria belonging to the family enterobacteriaceae. [1] wound infections may be caused by only one pathogen known as mono-microbial or by more than one pathogen known as poly-microbial. the control of wound infection has become more challenging due to widespread bacterial resistance to antibiotics. hospital acquired wounds are among the leading nosocomial cause of morbidity and increasing medical expense.[1] infection caused by methicillin resistant staphylococcus aureus (mrsa) and extended spectrum beta lactamase (esbl) producers pose a major challenge in the treatment of wound infection.[5] so, appropriate drugs selected by antibiotic sensitivity testing have great importance. the aim of this study was to identify the etiologies of various wound infections along with their antibiotic susceptibility. further, we also observed the prevalence of mrsa and esbl producing gram negative bacilli involved in wound infections. methods: this prospective study was conducted in the department of microbiology of lumbini medical college and teaching hospital (lmcth) over a period of six months from september 2019 to february 2020. ethical approval was obtained from the institutional review committee of the institute (irc – lmc 22-g/o19). the sample size was calculated by using the formula, n = zα 2pq/d2. taking the prevalence of wound infection (p)= 0.43,[6] and maximum tolerable error (d) as 0.05, the required minimum sample size calculated was 376. a total of 400 pus/ wound swab samples collected from both sexes and all aged patients sent to the microbiology department from various departments for aerobic bacterial culture were included in the study. dry wound swabs and improperly labelled specimens were excluded. quality control: strain of escherichia coli atcc 25922 and staphylococcus aureus atcc 25923 were used as reference strains for quality control of antibiotic sensitivity test and biochemical test. the same strain of escherichia coli and staphylococcus aureus were used as negative control for esbl and mrsa detection respectively. sample collection and processing: convenient sample technique was used for collection of samples. sterile cotton swabs or sterile syringes were used to collect pus samples from infected wound and were labeled properly with patient’s details along with date and time of sample collection. the collection and labeling of samples were done by trained nurses of respective departments. collected samples were delivered to microbiology laboratory within an hour for microbiological tests. all the microbiological tests were carried out by researchers themselves. macroscopic examination was performed for aspirated pus samples to note color, consistency and presence of granules. microscopic examination was done after gram stain for presumptive identification of gram positive and gram-negative bacteria. culture and identification of isolates: samples were inoculated into macconkey agar and blood agar. they were then incubated at 37ºc for 24 hours. after incubation, grown isolates were identified according to standard microbiological criteria such as colonies morphology, gram stain and biochemical properties.[7] gram positive cocci were identified up to species level by catalase test, coagulase test, bile esculin hydrolysis test and by using optochin and bacitracin disc whereas gram negative bacilli were identified by catalase test, oxidase test, methyl red test, voges prouskaure test, indole test, motility, hydrogen sulfide production, triple sugar iron test, urease test and citrate test.[7] antibiotic susceptibility test: antibiotic susceptibility test was performed for all bacterial isolates by a modified kirby – bauer disk diffusion method according to the guidelines of clinical and laboratory standard institute on mueller hinton agar.[8] antibiotic disc (hi media laboratories, pvt. limited, india) such as ampicillin (10 mcg), cloxacillin (10 mcg), cefoxitin (30 mcg), ciprofloxacin (5 mcg), cefixime (5 mcg), gentamicin (10 mcg), co-trimoxazole (25 mcg), cefotaxime (30 mcg), ceftazidime (30 mcg), piperacillin (100 mcg), carbenicillin (100 mcg), tetracycline (30 mcg), imipenem (10 mcg), amikacin (30 mcg), vancomycin (30 mcg), piperacillin-tazobactam (100/10 mcg) and linezolid (30 mcg) were used for antibiotic susceptibility tests. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 maharjan n, et al. bacteriological profile of wound infection and antibiotic susceptibility pattern of various isolates in a tertiary care center. 220 jlmc.edu.np identification of mrsa: cefoxitin (30 mcg) was used for identification of mrsa. staphylococcus aureus which showed a zone of inhibition ≤ 21 mm with cefoxitin on mueller hinton agar after overnight incubation at 35º c were considered as mrsa.[8] screening and confirmation of esbl: enterobacteriace showing zone of inhibition ≤ 27 for cefotaxime (30 μg) and/or ≤ 22 for ceftazidime (30 μg) and/or ≤ 25 for ceftriaxone (30 μg) and/or ≤ 27 for aztreonam (30 μg) respectively, the strain was suspected as a potential esbl produce. the isolates that were selected as potential esbl producers using the screening method were confirmed when inhibition zones of ceftazidime, clavulanic acid and cefotaxime clavulanic acid were greater or equal to 5 mm compared with ceftazidime and cefotaxime alone.[8] data were analyzed by statistical package for social science (spsstm) software version 18. data were presented as frequency and percentage. chi square test was calculated for categorical variables to analyze significant difference at 95% confidence interval. a p value < 0.05 was considered statistically significant. results: out of 400 samples collected from suspected wound infection, 259 (64.7%) showed growth of aerobic organism whereas 141 (35.3%) showed no growth. ten (2.5%) specimens showed growth of two different bacteria so total bacterial isolates was 269. among 269 isolates, 163 (60,6%) were gram positive and 104 (38.6%) were gram negative and two (0.7%) were candida albicans. among total specimens, 142 (35.5%) were aspirated pus and 258 (64.5%) were wound swabs. ninety-two (64.8%) of aspirated pus and 167 (64.7%) of wound swab showed growth. one hundred and eighty-nine (47.3%) of total specimens were collected from male patients and 211 (52.7%) were collected from female patients. most specimens were collected from the age group 21-40 years (33.2%) as presented in table 1. out of 400 cases, 276 (69%) were collected from in-patient departments; 130 cases were from surgery, 74 from orthopedics, 36 from gynecology, 16 from ear, nose and throat (ent), nine from intensive care unit (icu), five from pediatrics and six from internal medicine. sixteen (4%) were from emergency department (ed) and 108 (27%) from out-patient department (opd). out of 276 inpatients, 171 (61.9%) were growth positive, out of 108 out-patients, 77 (71.2%) were growth positive and out of 16 ed patients, 11 (68.7%) were growth positive. organisms isolated from wound infections are shown in figure 1. the antibiotic sensitivity patterns of gram positive and gram-negative bacteria are shown in table 2 and table 3 respectively. out of 130 staphylococcus aureus, 58 (44.6%) were mrsa positive. of them, 18 (31.1%) were isolated from surgery department, 13 (22.4%) were from orthopedics department, six (10.3%) were from obstetrics and gynecology department, 12 (20.6%) from opd, three (5.2%) from icu, three (5.2%) from ent department, two (3.5%) from pediatrics department and one (1.7%) from ed. out of 77 gram negative bacilli belonging to enterobacteriaceae family, 16 (20.7%) were esbl positive. eleven (68.7%) were escherichia coli, four (25%) were klebsiella pneumoniae, one (6.3%) table 1. type of specimen, sex and age wise distribution of wound infection (n = 400) variables growth (%) no growth (%) statistics specimen aspirated pus 92 (64.8%) 50 (35.2%) x2 = 0.008, df =1, p = 0.990 wound swab 167 (64.7%) 91 (35.3%) sex male 122 (64.6%) 67 (35.4%) x2= 0.006, df = 1, p = 0.937 female 137 (64.9%) 74 (35.1%) age (years) <20 79 (73.1%) 29 (26.9%) x2 = 5.53, df = 3, p = 0.137 21 40 84 (63.2%) 49 (36.8%) 41 60 52 (57.8%) 38 (42.2%) >60 44 (63.8%) 25 (36.2%) j. lumbini. med. coll. vol 8, no 2, july-dec 2020 maharjan n, et al. bacteriological profile of wound infection and antibiotic susceptibility pattern of various isolates in a tertiary care center. 221 jlmc.edu.np was enterobacter spp. antibiotic susceptibility test of both mrsa and esbl producers are shown in table 4. discussion: we conducted this study to identify the etiologies of various wound infections along with their antibiotic susceptibility. in this study, 259 (64.7%) specimens were found to be infected which was almost similar to the study carried out by sah et al. and upreti et al. that reported 62%.[9, 10] kc et al. reported 60.2% growth positive rate.[11] this reflects that wound infection is a major clinical challenge. in our study, 71.2%, 68.7% and 61.9 of specimens collected from opd, ed and in-patient table 2. antibiotic sensitivity pattern of gram-positive bacteria. bacteria frequency (%) of sensitivity to various antibiotics, n(%) amp cip cox cx cfm gen cot staphylococcs aureus (n = 130) 23 (17.7) 60 (46.2) 90 (69.2) 72 (55.4) 29 (22.3) 96 (73.8) 82 (63.1) enterococus spp (n =10) 9 (90) 10 (100) nt nt 6 (60) 6 (60) 9 (90) streptococcus spp (n = 8) 7 (87.5) 6 (75) nt nt 7 (87.5) 7 (87.5) 4 (50) coagulase negative staphylococcus (n = 15) 2 (13.3) 7 (40.7) 9 (60) 6 (40) 3 (20) 8 (53.3) 6 (40) amp – ampicillin, cip – ciprofloxacin, coxcloxacillin, cxcefoxitin, cfmcefixime, gengentamicin, cotcotrimoxazole, ntnot tested table 3. antibiotic sensitivity pattern of gram-negative bacteria. bacteria frequency (%) of sensitivity to various antibiotics, n(%) amp cip cfm gen cot ctx caz cb pi pit citrobacter spp (n = 5) 3 (60) 5 (100) 4 (80) 5 (100) 5 (100) 5 (100) 4 (80) nt nt nt escherichia coli (n = 44) 16 (36.4) 29 (65.9) 18 (40.9) 32 (72.7) 19 (43.2) 29 (65.9) 22 (50) nt nt nt klebsiella pneumoniae (n = 23) 0 (0) 16 (69.6) 13 (56.5) 15 (65.2) 13 (56.5) 13 (56.5) 13 (56.5) nt nt nt pseudomonas aeruginosa (n = 17) 1 (5.9) 13 (76.5) nt 12 (70.6) 4 (23.5) nt 9 (52.9) 11 (64.7) 10 (58.8) 16 (94.1) proteus spp (n = 3) 1 (33.3) 2 (66.7) 3 (100) 3 (100) 2 (66.7) 3 (100) 2 (66.7) nt nt nt acinetobacter spp (n = 9) 2 (22.2) 4 (44.4) 2 (22.2) 4 (44.4) 3 (33.3) 2 (22.2) 2 (22.2) nt nt nt enterobacter spp (n = 2) 1 (50) 1 (50) 0 (0) 0 (0) 0 (0) 1 (50) 1 (50) nt nt nt chromobacterium voilacium (n = 1) 0 (0) 1 (100) 0 (0) 1 (100) 1 (100) 1 (100) 1 (100) nt nt nt amp ampicillin, cip ciprofloxacin, cfm cefixime, gen gentamicin, cot cotrimoxazole, ctx cefotaxime, caz ceftazidime, cb carbenicillin, pi piperacillin, pip piperacillin tazobactam j. lumbini. med. coll. vol 8, no 2, july-dec 2020 maharjan n, et al. bacteriological profile of wound infection and antibiotic susceptibility pattern of various isolates in a tertiary care center. 222 jlmc.edu.np department respectively showed growth. the study done by yakha et al. showed 54.9%, 38.8% and 20.3% growth in in-patient, out-patient and ed respectively.[4] in our study, low growth rate in in-patient may be due to collection of specimens after antibiotic treatment or may be due to improper collection and transport up to laboratory. table 4. antibiotic sensitivity pattern of mrsa and esbl producers. antibiotic mrsa (n = 58) esbl (n = 16) frequency (%) frequency (%) ampicillin 0 (0) 0 (0) ciprofloxacin 13 (22.4) 04 (25) cefoxitin 0 (0) nt cefixime 0 (0) 0 (0) gentamicin 29 (50) 09 (56.3) cotrimoxazole 36 (62.1) 01(6.3) cefotaxime nt 0 (0) ceftazidime nt 0 (0) imipenem nt 15 (93.8) vancomycin 58 (100) nt amikacin 46 (79.3) 11 (68.8) tetracycline nt 08 (50) piperacillin tazobactam nt 14 (87.5) linezolid 58 (100) nt the growth of bacteria in both male and female specimens was almost similar in our study; 64.6% in male and 64.9% in female. whereas, the most studies showed higher growth of bacteria in specimens of male compared to female.[11, 14] the reason for this contrast finding may be the number of female patients included in our study is slightly higher than male patients. monomicrobial wound infection (96.13%) was higher than polymicrobial (3.8%). this was agreed by upereti et al and kc et al.[10, 11] the patient belonging age group < 20 (73.1%) were found to be highly infected followed by > 60 (63.8%). this may be due to weak immune system of old patients, and relatively younger patients and children. the isolation rate of gram-positive bacteria was greater (60.6%) than gram negative bacteria (38.6%) in our study. khanam et al. and pandey et al. showed similar results.[12,13] but giri et al. and sherchan et al. showed high isolation rate of gram negative bacteria.[14,15] staphylococcus aureus was the most predominant (48.3%) bacteria followed by escherichia coli (16.3%), similar to the studies conducted by kc et al. and pandey et al.[11,13] mahat et al. showed predominance of pseudomonas species.[6] the high rate of isolation of staphylococcus aureus in wound infection may be due to its presence in nasal cavity, as a normal flora, of most of the individuals. the unhygienic behavior like contact of wound site with the hand contaminated with the nasal discharge may be the possible reason. the carriers are two to nine times more likely to acquire infection than non-carriers. [16] isolation rate of gram-negative bacteria was found to be more (35.7%) than gram positive bacteria (29.6%) in the surgery department. this finding was just opposite in the orthopedics department where gram positive rate was 20.1% and gram negative was 14.3%. this was agreed by study done by kc et al.[11] gastrointestinal tract is a source of gram negative bacteria to contaminate wound so abdominal surgery without much precautions can be the reason whereas gram positive bacteria were generally acquired from skin surface itself to contaminate wound. the most effective antibiotic for staphylococcus aureus was gentamicin (73.8%) whereas ampicillin (17.7%) was least effective antibiotic. giri et al. also showed gentamicin fig. 1. organisms isolated from wound infection. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 maharjan n, et al. bacteriological profile of wound infection and antibiotic susceptibility pattern of various isolates in a tertiary care center. 223 jlmc.edu.np (77.78%) as effective drug and ampicillin (6.17%) as the least effective antibiotic.[14] escherichia coli was also highly sensitive to gentamicin (72.7%) followed by cefotaxime (65.9%) and ciprofloxacin (65.9%). again, ampicillin (36.4%) was the least effective. piperacillin tazobactam was an effective antibiotic for pseudomonas aeruginosa (94.1%) followed by ciprofloxacin (76.5%), and gentamicin (70.6%). similar study done by sherchan et al. showed all these three antibiotics were effective equally (80%).[15] fifty-eight (44.6%) of total staphylococcus aureus specimens were mrsa positive. this was slightly lower than the studies done by balchandra et al. (67.6%) and giri et al. (53.06%).[1,14] and was slightly higher than the study by pant et al.(30.70%). [5] this shows prevalence of mrsa is in increasing trend. the most effective drugs for mrsa were linezolid and vancomycin with 100% sensitivity followed by amikacin (79.3%). this was similar to the study done by harshan et al.[17] sixteen (20.7%) of enterobacteriaceae specimens were esbl positive similar to the study done by upreti et al. (22.7%).[10] but it was slightly lower than that reported by balchandra et al. (38.12%).[1] this slight difference may be because the prevalence of esbl producing isolates varies geographically. the effective antibiotic for esbl producers was found to be imipenem (carbapenems) (93.8%) followed by piperacillin-tazobactam (87.5%). sherchan et al. also showed highest sensitivity (97.14%) to meropenem (carbapenems). [15] there are a few limitations of the study. in this study esbl test was done only for enterobacteriaceae and not for other bacterial isolates. similarly, genetic level test, that identify the gene sequence responsible for mrsa and esbl producers, was also not performed. besides this, single centered study conducted in small sample size for small duration was also the limitation. conclusion: staphylococcus aureus was the main bacterial causative agent of wound infection followed by escherichia coli and klebsiella-pneumoniae. the antibiotic sensitivity pattern showed decreased sensitivity to most of the commonly used antibiotics like beta-lactams. proper care of wounds and early microbial analysis along with their antibiotic sensitivity test are therefore crucial for wound management. on the basis of the result, treatment of infection should be done with appropriate antibiotics like in case of mrsa, vancomycin and linezolid is the best antibiotic and in case of esbl producers carbapenem is the best antibiotic. the emergence of carbapenem resistant gram negative bacteria suggests performing metallo beta lactamase test to check whether the resistance is due to production of metallo beta lactamase or not. acknowledgement: menuka maharjan (laboratory assistant) and kamal thapa (laboratory technician) of clinical laboratory of microbiology department. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available for the study. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 maharjan n, et al. bacteriological profile of wound infection and antibiotic susceptibility pattern of various isolates in a tertiary care center. 224 jlmc.edu.np references: 1. balchandra mh, naik sd, verma pk. aerobic bacterial profile of wound infections and its sensitivity pattern at tertiary care hospital. international journal of current microbiology and applied sciences. 2018;7(6):1668-79. doi: https://doi.org/10.20546/ijcmas.2018.706.198 2. brooks gf, carroll kc, butel js, morse sa. jawetz, melnick and adelberg’s medical microbiology. 26th ed. new york: mcgraw hill lange, new york; 2013. http://microbiology. sbmu.ac.ir/uploads/jawetz_2013__medical_ miceobiology.pdf 3. ohalete cn, obi rk, emeakoroha mc. bacteriology of different wound infection and their antimicrobial susceptibility patterns in imo state nigeria. world journal of pharmacy and pharmaceutical sciences. 2012;3(1):1155-72. available from: https://www.researchgate.net/ publication/332849521 4. yakha jk, sharma ar, dahal n, lekhak b, banjara mr. antibiotic susceptibility pattern of bacterial isolates causing wound infection among the patients visiting b and b hospital. nepal journal of science and technology. 2014;15(2):91-6. doi: https://doi.org/10.3126/ njst.v15i2.12121 5. pant m, shrestha d, thapa s. antibiogram of bacterial species causing skin wound infections. novel research in microbiology journal. 2018;2(3):53-7. doi: https://doi.org/10.21608/ nrmj.2018.8153 6. mahat p, manandhar s, baidya r. bacteriological profile of wound infection and antibiotic susceptibility pattern of the isolates. journal of microbiology & experimentation. 2017;4(5):00126. doi: https://doi.org/10.15406/ jmen.2017.04.00126 7. cheesbrough m. district laboratory practice in tropical countries. 2nd ed. cambridge, uk: cambridge university press; 2009. doi: https:// doi.org/10.1017/cbo9780511543470 8. clinical laboratory standarda institute (clsi). performance standards for antimicrobial susceptibility testing. 29th ed. clsi supplement m100 wayne, pa: clinical and laboratory institute; 2019. https://clsi.org/media/2663/ m100ed29_sample.pdf 9. sah p, khanal r, upadhaya s. skin and soft tissue infections: bacteriological profile and antibiotic resistance pattern of isolates. journal of universal college medical science. 2013;1(3):18-21. doi: https://doi.org/10.3126/ jucms.v1i3.8759 10. upreti n, rayamajhee b, sherchan sp, choudhari mk, banjara mr. prevalence of methicillin resistant staphylococcus aureus, multidrug resistant and extended spectrum βlactamase producing gram negative bacilli causing wound infection at a tertiary care hospital of nepal. antimicrobial resistance and infection control. 2018;7(0):121. doi: https://doi.org/10.1186/ s13756-018-0408-z 11. kc r, shrestha a, sharma vk. bacteriological study of wound infection and antibiotic susceptibility pattern of the isolates. nepal journal of science and technology. 2013;14(2):143-7. doi: https://doi.org/10.3126/njst.v14i2.10428 12. khanam ra, islam mr, sharif a, parveen r, sharmin i, yusuf ma. bacteriological profile of pus with antimicrobial sensitivity pattern at a teaching hospital in dhaka city. bangladesh journal of infectious disease. 2018;5(1):10-14. doi: http://dx.doi.org/10.3329/bjid.v5il.37710 13. pandey u, raut m, bhattarai s, bhatt pr, dahal pr. bacteriological profile and antibiogram of bacterial isolates from pus sample in tertiary care hospital of kathmandu. tribhuvan uni j microbiol. 2017;4(1):55-62. doi: https://doi. org/10.3126/tujm.v4i0.21678 14. giri k, gurung s, subedi s, singh a, adhikari n. antibiotic susceptibility pattern of bacterial isolates from soft tissues infection among patients visiting birendra military hospital, chhauni, kathmandu. tribhuvan uni j microbiol. 2019;6(1):119-26. doi: https://doi.org/10.3126/ tujm.v6i0.26595 15. sherchan jb, gurung p. antibiotic susceptibility pattern of bacteriological pathogens isolated from infected lesions. j nepal health res council. 2018;16(41):446-51. doi: https://doi. org/10.33314/jnhrc.v16i41.1631 16. portigliatti barbos m, mognetti b, pecorara s, picco w, veglio v. decolonization of orthopedic surgical team s. aureus carriers: impact on surgical-site infections. j orthopaed traumatol. 2010;11(1):47-9. pmid: 20119678. doi: https:// doi.org/10.1007/s10195-010-0081-3 17. harshan kh, chavan skd. prevalence and susceptibility pattern of methicillin resistant staphylococcus aureus (mrsa) in pus samples at tertiary care hospital in trivandrum, india. international journal of current microbiology and applied sciences. 2015;4(11):718-23. https:// www.ijcmas.com/archives-36.php j. lumbini. med. coll. vol 9, no 2, july-dec 2021 https://doi.org/10.22502/jlmc.v9i2.455 original research article impact of lockdown of covid 19 pandemic in pregnancy outcomes in a tertiary care centre: what to expect? anjali subedia,e, poonam magarb,e junu shresthac,e seema subedid,f abstract introduction: corona virus disease 19 (covid-19) was declared a "pandemic" in march 2020 by who and advocated lockdown measures with the use of mask, frequent hand washing and social distancing for decreasing the transmission of disease. in nepal where antenatal coverage is just 50% and institutional deliveries 54%, this lockdown has further reduced the regular antenatal visits, institutional deliveries posing an increased adverse effect in pregnancy outcome. this study aimed to reveal the impact of lockdown of covid 19 pandemic in pregnancy outcomes in a tertiary care center. methods: it was a cross-sectional, analytical study done in the department of obstetrics and gynecology, manipal teaching hospital for three months lockdown period (march 2020 to june 2020) and total deliveries along with maternal and perinatal complications were studied in the lockdown period and compared with those in non-lockdown period. results: during the lockdown period, there were total 1070 deliveries and maternal complication was seen in 17.38% of deliveries. in the non-lockdown period, there were total of 982 deliveries and maternal complication was present in 18.43% of deliveries (p= 0.53). in the study, more cases of early pregnancy complications were seen in lockdown period than in non-lockdown period. regarding obstetric complications, hypertensive disorder was the most common one observed during lockdown period whereas preterm labor was common in non-lockdown period. there was no increase in perinatal complications during lockdown period on comparing to non-lockdown period. conclusion: there was no increase in adverse pregnancy outcomes during lockdown of covid 19 pandemic in a tertiary care center. keywords: covid 19, lockdown, pandemic, pregnancy outcome. introduction: corona virus infection disease-2019 (covid 19) is a respiratory disease caused by severe acute respiratory syndrome corona virus 2 (sars-cov2) and was declared a "pandemic" in march, 2020 by who.[1] as it has a very high transmission rate with ___________________________________________________________________________________ submitted: 13 july, 2021 accepted: 30 december, 2021 published: 3 january, 2022 aassistant professor, department of obstetrics & gynaecology. bmedical officer, department of obstetrics & gynaecology. cassociate professor, department of obstetrics & gynaecology. dfaculty associate, global disease epidemiology and control division, international health department. emanipal college of medical sciences, pokhara, nepal. fjohns hopkins bloomberg school of public health, usa. corresponding author: anjali subedi. email: anzee739@gmail.com orcid: https://orcid.org/0000-0002-9809-6180 ___________________________________________________________________________________ low pathogenicity,[2] who has advocated lockdown measures with the use of mask, frequent hand washing and social distancing for decreasing the transmission from symptomatic as well as asymptomatic to the healthy people and special group of people like pregnant women, to decrease the chance of acquiring covid infection. who antenatal care (anc) guidelines 2016 recommend a minimum of eight anc visits to reduce maternal and fetal morbidities and mortalities.[3] in nepal where anc coverage is just 50% and institutional deliveries 54%, [4] this subedi a, magar p, shrestha j, subedi s. impact of lockdown of covid 19 pandemic in pregnancy outcomes in a tertiary care centre: what to expect? journal of lumbini medical college. 2022 ;9(2):7 pages. doi: https://doi.org/10.22502/jlmc.v9i2.455. epub: 3 january, 2022 how to cite this article: licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. https://doi.org/10.22502/jlmc.v9i2.455 mailto:anzee739@gmail.com https://orcid.org/0000-0002-9809-6180 https://doi.org/10.22502/jlmc.v9i2.455 subedi a, et al. impact of lockdown of covid 19 pandemic in pregnancy outcomes in a tertiary care centre: what to expect? j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np lockdown has further reduced the regular visits and institutional deliveries posing an increased adverse effect in pregnancy outcome. this study therefore aimed to reveal the impact of lockdown of covid 19 pandemic in pregnancy outcomes in our center. methods this was a cross-sectional, analytical study conducted in the department of obstetrics and gynecology, manipal teaching hospital, pokhara, nepal. it was done during the first phase of lockdown as implemented by the government for three months (march 2020 to june2020) and the data of the corresponding months of the previous year was also taken. all the women admitted to the ward either for termination of pregnancy or for delivery were enrolled in the study after their consent. however, pregnant women with early pregnancy complications(abortion and ectopic),obstetric complications like hypertensive disorder, preterm labor, pre-labour rupture of membrane, antepartum haemorrhage, intrauterine fetal demise, and others were only analyzed in the study. women not consenting for study were excluded. obstetric parameters like age at delivery, period of gestation at delivery, parity, mode of delivery, indications for caesarean section in the women with complications were studied. for perinatal outcome, variables studied were congenital anomaly, still birth and neonatal death. for all the required information of corresponding months of previous year, hospital records were used. ethical clearance was taken from institutional review committee, manipal college of medical sciences, pokhara, nepal (memg/irc/361/ga). the data were recoded and entered instata15. all the figures have been presented for two groups: lockdown versus non-lockdown groups. total deliveries are presented in number and the complication variables are presented as percentage of total complications occurring during the lockdown period. comparison of all the variables, among the lockdown and non-lockdown group, are shown through the bar diagrams and other relevant figures and tables and statistical significance was analyzed using pearson chi square test (confidence interval of 95% and p value < 0.05 as level of significance) and t-test (confidence interval of 95%and p value < 0.05 as level of significance) where applicable. the main variables of interest were • total number of deliveries in the period (lockdown and non-lockdown) • percentage of maternal complications and perinatal complications. results in the lockdown period, there were a total of 1070 deliveries. in the non-lockdown period, there were 982 deliveries. maternal complications: among 1070 deliveries, there were 186 (17.38%) cases of maternal complications during the lockdown period. in the non-lockdown period, among 982 deliveries, there were 181 (18.43%) cases of maternal complications. however, this difference was not statistically significant (χ2=0.38, df=1, p=0.53) on analyzing the profile of women with complications, the mean age, parity and mean gestational age of women having complications during lockdown were statistically not significant with those during the non-lockdown period (table 1). we found that there were increased cases of early pregnancy complications in the lockdown period in comparison to the non-lockdown period (figure 1). the most common maternal complication observed during the lockdown period was hypertensive disorderwhich accounted for48(25.8%) of total complications. among the hypertensive disorder, there were six cases of eclampsia and 42 cases of severe pre-eclampsia. it was also observed that there were 37 (19.89%)cases of preterm labor, 26 (13.97%)cases of pre-labour rupture of membranes, 24 (12.9%) cases of preterm pre-labourrupture of membrane and 19(10.21%)cases of antepartum haemorrhage. subedi a, et al. impact of lockdown of covid 19 pandemic in pregnancy outcomes in a tertiary care centre: what to expect? j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np table 1. clinical profile of patients with complications in the lockdown and the non-lockdown groups clinical profile lockdown period (n=186) nonlockdown period (n=181) p-value mean age± sd (years) 26.6 ±5.1 26.7±5.8 0.86* parity primipara 94(50.5%) 79 (43.6%) 0.19# multipara 92 (49.5%) 102 (56.4%) mean gestational age at delivery± sd (weeks) 33.3±8.1 33.7±7.1 0.61* * student's t test, # chi-square test figure 1. early pregnancy complications in the lockdown and the non-lockdown periods. in the non-lockdown period, the most common maternal complication seen was preterm labor which comprised 55 (30.38%) of total complications. hypertensive disorder comprised 31 (17.12%) of total complicationsincludingtwo cases of eclampsia and 29 cases of severe pre-eclampsia (figure 2). mode of delivery: in the lockdown period, among 186 cases, 104 cases underwent caesarean section accounting for 55.9% whereas during the non-lockdown period, 45.9% of women with complications underwent caesarean delivery. in the lockdown group, the most common indication for caesarean delivery was severe pre-eclampsia (n=40, 38.4%) followed by oligohydramnios (n=21, 20.1%), antepartum haemorrhage (n=14, 13.4%), mal-presentation (n=8, 7.6%), previous caesarean section (n=7, 6.7%) and eclampsia (n=4, 3.8%). the indications for caesarean section in the nonlockdown group were similar to that of lockdown period as shown in figure 3. 7 3 12 8 0 2 4 6 8 10 12 14 lockdown period non-lockdown period abortion ruptured ectopic subedi a, et al. impact of lockdown of covid 19 pandemic in pregnancy outcomes in a tertiary care centre: what to expect? j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np 48 31 37 55 26 2324 21 19 13 0 10 20 30 40 50 60 maternal complications in lockdown period maternal complications in non lockdown period hypertensive disorder preterm labor prom pprom aph 0 5 10 15 20 25 30 35 40 45 lockdown period non lockdown period indication for caesarean section severe pre-eclampsia oligohydraminos aph previous cs malpresentation iugr eclampsia fetal distress failed induction multiple pregnancy heart disease prompre-labour rupture of membrane, pprompreterm pre-labour rupture of membrane, aph antepartum haemorrhage figure 2: types of maternal complications seen during the lockdown and the non-lockdown periods. iugrintrauterine growth restriction aphantepartum haemorrhage cscaesarean section figure 3. indications for caesarean section during the lockdown and the non-lockdown periods subedi a, et al. impact of lockdown of covid 19 pandemic in pregnancy outcomes in a tertiary care centre: what to expect? j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np perinatal complications: in the lock down period, regarding the perinatal outcomes, there were 21 (1.96%) cases of still birth. in the non-lockdown period, there were 19 (1.93%) cases of still birth and this difference was not statistically significant (χ2=0.00, df=1, p=0.96).similarly, the difference in neonatal death between the lockdown (n=10, 0.93%) and the nonlockdown (n=6, 0.61%) periods was also statistically not significant (χ2=0.69, df=1, p=0.405). there were six cases of congenital anomaly which included two cases of neural tube defects and hydrops each and one case each of club foot and heart disease in the lockdown period whereas in the nonlockdown period,there were three cases of congenital anomaly which included one case each of neural tube defect, hydrops and omphalocele. discussion covid 19 infection is a respiratory infection with high infectivity rate.[5] for the containment of the infection and to curb the widespread of the disease, who ushered for lockdown measures, social distancing, and frequent hand washing. lockdown measures included varying degree of travel restrictions and closure of regular outpatient department in hospitals. as lockdown measures were implemented by the countries worldwide, it was found out that especially in developing countries, it halted women from seeking care from health facility due to undue fear of disease transmission from hospitals.[6] a study done in jordan which evaluated the impact of lockdown on antenatal care showed that there was significant increase of pregnant women not receiving antenatal care from 4% to 59.3%.[7] in nepal, the scenario is expected to be similar as we already have less women receiving antenatal care and this lockdown is expected to further reduce the number. and there is also very little scope of telemedicine, and telephone consultation in our country. so, it can be expected that there may be adverse effect on pregnancy outcome during the period of lockdown. however, in our study, we observed that there was no significant change in the number of deliveries during the lockdown period on comparing to the non-lockdown period and this may be due to the diversion of patients to our center from the government hospital which was converted to covid dedicated center. in a study done in nepal regarding the impact of covid 19 pandemic response in pregnancy outcome, it was found that the institutional deliveries in study hospitals were reduced by approximately half in comparison to the non-lockdown period.[8] similarly during ebola outbreak in 2014-2016 in west africa, there was significant reduction in utilization of antenatal care and facility based deliveries in comparison to pre outbreak period.[9] so whenever there was an outbreak of a disease, fear of transmission and increased risk of infection in pregnancy might have precluded women from having a supervised antenatal care and deliveries. as the use and quality of antenatal care decrease, there is high probability that the pregnancy related complications increase. in an article published in an esteemed newspaper of nepal, it was cited that the maternal mortality was found to increase sharply (200%) during the lockdown period.[10] but in our study, we could see that the percentage of maternal complications (17.38%) was similar to that of non-lockdown period (18.43%) and there was no case of maternal mortality in the study period. this can be attributed to the fact that despite the implementation of lockdown, our center resumed its services with no compromise in the quality of health care provided to our patients. but on analyzing the early pregnancy complications including abortion and ruptured ectopic, the cases were more in lockdown period than in nonlockdown period. the reason behind this increase can be explained by travel restrictions, and closure of clinics and opds, decrease in the supply chain, which barred women to access family planning counseling and contraception and hence increasing the proportion of women with unmet contraception needs as cited in study by aly et al.[11] on exploring the maternal complications, though the incidence was similar during the lockdown and the non-lockdown periods, the spectrum of complications differed from that in the nonlockdown time. there were more cases of hypertensive disorder in the lockdown period which subedi a, et al. impact of lockdown of covid 19 pandemic in pregnancy outcomes in a tertiary care centre: what to expect? j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np may be increased due to unsupervised antenatal care and late presentations delaying early management of the cases. there has also been a lot of psychosocial stress to pregnant women during this covid 19 pandemic which might have led to the increased incidence of hypertension. [12, 13] in our study, we found that there was no increase in still birth and neonatal death during the lockdown period in comparison to the non-lockdown period which contradicted the findings in the study by ashish et al. [8] in their study, there was significant rise of still birth and neonatal death in comparison to pre-lockdown period. this divergent finding may be because our hospital did not compromise on the delivery of quality health services as there was no cut down of manpower or any other facilities during the period of lockdown. there are a few limitations of this study. it was a cross-sectional study done for three months of lockdown period which was a shorter duration to see the real impact as during that lockdown period, there was no evidence of community spread due to which the implementation of travel restriction was not fully implemented. so the findings in the study cannot be generalized. this study also falls back in assessing the percentage of antenatal coverage during the lockdown period and psychosocial status of pregnant women during the time of delivery. conclusions despite the lockdown measure implemented for the containment of covid 19 pandemic, it did not have any negative impact on institutional deliveries, maternal and perinatal outcomes in this tertiary care center. conflict of interest: none. references: 1. dhama k, khan s, tiwari r, dadar m, malik ys, singh kp, et al.covid-19, an emerging coronavirus infection: advances and prospects in designing and developing vaccines, immunotherapeutics, and therapeutics. hum vaccin immunother. 2020;16(6):1232-38. pmid: 32186952 doi: https://doi.org/10.1080/21645515.2020.1735227 2. zhao s, lin q, ran j, musa ss, yang g, wang w, et al. preliminary estimation of the basic reproduction number of novel coronavirus (2019-ncov ) in china, from 2019 to 2020: a data-driven analysis in the early phase of the outbreak. international journal of infectious diseases. 2020;92(0):214-17. doi: https://doi.org/10.1016/j.ijid.2020.01.050 3. world health organization. who recommendations on antenatal care for a positive pregnancy experience: summary [internet]. geneva, switzerland: who, 2018. [accessed on 26th september, 2020]. available from: https://apps.who.int/iris/bitstream/handle/10665/ 259947/who-rhr-18.02-eng.pdf 4. ministry of health and population. department of health services, kathmandu, nepal. annual report 2074/75 (2017/18) [internet]. kathmandu, nepal: department of health services, 2018. [accessed on 3rd july,2020] available from: https://dohs.gov.np/annualreport-2074-75/ 5. martines rb, ritter jm, matkovic e, gary j, bollweg bc, bullock h, et al. pathology and pathogenesis of sars-cov-2 associated with fatal coronavirus disease, united states. emerg infect dis. 2020;26(9):2005-15. pmid: 32437316 doi: https://doi.org/10.3201/eid2609.202095 https://pubmed.ncbi.nlm.nih.gov/32186952/ https://doi.org/10.1080/21645515.2020.1735227 https://doi.org/10.1016/j.ijid.2020.01.050 https://apps.who.int/iris/bitstream/handle/10665/259947/who-rhr-18.02-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/259947/who-rhr-18.02-eng.pdf https://dohs.gov.np/annual-report-2074-75/ https://dohs.gov.np/annual-report-2074-75/ https://pubmed.ncbi.nlm.nih.gov/32437316/ https://pubmed.ncbi.nlm.nih.gov/32437316/ https://doi.org/10.3201/eid2609.202095 subedi a, et al. impact of lockdown of covid 19 pandemic in pregnancy outcomes in a tertiary care centre: what to expect? j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np 6. graham wj, afolabi b, benova l, campbell omr, filippi v, nakimuli a, et al. protecting hard-won gains for mothers and and newborns in lowincome and middle-income countries in the face of covid-19: call for a service safety net. bmj glob health. 2020;5(6):e002754. pmid: 32499220 doi: https://doi.org/10.1136/bmjgh-2020-002754 7. muhaidat n, fram k, thekrallah f, qatawneh a, al-btoush a. pregnancy during covid-19 outbreak: the impact of lockdown in a middleincome country on antenatal healthcare and wellbeing. int j womens health. 2020;12(0):1065-73. pmid: 33235516 doi: https://doi.org/10.2147/ijwh.s280342 8. kc a, gurung r, kinney mv, sunny ak, moinuddin m, basnet o, et al. effect of the covid-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in nepal: a prospective observational study. the lancet global health. 2020;8(10):e1273-81. doi: https://doi.org/10.1016/s2214109x(20)30345-4 9. yerger p, jalloh m, coltart cem, king c. barriers to maternal health services during the ebola outbreak in three west african countries: a literature review. bmj global health. 2020;5(9):4-10. doi: http://dx.doi.org/10.1136/bmjgh-2020-002974 10. poudel a. a 200 percent increase in maternal mortality since the lockdown began [internet]. kathmandu, nepal: the kathmandu post,2020.[accessed on march 21,2021]available from: https://kathmandupost.com/national/2020/05/27/ a-200-percent-increase-in-maternal-mortalitysince-the-lockdown-began 11. singh ak, jain pk, singh np, kumar s, bajpai pk, singh s, et al. impact of covid-19 pandemic on maternal and child health services in uttar pradesh, india. j family med prim care. 2021;10(1):509-13. pmid: 34017779 doi: https://doi.org/10.4103/jfmpc.jfmpc_1550_20 12. shapiro gd, fraser wd, frasch mg, séguin jr. psychosocial stress in pregnancy and preterm birth: associations and mechanisms. j perinat med. 2013;41(6):631-45. pmid: 24216160 doi: https://doi.org/10.1515/jpm2012-0295 13. sm, goin de, izano ma, cushing l, demicco e, padula am, et al. relationships between psychosocial stressors among pregnant women in san fransico: a path analysis. plos one 2020;15(6):e0234579. pmid: 32530956 doi: https://doi.org/10.1371/journal.pone.0234579 https://pubmed.ncbi.nlm.nih.gov/32499220/ https://doi.org/10.1136/bmjgh-2020-002754 https://pubmed.ncbi.nlm.nih.gov/33235516/ https://doi.org/10.2147/ijwh.s280342 https://doi.org/10.1016/s2214-109x(20)30345-4 https://doi.org/10.1016/s2214-109x(20)30345-4 http://dx.doi.org/10.1136/bmjgh-2020-002974 https://kathmandupost.com/national/2020/05/27/a-200-percent-increase-in-maternal-mortality-since-the-lockdown-began https://kathmandupost.com/national/2020/05/27/a-200-percent-increase-in-maternal-mortality-since-the-lockdown-began https://kathmandupost.com/national/2020/05/27/a-200-percent-increase-in-maternal-mortality-since-the-lockdown-began https://pubmed.ncbi.nlm.nih.gov/34017779/ https://doi.org/10.4103/jfmpc.jfmpc_1550_20 https://pubmed.ncbi.nlm.nih.gov/24216160/ https://pubmed.ncbi.nlm.nih.gov/24216160/ https://doi.org/10.1515/jpm-2012-0295 https://doi.org/10.1515/jpm-2012-0295 https://pubmed.ncbi.nlm.nih.gov/32530956/ https://doi.org/10.1371/journal.pone.0234579 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 9, no 2, july-dec 2021 ___________________________________________________________________________________ submitted: 04 october, 2021 accepted: 04 january, 2022 published: 12 january, 2022 a assistant professor b lecturer c associate professor d department of obstetrics and gynaecology, lumbini medical college, pravas, palpa. corresponding author: deepak shrestha department of obstetrics and gynaecology, lumbini medical college pravas, palpa, nepal e-mail: @yahoo.com orcid: https://orcid.org/0000-0002-9006-3640_______________________________________________________ —–————————————————————————————————————————————— abstract: introduction: maternal obesity is an established risk factor for various adverse pregnancy outcomes. for instance, increased chances of labour induction, prolonged labour, instrumental and cesarean deliveries, medical disorders of pregnancy, post partum haemorrhage, preterm deliveries, macrosomia, and low apgar score are well recognised risks of maternal obesity. this study aimed to evaluate these maternal and fetal outcomes in relation to the maternal body mass index (bmi). methods: a prospective cohort study involving 115 overweight and obese women was conducted. various maternal and fetal outcomes were studied and compared with those of 115 postpartum women with normal bmi. statistical analysis was done using student's t-test and chi square test. binomial logistic regression analysis was carried out to examine the magnitude and significance of the independent effect of bmi. results: the three groups were comparable in terms of maternal age and gestational age at delivery. the total blood loss was significantly higher in the obese group as compared to the normal bmi (p=0.001) or overweight groups (p=0.005). vaginal delivery was 69% less common in the obese group in comparison to the normal bmi group. the prevalence of meconium-stained liquor, labour induction, preterm labour, and neonatal intensive care unit admission were not significantly different across the three groups. conclusion: this study highlighted the increased risk of total blood loss and birth weight >3500 grams with increasing bmi of pregnant women. a multicentric prospective study with larger sample size would shed further light on the strength of association between maternal bmi and various outcomes. keywords: body mass index, obesity, overweight, pregnancy outcomes original research articlehttps://doi.org/10.22502/jlmc.v9i2.459 deepak shresthaa,d kritina singhb,d shreyashi aryalc,d adverse pregnancy outcomes in overweight and obese pregnant women visiting a tertiary care center in western nepal: a prospective cohort study introduction: the prevalence of obesity in pregnancy has been on a constant rise worldwide. the global burden of overweight and obesity in women reportedly were 40% and 15% respectively in 2016.[1] this prevalence of overweight and obesity is climbing up even more alarmingly in lowand middleincome countries (lmics).[2] the national demographic how to cite this article: shrestha d, singh k, aryal s. adverse pregnancy outcomes in overweight and obese pregnant women visiting a tertiaty care centre in western nepal: a prospective cohort study. journal of lumbini medical college. 2021;9(2):6 pages. doi: 10.22502/jlmc. v9i2.459. epub: 2021 dec 30. and health survey (ndhs) 2016 reported that among reproductive women aged 15-49 years, 22% were overweight and 5% were obese.[3] maternal obesity is an established risk factor for adverse pregnancy outcomes, both maternal and neonatal. it is associated with an increased maternal risk of hypertensive disorder of pregnancy (hdp), gestational diabetes mellitus (gdm), post-datism, induction of labor (iol), prolonged duration of labour, instrumental and cesarean deliveries, and postpartum hemorrhage (pph).[4,5,6] adverse fetal outcomes include still birth, low apgar score, neonatal intensive care unit (nicu) admission, macrosomia, and neonatal death.[7,8,9] however, there is very little published literature available from western nepal examining these findings. this https://orcid.org/0000-0002-9006-3640 shrestha d. et al. adverse pregnancy outcomes in overweight and obese pregnant women jlmc.edu.np study aimed to evaluate the increasing prevalence of obesity in our region and compare its adverse impacts on pregnancy outcomes in women with normal body mass index (bmi) with overweight/ obese women. methods: this was a prospective cohort study conducted in the department of obstetrics and gynecology, lumbini medical college and teaching hospital (lmcth) for a period of three months from 15th may 2021 to 16th august 2021. inclusion and exclusion criteria: all singleton pregnancies with/without booking visit in our hospital, with documented weight taken pre-pregnancy or in the first trimester <14 weeks and delivering at our facility after 28 weeks were included in the study. those with multiple pregnancies, mal-presentations, still births or major congenital anomalies were excluded. sample size calculation: the sample size was calculated using the following formula: n = [ z 1 α / 2 √ { ( r + 1 ) * p ( 1 p ) } + z 1 β √ { r p 1 ( 1 p1)+p2(1-p2)}]2 / r(p2-p1)2 and n (exposure) >n/4[1+√{1+2(r+1)/nr|p2-p1|}]2 where, α=0.05, β=0.2, r=sample size ratio (non exposure to exposure), p1=prevalence of outcome in non-exposure group, p2=p1*or/[1+p1(or-1)], and p= (p1+rp2)/(1+r). taking or=2.2 and p=38.6%, from the study of ojha n,[10] the minimum sample size calculated in each group was 113. data collection: the weight of the women was documented at their first antenatal visit to the hospital. for those without booking visit before 14 weeks in our center, the weight was recorded from the antenatal care (anc) card of the nearby government health facility (health post, primary health care center or district hospital) where they had their first antenatal visit. it has been shown that the maternal weight does not increase much in the first trimester and hence the baseline body mass index during pregnancy can be calculated accurately up to 18-20 weeks gestation. [12] so, in this study bmi up to 14 weeks was taken. in case of undocumented weight, self-reported prepregnancy weight was taken to calculate bmi. on their first visit to this center, the height was measured in the standard fashion in our out-patient department (opd). the participants were categorized based on their bmi (calculated as weight in kilograms divided by square of height in meters) into exposure (study) and non-exposure (reference) groups. based on bmi, participants were categorized according to who into three groups: normal (18.5–24.9 kg/m2), overweight (25.0-29.9 kg/m2) and obese (>30 kg/ m2).[11] women delivering immediately before or after the index case with normal bmi and matched to age (+ 5 years) and gestational age (+ 2 weeks) were included for the reference group. the information on maternal characteristics as age, residence, ethnicity, parity, and gestational age at delivery were obtained from case sheet. maternal complications like hdp, gdm, hypothyroidism, meconium stained liquor (msl), and shoulder dystocia were recorded. the obstetrical parameters as iol, mode of delivery, and total blood loss were noted. visual estimation method was used for the evaluation of the amount of total blood loss. the neonatal outcomes of interest were birth weight, preterm delivery, apgar scores at 1 and 5 minutes, and nicu admission. obstetrical and neonatal outcomes were then evaluated taking the normal bmi group as reference. a low apgar score was defined as a score less than seven at 5 minute after birth. stillbirth was defined as intrauterine death occurring after 22 completed weeks of gestation. birth weight was measured and recorded at birth by the attending nurse or pediatrician using a calibrated digital weighing machine. all the data were collected by one of the investigators and recorded in a preformed proforma. the data thus collected were entered in statistical package for social sciences (spss) software version 16. the frequencies with percentages of the various outcomes of pregnancy were calculated within the maternal bmi groups. quantitative data j. lumbini. med. coll. vol 9, no 2, july-dec 2021 shrestha d. et al. adverse pregnancy outcomes in overweight and obese pregnant women jlmc.edu.npj. lumbini. med. coll. vol 9, no 2, july-dec 2021 table 1: socio-demographic and clinical characteristics of the normal bmi, overweight and obese groups were presented in means with standard deviation. qualitative data were expressed in frequency and percentages. statistical analysis was done using student's t-test, anova and chi square test. binomial logistic regression analysis was carried out to examine the magnitude and significance of the independent effect of bmi. risks are presented as crude odds ratios (ors) with 95% confidence intervals (ci). a p value <0.05 was taken for statistical significance. ethical approval: the ethical clearance for the study was taken from the institutional review committee of the institute prior to commencement of data collection (irc-lmc 02-g/020). informed consents were taken from all the participants after explaining the study objectives and procedure. confidentiality of the participants were maintained. results: during the study period, there were 345 mothers who delivered in the facility. a total of 115 overweight and obese mothers were enrolled in the study and an equal number of normal bmi mothers. therefore, the prevalence of overweight and obese women was 28.69% and 4.63% respectively in this study. table 1 compares the comparison of sociodemographic and clinical characteristics among the normal bmi, overweight and obese groups. all the three groups were comparable in age (p=0.575) and height (0.664). statistical analysis showed that only weight and total blood loss were statistically significant across the three groups. on post hoc analysis, it was found that difference in mean weight was significant across all the three groups (p<0.001). whereas in total blood loss, the mean difference was statistically significant for obese group against normal bmi (p=0.001) or overweight groups (p=0.005) only. the difference in blood loss was not statistically significant between the normal bmi and overweight groups (p=0.785). table 2 shows that iol and prevalence of msl were less in overweight and obese women than the normal bmi group but they were not statistically significant. however, the occurrence of vaginal delivery in the characteristics normal bmi (n=115) overweight (n=99) obese (n=16) p-value * maternal age (years) 26.69+5.82 26.78+5.86 28.31+5.82 0.575 height (cm) 150.40+3.12 150.02+2.84 150.25+3.87 0.664 weight (kg) 52.89+3.70 59.93+3.76 75.44+10.61 <0.001 bmi (kg/m2) 23.32+1.15 26.61+1.18 33.54+3.66 parity primipara 53 (46.09%) 45 (45.45%) 5 (31.25%) multipara 62 (53.91%) 54 (54.54%) 11 (68.75%) ethnicity brahmin 30 (26.01%) 28 (28.28) 3(18.75%) chhetri 12 (10.43%) 8 (8.08) 4 (25%) janajati 32 (27.83%) 27 (27.27%) 5 (31.25%) dalit 41(35.65%) 36 (36.36%) 4 (25%) gestational age (weeks) 39.15+2.46 39.27+2.12 38.08+2.91 0.170 hospital stay (days) 2.46+1.27 2.51+1.17 3.06+1.53 0.194 total blood loss (ml) 149.78+91.90 159.24+95.68 248.13+200.31 0.002 birth weight (grams) 2929.80+524.04 2964.16+444.21 3150.00+697.47 0.884 pre-term labour 8 (7.96%) 7 (7.07%) 3 (18.75) nicu admission 14 (12.17%) 10 (10.10%) 1 (6.25) low apgar at 1 min 14 (12.17%) 10 (10.10%) 1 (6.25) birth weight >3500 grams 12 (10.43%) 9 (9.09%) 2 (12.50%) shrestha d. et al. adverse pregnancy outcomes in overweight and obese pregnant women jlmc.edu.npj. lumbini. med. coll. vol 9, no 2, july-dec 2021 obese group was 69% less than the reference group. no cases of shoulder dystocia were encountered. however, there were four cases of hdp in obese group, and one each in normal bmi and overweight groups. similarly, there was one case of hypothyroidism in normal bmi and overweight groups. as seen in table 3, the chances of low apgar score at 5 min., preterm labour, and nicu admission were not statistically significant across the groups. however, birth weight >3500 grams was 1.86 times more in the overweight group and 2.23 times more in the obese group than the normal bmi group. discussion: maternal obesity is a growing epidemic and its adverse effects on the outcomes of pregnancy and delivery are widely studied, both nationally and globally. therefore, this study aimed to report the impact of maternal obesity on pregnancy complications in this part of the country. the present study showed that the likelihood of vaginal delivery in the obese group was 69% less as compared to the reference group, which was statistically significant. this is probably because most obese women are likely to undergo cesarean sections, either elective or emergency, due to table 2: comparison of obstetrical outcomes among study and reference groups table 3: comparison of neonatal outcomes among the study and reference groups various indications as failed inductions, nonprogress of labour, fetal macrosomia, cephalo-pelvic disproportion etc. similar findings were reported by other studies too. [4,10] overweight and obese women are more likely to require elective termination of pregnancy for various medical and fetal complications as hdp, gdm, macrosomia etc.[12] these women undergo maternal bmi induction of labour meconium stained liquor mode of delivery n (%) or (95% ci) n (%) or (95% ci) n (%) (vaginal) or 95% ci normal 33 (28.70) 1 15 (13.04) 1 88 (76.52) 1 overweight 24 (24.24) 0.80 (0.431.47) 8 (8.08) 1.71 (0.70-4.21) 71 (71.71) 0.78 (0.42-1.44) obese 1 (6.25) 0.17 (0.02-1.3) 1 (6.25) 2.25 (0.28-18.30) 8 (50) 0.31 (0.11-0.90) maternal bmi low apgar at 5 min preterm labour birth weight >3500 grams nicu admission n (%) or 95% ci n (%) or 95% ci n (%) or 95% ci n (%) or 95% ci normal 14 (12.17) 1 8 (6.96) 1 4 (3.48) 1 14 (12.17) 1 overweight 10 (10.10) 1.23 (0.52-2.92) 7 (7.07) 0.98 (0.34-2.81) 15 (15.15) 1.86 (1.35-3.13) 10 (10.10) 0.81 (0.34-1.92) obese 1 (6.25) 2.08 (0.26-16.98) 3 (18.75) 0.32 (0.08-1.38) 7 (43.75) 2.23 (1.25-6.06) 1 (6.25) 0.48 (0.06-3.93) induction of labour (iol) more and the chances of cesarean deliveries also increase.[13] however, this study showed no statistically significant difference in iol among the three groups. this might be attributed to our study's lower prevalence of medical and fetal complications and smaller sample size. our findings were similar to those in the study by ojha n.[10] the occurrence of preterm labour was similar between normal bmi and overweight groups but it was relatively high in the obese group. however this difference was not statistically significant. the chances of pregnancies being complicated with meconium-stained liquor were also not significant in our study, which agrees with another study.[10] the mean total blood loss was significantly higher in the obese group than the overweight or normal bmi group however, it was not significantly different between the overweight and normal bmi groups. this could be attributed to the higher rate of iol, operative interventions and macrosomia encountered in the obese groups which are themselves independent risk factors for higher blood loss. these findings are congruent with other studies as well.[4,5,10]. the total hospital stay in our study was not significantly different across the three groups. however, a study by ojha n reported that the total hospital stay was significantly higher in the overweight and obese groups.[10] in our center, most of the patients after cesarean are discharged on the third post-operative day with the instruction of wound dressing and suture removal to be done at nearby health facilities. also, medical complications like hdp and gdm and delivery complications as pph were less in our study which might have been responsible for longer hospital stay in other studies. in this study, the mean birth weight of the babies increased with increasing bmi. however, the mean birth weights' difference were not significant statistically across the three groups. but the odds of having babies >3500 grams were almost 1.9 times higher in the overweight group and 2.2 times higher in the obese group in comparison to the normal bmi group. this finding was consistent with other published works too.[4,10] the occurrence of low apgar score at 5 min. was higher in the overweight and obese groups as compared to the reference group in our study but this was not statistically significant. this might be due to a smaller sample size. also, comparisons were made between individual groups instead of another study where both the overweight and obese categories were combined as a single group and compared with the normal bmi group instead of individual comparison.[10] our study found no significant difference in nicu admission among the normal bmi (12.17%), overweight (10.10%) and obese (6.25%) groups. these findings are following some other large studies too.[6,13] the study by ojha n reported increased admission to nicu in overweight and obese groups. increased risk of admission to neonatal care has also been found in other studies.[4,9] this difference could be due to the difference in criteria and indications for nicu admission in different centers. in this study the prevalence of medical disorders in pregnancy was not much compared to other studies,[1,10] which have reported a higher prevalence of hypertensive disorders and gdm in overweight and obese mothers. this can probably be explained on the basis of geographical variation of prevalence of obesity and non-communicable diseases. people in this region are generally more physically active and have a healthier diet which might be the reasons for low prevalence of medical disorders. there are some notable limitations of this study. the duration of labour was not examined as a possible complication of maternal obesity. the occurrence of third or fourth degree perineal tears and venous thrombosis were also not studied. conclusion: this study showed that increasing obesity in pregnant women impacts several maternal and fetal outcomes. the total blood loss was significantly higher in the obese group as was the birth weight of more than 3500 grams. vaginal delivery was less common in the obese group. the occurrence of meconium stained liquor, induction of labour, preterm labour, low apgar score and nicu admission were comparable across the three groups. a multicentric prospective study with larger sample size would shed further light on the strength of association between maternal bmi and various outcomes. shrestha d. et al. adverse pregnancy outcomes in overweight and obese pregnant women j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np 1. world health organization.  obesity and overweight [internet]. geneva, switzerland: who, 2021. [accessed on 15 oct 2021] available from:  https://www.who.int/news-room/factsheets/detail/obesity-and-overweight 2. swinburn ba, sacks g, hall kd, mcpherson k, finegood dt, moodie ml, et al. the global obesity pandemic: shaped by global drivers and local environments. lancet. 2011;378(9793):804-14. pmid: 21872749 doi: https://doi.org/10.1016/ s0140-6736(11)60813-1 3. ministry of health nepal, new era, icf. nepal demographic and health survey 2016 [internet]. kathmandu, nepal: ministry of health, 2017. [accessed on 14 oct 2021] available from: https://www.dhsprogram.com/pubs/pdf/fr336/ fr336.pdf 4. usha kira ts, hemmadi s, bethel j, evans j. outcome of pregnancy in a woman with an increased body mass index. bjog. 2005;112(6):768-72. pmid: 15924535 doi: https://doi.org/10.1111/j.14710528.2004.00546.x 5. schrauwers c, dekkra g. maternal and perinatal outcome in obese pregnant patients. j matern fetal neonatal med. 2009;22(3):218-26. pmid: 19330705 doi: https://pubmed.ncbi.nlm.nih. gov/19330705/ 6. manzanares sg, santallaa ha, vicoa zi, criadoa msl, pineda la, galloa vjl. abnormal maternal body mass index and obstetric and neonatal outcome. j matern fetal neonatal med. 2012;25(3):308-12. pmid: 21615231 doi: https://doi.org/10.3109/14767058.2011.575905 7. nohr ea, vaeth m, baker jl, sørensen tia, olsen j, rasmussen km. combined association of prepregnancy body mass index and gestational weight gain with the outcome of pregnancy. am j clin nutr. 2008;87(6):1750-9. pmid: 18541565 doi: https://doi.org/10.1093/ajcn/87.6.1750 8. tenant pwg, rankin j, bell r. maternal body mass index and the risk of fetal and infant death: a cohort study from the north of england. hum reprod. 2011;26(6):1501-11. pmid: 21467206 doi: https://doi.org/10.1093/humrep/der052 9. persson m, johansson s, villamor e, cnattingius s. maternal overweight and obesity and risks of severe birth-asphyxia-related complications in term infants: a population-based cohort study in sweden. plos med. 2014;11(5):e1001648. pmid: 24845218 doi: https://doi.org/10.1371/ journal.pmed.1001648 10. ojha n. pregnancy outcome in overweight and obese mothers at a tertiary care hospital. journal of institute of medicine. 2016;38(2/3):56-62. available from: 11. world health organization. obesity: preventing and managing the global epidemic. geneva, switzerland: world health organization. report number: who technical report series 894, 2000. available from: https://apps.who.int/iris/ handle/10665/42330 12. o’dwyer v, o’kelly s, monaghan b, rowan a, farah n, turner mj, et al. maternal obesity and induction of labor. acta obstet gynecol scand. 2013;92(12):1414-8. pmid: 24116732 doi: https://doi.org/10.1111/aogs.12263 13. vinturache ae, mcdonald s, slater d, tough s. perinatal outcomes of maternal overweight and obesity in term infants: a populationbased cohort study in canada. 2015;5(0):9334. pmid: 25791339 doi: https://doi.org/10.1038/ srep09334 acknowledgement dr. ashish joshi, dr. arbin dev sapkota. conflict of interest: the authors declare that the principal author was not involved in the editorial workflow of the article. shrestha d. et al. adverse pregnancy outcomes in overweight and obese pregnant women financial disclosure: no funds were available. references: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight https://pubmed.ncbi.nlm.nih.gov/21872749/ https://doi.org/10.1016/s0140-6736(11)60813-1 https://doi.org/10.1016/s0140-6736(11)60813-1 https://www.dhsprogram.com/pubs/pdf/fr336/fr336.pdf https://www.dhsprogram.com/pubs/pdf/fr336/fr336.pdf https://pubmed.ncbi.nlm.nih.gov/15924535/ https://doi.org/10.1111/j.1471-0528.2004.00546.x https://doi.org/10.1111/j.1471-0528.2004.00546.x https://pubmed.ncbi.nlm.nih.gov/19330705/ https://pubmed.ncbi.nlm.nih.gov/19330705/ https://pubmed.ncbi.nlm.nih.gov/19330705/ https://pubmed.ncbi.nlm.nih.gov/19330705/ https://pubmed.ncbi.nlm.nih.gov/21615231/ https://doi.org/10.3109/14767058.2011.575905 https://pubmed.ncbi.nlm.nih.gov/18541565/ https://doi.org/10.1093/ajcn/87.6.1750 https://pubmed.ncbi.nlm.nih.gov/21467206/ https://doi.org/10.1093/humrep/der052 https://pubmed.ncbi.nlm.nih.gov/24845218/ https://doi.org/10.1371/journal.pmed.1001648 https://doi.org/10.1371/journal.pmed.1001648 https://apps.who.int/iris/handle/10665/42330 https://apps.who.int/iris/handle/10665/42330 https://pubmed.ncbi.nlm.nih.gov/24116732/ https://doi.org/10.1111/aogs.12263 https://pubmed.ncbi.nlm.nih.gov/25791339/ https://doi.org/10.1038/srep09334 https://doi.org/10.1038/srep09334 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 adhikari sp, et al. intensive physiotherapy interventions in speedy recovery of sub-acute stroke: a case seriesadhikari sp, et al. intensive physiotherapy interventions in speedy recovery of sub-acute stroke: a case series 275 jlmc.edu.np ___________________________________________________________________________________ submitted: 7 june, 2020 accepted: 18 december, 2020 published: 25 december, 2020 aassistant professor, department of physiotherapy, bphysiotherapist, department of physiotherapy, clecturer, department of neurosurgery, dschool of medical sciences, kathmandu university, dhulikhel, nepal. corresponding author: dr. shambhu p.adhikari e-mail: spsaur@gmail.com orcid: https://orcid.org/0000-0002-2635-6844_______________________________________________________ abstract: introduction: intensive physiotherapy interventions have shown good recovery in stroke if applied to stable patients who can tolerate it. influence of enriched environment on intensive physiotherapy interventions after acute care has not been studied in low-resource contexts, and therefore, we reported outcome of the interventions in multiple cases with stroke in nepalese context and cultural background. case reports: three patients in sub-acute stage of stroke were admitted in intensive physiotherapy treatment unit where the environment was therapeutically enriched. the therapist-administered interventions were intensive for each domain of impairment and activity limitations, every day for six days a week. patients were trained to carry out caregiver-assisted practice or self-practice in enriched environment. training demonstrated visible and measurable outcome in all cases. conclusion: intensive physiotherapy interventions in an enriched environment promoted good recovery in short period in stroke. the interventions applied, and the principles adopted were based on the established evidence, and therefore findings of this study may support for its feasibility and applicability. keywords: enriched environment, intensive physiotherapy intervention, stroke, sub-acute case reporthttps://doi.org/10.22502/jlmc.v8i2.375 shambhu p adhikari,a,d riju maharjan,b,d redisha jakibanjar,b,d anushree balla,b,d manisha shrestha,b,d narendra shalike,c,d govinda m nepal a,d intensive physiotherapy interventions in speedy recovery of sub-acute stroke: a case series how to cite this article:how to cite this article: adhikari sp, maharjan r, jakibanjar r, balla a, shrestha m, shalike adhikari sp, maharjan r, jakibanjar r, balla a, shrestha m, shalike n, nepal gm. intensive physiotherapy interventions in speedy n, nepal gm. intensive physiotherapy interventions in speedy recovery of sub-acute stroke: a case series. journal of lumbini recovery of sub-acute stroke: a case series. journal of lumbini medical college. 2020;8(2):275-280. doi: medical college. 2020;8(2):275-280. doi: https://doi.org/10.22502/ jlmc.v8i2.375. epub: 2020 december 25. epub: 2020 december 25. introduction: intensive physiotherapy interventions (ipi) showed good recovery in stroke if applied to stable patients who can tolerate them.[1,2] the subacute stage is better for ipi as it is safe compared to very early phase, and it has a defined ‘plastic window’ during which injured brain is primed with physiotherapy interventions.[3,4] additionally, selfpractice in an enriched environment (ee) reinforces therapist-administered interventions (tai) for better and faster recovery. in high-resource context, patients receive institution-based physiotherapy after acute care (14 days to 38 weeks) which is nonexistent in low-resource context.[1,5] therefore, this study reported outcome of ipi administered in ee in nepal. case report: three patients in sub-acute phase (<1 month) of stroke were admitted in intensive physiotherapy treatment unit(iptu) where the environment was therapeutically enriched with an aim to administer evidence-based, problem-specific tai primed with ee. the iptu has been equipped in such a way that caregivers or patients could continue practicing as per prescription with the aim to achieve added effect on the tai through patient-regulated exercises, increased therapy time, group training, family participation, task oriented training, and socialization.[6] the unit consisted of two sections: one for tai and another for self-practice to the patients. it was made sure that all the requirements licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 adhikari sp, et al. intensive physiotherapy interventions in speedy recovery of sub-acute stroke: a case seriesadhikari sp, et al. intensive physiotherapy interventions in speedy recovery of sub-acute stroke: a case series 276 jlmc.edu.np such as equipment, materials and space required for exercises as per therapist’s prescription were available in the self-practice section. patients could practice individually or in a group. self-assessment materials and objects were available so that patients could check performance outcome themselves which motivates them to continue self-practice. the space was enough to do exercises and was comfortable (beds and resting chairs were available) to take rest in between the sessions whenever required. the self-practice section used to be 24-hour open so that patients could do exercises whenever they felt comfortable. individual diary was maintained in the section so that each patient or his/her care giver could record to make sure that they did self-practice as per the prescription. additional self-practice in an ee not only reinforces tai by promoting recruitment of endogenous pathways, endothelial cell proliferation, angiogenesis, neurogenesis and functional recovery but also saves therapists’ time and effort.[7]the physiotherapy interventions were called intensive when active interventions were prescribed for ≥ 45 minutes per session or ≥ two sessions per day lasting at least 30 minutes each with ≥ 5 days/week with additional self-practice.[3,4] in this case study, the ipi was modified to make appropriate to nepalese individuals to their cultural context and background based on a study by adhikari et al.,[4] in which protocol was adapted for nepalese patients with stroke and the concept of intensive interventions was integrated in deriving action observation-execution and motor training protocol. the tai was administered as per patienttable 1. case description and interventions with pre and post assessment findings of case 1. case description pre-training assessment intensive physiotherapy interventions post-training assessment • a 60-year male farmer • sudden onset, with inability to move right extremities • known case of hypertension • diagnosis: left thalamo-ganglionic intracranial hemorrhage • routine and basic physiotherapy treatment was provided in acute care • at one week he was medically/surgically stable • he was shifted to iptu for ipi of 3 weeks. • major complaints: inability to walk, inability to use his dominant right hand for eating/ drinking independently, wheelchair bound. • he required maximum assistance for his adl. • secondary problem: traumatic knee flexion deformity in chronic stage. • fma: ue: motor39/66, le: motor 10/34 (right) • barthel index: 7/20 • drinking task: unable (with right hand) • sit to stand and standing: unable • tug: unable • sensation: absent or impaired (superficial and proprioception) at ue and le • mmt: varied between 0 and 4 (right). • aoe: it was first line of physiotherapy treatment. protocol adopted was based on the study by adhikari et al.,(4). parameters: 3 min of ao + 2 min of e*5 repetitions (reps) per component, total 30 min/session/day*6 days/week • modified cimt: the modified cimt primed with aoe on second week, the modified cimt of 45 min for was administered based on protocol of a trial by winstein et al., (9) • bwstt: the protocol was adopted from the study by ada et al.,(10).training was for 15 minutes/session*2 sessions/day • iot: dynamic quads, bridging, alternating isometrics of weak muscles of ue and le, 5 reps* 5 sets / session for 2 weeks • body activities with controlled and corrected gait training: sitting to standing, standing, wall squats, weight shifting, side walking, walking against wall, stairs climbing up and down, 40 min per day (10 min each) for 2 weeks. • caregiver supported training/ patient’s self-practice: as per physiotherapists’ prescription. • fma: ue-motor: 52/66, le-motor: 21/34 (right) • barthel index: 15/20, • drinking task: able to perform using right hand • sit to stand: able independently • standing: able, duration: 10 sec • tug: able, time: 62 seconds • sensation (superficial and proprioception): absent changed to present but impaired, and impaired changed to normal improved • muscle strength (out of 5): 0 and 1 improved to 2, 2 improved to 3, 3 and 4 improved to 5 (right). aoe: action observation execution, cimt: constraint induced movement therapy, bwstt: body weighted supported treadmill training, iot: impairment oriented training, fma ue and le: fugl meyer assessment scale for upper extremity and lower extremity, tug: timed up and go test, fim: functional independent measures, adl: activities of daily living, iptu: intensive physiotherapy treatment unit, ipi: intensive physiotherapy interventions j. lumbini. med. coll. vol 8, no 2, july-dec 2020 adhikari sp, et al. intensive physiotherapy interventions in speedy recovery of sub-acute stroke: a case seriesadhikari sp, et al. intensive physiotherapy interventions in speedy recovery of sub-acute stroke: a case series 277 jlmc.edu.np therapist collaboration[4] based on assessment findings. it was scheduled in such a way that each domain (motor, sensory. cognitive, activity, functional and locomotion) received tai at least one session every day for six days/week. in between tai sessions, patient or caregiver was trained to carry out caregiver-assisted practice (cap) or selfpractice (sp) as prescribed by physiotherapists. the patients/caregiver was asked to record their practice diary. the ipi schedule has been described in figure 1. the medical and surgical consultations were provided whenever required which gave an additional advantage of multidisciplinary approach in patient care. the nurses who were trained for therapeutic care provided education and counseling sessions to motivate patients for practice and monitor practice sessions in addition to routine nursing care. one physiotherapist assessed the patient before and after the intervention. two other physiotherapists completed the treatment. patients’ information, physiotherapy interventions and pre-post assessment findings have been presented in tables 1, 2 and 3. discussion: the ipi administered in an ee in sub-acute stroke yielded good recovery in relatively short duration. all patients completed three weeks of intensive physiotherapy at iptu. none of the patient table 2: case description and interventions with pre and post assessment findings of case 2. case description pre-training assessment intensive physiotherapy interventions post-training assessment • a 60-year female • sudden onset with inability to move right extremities • known case of hypertension, no other relevant medical history • diagnosis: left thalamo-ganglionic hematoma with extension to lateral ventricle • routine and basic physiotherapy treatment was provided in acute care • at one week she was medically/ surgically stable • she was shifted to iptu for ipi of 3 weeks. • major complaints: wheelchair bounded, unable to do her adl. • she was on foley’s catheter. • no secondary problem reported • fma: ue-motor: 18/66, le-motor: 4/34 (right) • fim: 48/126: • tone: bulk muscles of ueflaccid (right) • tug: unable to perform • drinking task: unable to reach and grasp using right ue • consciousness: glasgow coma scale: 15/15, • cranial nerve: intact • sensation: diminished over right half of the body. • modified cimt:it was the first line of physiotherapy treatment. the modified cimt of 45 min was administered based on the protocol of a trial by winstein et al., (9). task: drinking (components: reaching, grasping, transporting), adapting shaping, distributed practice, rest minimum, duration: 30 min*twice a day*6days per week for 3 weeks, progression: task complexity • iot: finger mass flexion extension training, shortened held resisted contraction, active-assisted/active range of motion exercise, weight shifting, bridging, tapping induced reeducation, tone facilitation, 5-10 reps*2 sets*6days/week for 3 weeks. • pnf: overflow to muscles at 0 and 1 out of 5, mass movement pattern, 5-10 reps*2 sets*6days/ week for 3 weeks • bwstt: sitting to standing, standing, weight shifting, controlled and corrected walking, 5-10% weight bear on progression, 0.5 km/hr*1min and 30 sec rest*5reps.the protocol was adopted from the study by brown et al, and ada et al,(10). • forced used of the affected le: step forward and backward, stepping up and down in stairs, 15 min/day*6 days for 3 weeks. the concept was adopted from of a trial by winstein et al, (9). • functional training: controlled and corrected walking, walking along the wall, climbing up and down the stairs, independent walking, 30 min*2 sessions, 10 min each component, for 3 weeks • caregiver supported training/patient’s self-practice: as per physiotherapists’ prescription. • fma: ue-motor: 42/66, le-motor: 11/34 (right) • fim: 80/126, • tone: normal (muscles of right extremities) • tug: able (but > 30 sec time with walker) • drinking task: able to reach, grasp and drink independently using right ue. aoe: action observation execution, cimt: constraint induced movement therapy, bwstt: body weighted supported treadmill training, iot: impairment oriented training, fma ue and le: fugl meyer assessment scale for upper extremity and lower extremity, tug: timed up and go test, fim: functional independent measures, adl: activities of daily living, iptu: intensive physiotherapy treatment unit, ipi: intensive physiotherapy interventions, pnf: proprioceptive neuromuscular facilitation j. lumbini. med. coll. vol 8, no 2, july-dec 2020 adhikari sp, et al. intensive physiotherapy interventions in speedy recovery of sub-acute stroke: a case seriesadhikari sp, et al. intensive physiotherapy interventions in speedy recovery of sub-acute stroke: a case series 278 jlmc.edu.np demonstrated any adverse effects. the intervention’s effect that all patients demonstrated was visible and measurable on the outcome measures. all cases were treated in sub-acute stage which is a golden period of stroke recovery.[4] the marked improvement achieved indicated good and fast recovery within three weeks of the treatment. structured, evidence-based interventions table 3: case description and interventions with pre and post assessment findings of case 3. case description pre-training assessment intensive physiotherapy interventions post-training assessment • a 40-year male • presented with history of trauma • no relevant past medical and surgical history. • diagnosis: right-sided intra-cranial hematoma over frontal and parietal lobe. • routine and basic physiotherapy treatment was provided in acute care. • at one week he was medically/ surgically stable. • he was shifted to iptu for ipi of 3 weeks. • major complaints: wheelchair bound, ue: relatively weak but it can be moved • arm sling was placed on affected arm to prevent shoulder subluxation. • fma (left): ue-motor: 56/66, le-motor: 6/34 • fma (left): ue: light touch2/4 and position8/12, le: light touch: 0/4 and position: 1/8 • fma (left): ue total – 111/126, le total – 57/86 • bbs: 12/56, • fim: 73/126 • tug: unable to perform, wheelchair bound • tone (left): major muscles of uenormal, major muscles of leflaccid • no any cognitive, perceptual problem or cranial nerve abnormality. • iot integrated with controlled functional training: it was first line of physiotherapy treatment. intensive supervised physiotherapy sessions lasting for 60-90 min*two sessions with an interval of at least 3 hours between sessions for 6 days/week. • pnf: overflow principle for knee flexors and ankle dorsiflexors through hip flexors, assisted diagonal pattern movement, quick tapping and stroking of muscles of left le for 1 week. on progression: rhythmic initiation and alternating isometrics exercises at pelvis during bridging and kneel standing • sensory re-education: tactile localization and position sense training in left ue and le using different textured-objects, initially with vision and later with visual occlusion. • forced used therapy with functional training of left limb: forced used therapy of affected limb followed by treadmill walking, elliptical cycling with minimal or without support. • sensory re-education incorporated with strengthening exercises: supported bridging, concentric hold of shoulder against gravity in different directions, scapular stabilizers strengthening. on progression, bridging on foam, pelvic lift with squeeze ball below knees, wall squat, back extensors isometric exercise with tactile feedback, quadruped limb loading exercises, dynamic quads, standing on foam with feet apart with and without eyes closed, mat exercises for various activities • caregiver supported training/patient’s self-practice: as per physiotherapists’ prescription. • fma (left): ue-motor: 66/66, le-motor: 25/34 • fma (left): ue light touch: 4/4 and position: 12/12, le light touch: 2/4 and position: 7/8 • fma (left): ue total – 124/126, le total – 68/86 • bbs: 48/56, • fim: 108/126 • tug: able to perform, time: 40 sec • tone (left): major muscles of ue and le normal aoe: action observation execution, iot: impairment oriented training, fma ue and le: fugl meyer assessment scale for upper extremity and lower extremity, tug: timed up and go test, adl: activities of daily living, iptu: intensive physiotherapy treatment unit, ipi: intensive physiotherapy interventions, pnf: proprioceptive neuromuscular facilitation, mas: modified ashworth scale, bbs: berg balance scale j. lumbini. med. coll. vol 8, no 2, july-dec 2020 adhikari sp, et al. intensive physiotherapy interventions in speedy recovery of sub-acute stroke: a case seriesadhikari sp, et al. intensive physiotherapy interventions in speedy recovery of sub-acute stroke: a case series 279 jlmc.edu.np were applied to all the cases with the necessary modification based on a study by adhikari et al.[4] patient-therapist collaboration as described by adhikari et al., in their study [4] further supported for intervention modification to make interventions feasible and appropriate in nepalese cultural context and background. all cases demonstrated marked improvement both in impairment and activity level as shown by various outcome measures, which indicated that, the interventions were able to address all the domains. it was not possible to administer tai as per the protocol for all the domains if the patients were not admitted in the institution. this is because the intensive interventions required longer time with rest time in between for each impairment and activity limitations. additionally, the interval between the sessions has to be enough (≥ 2 hours) to avoid fatigue and to allow enough time for consolidation of the learned task. the load, duration and rest period were managed in such a way that the interventions were neither too less (enough to engage the patients and induce neuroplasticity) nor too more (enough rest period in between to avoid fatigue) based on the principles of exercise dependent neuroplasticity.[8] furthermore, the ee set in the iptu engaged patients to practice the prescribed exercises. this finding was consistent with the findings from tijsen et al., who demonstrated improvement in activity level when the environment was well enriched for therapeutic goals.[6]the ee might have helped to transfer the skills from one activity to another, because, as per kleim et al., there will be transference of skills when similar activities are matched while training.[8] therefore, matching tai with that of cap/sp was one of the important factors to enhance transference and avoid interference, which was achieved while treating patients admitting in iptu in the present study. the total therapeutic time (tai and cap/ sp) was ≥ 5 hours per day, which was much more than the time engaged when a patient is treated in an outpatient basis or at home. the effect of increased engaged-time supported recovery as demonstrated in a study by tijsen et al.[6] thus, administration of evidence-based protocol, long duration of engagement in exercises, matching tai with cap/ sp, enriched environment and multidisciplinary care, all supported to yield better and faster recovery in present case study and highlighted the need and of institution based ipi in sub-acute stroke. all participants and their caregivers got motivated due to the improvement seen over time. they also actively participated as the environment encouraged them to carry out prescribed exercises. the timely support from the nurses, frequent consultation from the surgeon/physician within the unit further supported to result better outcome in short duration. conclusion: all cases demonstrated marked improvement both in impairment and activity levels, which indicated good and speedy recovery with ipi administered in an ee. the interventions applied, and the principles adapted were based on established evidence, and therefore findings of this study may support for its feasibility and applicability. however, large-scale studies are warranted. acknowledgements: department of physiotherapy, department of nursing and department of neurosurgery, dhulikhel hospital. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available for the study. figure 1. intensive physiotherapy interventions of each day. cap: caregiverassisted practice, sp: self practice, tai: therapist-administered interventions. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 adhikari sp, et al. intensive physiotherapy interventions in speedy recovery of sub-acute stroke: a case seriesadhikari sp, et al. intensive physiotherapy interventions in speedy recovery of sub-acute stroke: a case series 280 jlmc.edu.np references: 1. langhorne p, wu o, rodgers h, ashburn a, bernhardt j. a very early rehabilitation trial after stroke (avert): a phase iii, multicentre, randomised controlled trial. health technol assess. 2017;21(54):1-120. pmid: 28967376. doi: https://doi.org/10.3310/hta21540 2. rosenbaum am, gordon wa, joannou a, berman ba. functional outcomes following post-acute rehabilitation for moderate-to-severe traumatic brain injury. brain inj. 2018;32(7):90714. pmid: 29738278. doi: https://doi.org/10.108 0/02699052.2018.1469040 3. coleman er, moudgal r, lang k, hyacinth hi, awosika oo, kissela bm, et al. early rehabilitation after stroke: a narrative review. curr atheroscler rep. 2017;19(12):59. pmid: 29116473. doi: https://doi.org/10.1007/s11883017-0686-6 4. adhikari sp, tretriluxana j, chaiyawat p, jalayondeja c. enhanced upper extremity functions with a single session of actionobservation-execution and accelerated skill acquisition program in subacute stroke. stroke res treat. 2018;2018(0):1490692. pmid: 30009017. doi: https://doi. org/10.1155/2018/1490692 5. bernhardt j, godecke e, johnson l, langhorne p. early rehabilitation after stroke. curr opin neurol. 2017;30(1):48-54. pmid: 27845945. doi: https://doi.org/10.1097/wco.0000000000000404 6. tijsen lm, derksen ew, achterberg wp, buijck bi. challenging rehabilitation environment for older patients. clin interv aging. 2019;14(0):145160. pmid: 31496672. doi: https://doi.org/10.2147/ cia.s207863 7. xie h, yu k, zhou n, shen x, tian s, zhang b, et al. enriched environment elicits proangiogenic mechanisms after focal cerebral ischemia. transl stroke res. 2019;10(2):150-9. pmid: 29700717. doi: https://doi.org/10.1007/s12975018-0629-8 8. kleim ja, jones ta. principles of experiencedependent neural plasticity: implications for rehabilitation after brain damage. j speech lang hear res. 2008;51(1):s225-39. pmid: 18230848. doi: https://doi.org/10.1044/10924388(2008/018) 9. winstein cj, miller jp, blanton s, taub e, uswatte g, morris d, et al. methods for a multisite randomized trial to investigate the effect of constraint-induced movement therapy in improving upper extremity function among adults recovering from a cerebrovascular stroke. neurorehabil neural repair. 2003;17(3):13752. pmid: 14503435. doi: https://doi. org/10.1177/0888439003255511 10. ada l, dean cm, morris me, simpson jm, katrak p. randomized trial of treadmill walking with body weight support to establish walking in subacute stroke: the mobilise trial. stroke. 2010;41(6):1237-42. pmid: 20413741. doi: https://doi.org/10.1161/strokeaha.109.569483 j. lumbini. med. coll. vol 9, no 2, july-dec 2021 rana s et al. fatigue and sleep quality among staff nurses working in a tertiary care hospital during covid-19 pandemic jlmc.edu.np ___________________________________________________________________________________ submitted: 30 july, 2021 accepted: 04 october, 2021 published: 11 october, 2021 alecturer, college of nursing bassistant professor, college of nursing cnursing officer, department of anaesthesiology and critical care d-nursing officer, department of internal medicine elumbini medical college teaching hospital, palpa, nepal. corresponding author: sunita rana e-mail: rsunita25@gmail.com orcid: https://orcid.org/0000-0002-4987-6607_______________________________________________________ abstract introduction: fatigue, a universal phenomenon, is a suboptimal psychophysiological condition caused by physical and/or mental exertion. insufficient recovery between work shifts causes accumulated acute fatigue to progress into chronic. as fatigue and sleep quality are related, adequate sleep and inter shift recovery are thus vital to the overall health. the current covid-19 pandemic has caused added burden to the nursing workforce worldwide. this study aimed to assess fatigue and sleep quality among staff nurses of a tertiary care hospital during the pandemic. methods: a descriptive cross-sectional study was conducted among 151 staff nurses of lumbini medical college and teaching hospital (lmcth) using enumerative sampling method. valid and reliable instruments i.e., occupational fatigue exhaustion recovery (ofer) and pittsburgh sleep quality index (psqi) were used. analysis was done using descriptive and inferential statistics. results: the mean ±sd age of the participants was 26.54±6.93 years. less than half (39.1%) of them had moderate to high acute fatigue. nearly half (41.2%) had high chronic fatigue and most (61.6%) had low to moderate inter shift recovery. poor sleep was found among 60.9% of the participants with mean global psqi score of 6.74. sleep quality had moderate positive correlation with chronic (r=0.4, p<0.001) and acute (r=0.39, p<0.001) fatigue whereas had moderate negative correlation with inter shift recovery (r=0.41, p<0.001) which were statistically significant. conclusion: the staff nurses had fatigue and poor sleep during covid-19 pandemic. nursing administration should take appropriate measures timely to decrease fatigue and improve sleep to prevent serious consequences. key words: covid-19 pandemic; fatigue; sleep quality; tertiary care hospital original research articlehttps://doi.org/10.22502/jlmc.v9i2.457 sunita rana,a,e mamta koirala,b,e nongmaithem jid noon baral thapa,c,e samikshya kc d,e fatigue and sleep quality among staff nurses working in a tertiary care hospital during covid-19 pandemic how to cite this article:how to cite this article: rana s, koirala m, thapa njnb, kc s. fatigue and sleep quality among staff nurses working in a tertiary care hospital during covid-19 pandemic. journal of lumbini medical college. 2021;9(2):6 pages. doi: https://doi.org/10.22502/jlmc.v9i2.457. epub: october 11, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: fatigue, a universal phenomenon, is a suboptimal psychophysiological condition caused by physical and/or mental exertion. in the absence of adequate recovery, acute fatigue may lead to chronic fatigue.[1] nurses working in shifts are at greater chance of getting fatigued.[2,3] the term ‘work shift’ is applicable to occupations working throughout the 24-hour cycle.[4] nursing work in itself is physically and mentally strenuous. nurses frequently encounter non-standard work schedules, long working hours and frequent circadian adjustment to night shift which make them physically, mentally and emotionally tired putting them at a greater risk of developing chronic fatigue. thus, work-related fatigue is significant among nurses especially those working at tertiary hospitals.[5] fatigue and sleep are intricately woven. sleep quality has correlations with fatigue.[6] subjective sleep quality can be defined as the satisfaction towards overall sleep experience, including initiation, maintenance, quantity, and feeling of refreshment upon awakening whereas objective sleep quality consists of the total duration j. lumbini. med. coll. vol 9, no 2, july-dec 2021 rana s et al. fatigue and sleep quality among staff nurses working in a tertiary care hospital during covid-19 pandemic jlmc.edu.np of sleep, the architecture of sleep and the frequency of awakenings across the night.[7] adequate sleep and full inter shift recovery are vital to the overall health of an individual. working in day/night shift rotation is responsible for irregular and disturbed sleep causing the shift workers to be more fatigued. [8,9] insufficient sleep and consequent fatigue may impair cognitive function and increase risk of workrelated errors and accidents.[8-12] international council of nurses (2020) concluded that nursing workforce worldwide are over worked. the covid-19 pandemic has escalated already demanding and stressful working conditions in hospital nurses.[13] the recent change in duty pattern from 8 to 12 hours per day during covid-19 pandemic forced the nurses working in inpatient units of lumbini medical college and teaching hospital (lmcth) to work longer hours. this study aimed to assess fatigue and sleep quality among the staff nurses of lmcth during covid-19 pandemic. methods: a cross-sectional descriptive design was adopted to study the fatigue and sleep quality of staff nurses working in lmcth after obtaining ethical clearance from institutional review committee (irc-lmc 02/a021). enumerative sampling method was used to collect data within two weeks from 23rd february to 9th march 2021. out of 191, only 151 staff nurses gave consent to participate in the study making response rate of 87%. the participants were informed that their participation will be kept anonymous and the data collected would be used exclusively for scientific research purpose only. participation in the study was voluntary. three-part self-administered structured questionnaire was used as follows part i: a. demographic variables of the participants (age, education, marital status, caring for under five years children and elderly family member at home). b. work-related variables of the participants (work experience, work area, pattern of shift, shift profile, duration of current shift pattern and work hour per week). part ii: occupational fatigue exhaustion recovery (ofer) scale questionnaire ofer comprises 15 self-report items with three subscales: chronic fatigue (1-5), acute fatigue (610), and inter shift recovery (11-15). the items are scored on a 7-point likert scale (0= strongly disagree, 1=disagree, 2=slightly disagree, 3=neither agree or disagree, 4=slightly agree, 5=agree and 6= strongly agree). items 9,10,11,13 and 15 are reverse scored. scores range from 0-90.the obtained score was converted to percentage. for comparative purposes, cut-points into levels of “low, low/ moderate, moderate/high and high” on each subscale was computed according to quartiles of scale score distribution. the ofer has high construct, discriminate validity and internal reliability. cronbach’s alpha coefficients are at least 0.84 for each subscale.[4] part iii: pittsburgh sleep quality index (psqi) questionnaire psqi subjectively measures the quality and patterns of sleep during the past month. it measures 7 sleep componentssubjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction. each component is scored on a likert-type 4-point scale (0,1,2,3) and weighs equally from 0 to 3. adding 7 component scores gives a global score in the range of 0 to 21; the higher the score, the worse the sleep quality. a score of 5 or greater indicates “poor” sleep. the cronbach alfa for psqi is 0.83.[14] permission to use both tools from the developers were obtained. data was collected by the principal and coauthors by distributing the questionnaires among the staff nurses in their respective workplace during lunch or break time. after explaining the objectives and obtaining voluntary consent, data was collected. data was analyzed by using statistical packages for social sciences (spss) version 16. frequency, percentage, mean, standard deviation, range and quartiles were used for descriptive statistics whereas to find out the association between selected variables and fatigue level and sleep quality, chi square and fisher’s exact test were used. pearson’s correlation coefficient was used to find out correlation among the variables. the confidence level was set at 95% with p-value <0.05. results: the mean age of the participants was 26.54±6.93 years. majority (72.1%) of them had completed proficiency certificate level (pcl) j. lumbini. med. coll. vol 9, no 2, july-dec 2021 rana s et al. fatigue and sleep quality among staff nurses working in a tertiary care hospital during covid-19 pandemic jlmc.edu.np nursing. more than half (60.3%) of them were single. most (62.9%) were caring for elderly family members at home. more than half (57%) of the participants were working for more than 24 months. more than one-fourth (29.2%) of them were working in surgery department. regarding shift pattern, most (88.1%) participants had routinely rotating shift. likewise, majority (86.8%) were performing 12-hour shift. the mean duration of current shift pattern in month was 16.06±23.05. all (100%) of them were doing 48 hours duty per week. regarding level, less than half (39.1%) of the participants had moderate to high acute fatigue. nearly half (41.2%) had high chronic fatigue and most (61.6%) had low to moderate inter shift recovery. (table 1) acute fatigue, chronic fatigue and inter shift recovery were statistically significant with age (p=0.020, 0.040 and <0.001), education(p=0.001, 0.005 and <0.001), marital status(p=0.002, <0.001 and <0.001), work experience (p=0.032, 0.020 and 0.038), work area(p=0.005 and <0.001), pattern of shift (p<0.001, <0.001 and <0.001), shift profile (p<0.001, <0.001 and <0.001), and duration of current shift pattern (p<0.001, <0.001 and <0.001). table 2 shows that mean score of acute fatigue, chronic fatigue and inter shift recovery were 69.05±22.16, 64.83±21.18 and 40.42±20.27 respectively. acute fatigue was moderately and table 1: participants’ level of acute fatigue, chronic fatigue and inter shift recovery (n=151). variables level of fatigue low n (%) low/moderate n (%) moderate/high n (%) high n (%) acute fatigue 4 (2.6) 40 (26.5) 59 (39.1) 48 (31.8) chronic fatigue 4 (2.6) 28 (18.5) 57 (37.7) 62 (41.2) inter shift recovery 25 (16.6) 93 (61.6) 20 (13.2) 13 (8.6) table 2: correlation among acute fatigue, chronic fatigue and inter shift recovery of the participants (n=151). variables mean ± sd pearson correlation acute fatigue chronic fatigue inter shift recovery acute fatigue 69.05±22.163 1 0.721* -0.658* chronic fatigue 64.83± 21.183 0.721* 1 -0.639* inter shift recovery 40.42± 20.273 -0.658* -0.639* 1 *p<0.05 table 3: association between sleep quality and selected variables of the participants (n=151). variables sleep quality df chi square p valuegood n (%) poor n (%) 59 (39.1) 92 (60.9) education anm pcl and above 24 (58.5) 35 (31.8) 17 (41.5) 75 (68.2) 1 8.956 0.003 pattern of shift fixed routinely rotating 14 (77.8) 45 (33.8) 4 (22.2) 88 (66.2) 1 12.86 <0.001 shift profile 12-hrs 8-hrs 44 (33.6) 15 (75.0) 87 (66.4) 5 (25.0) 1 12.5 <0.001 duration of current shift pattern (months) ≤11 >11 46 (34.6) 13 (72.2) 87 (65.4) 5 (27.8) 1 9.433 0.002 j. lumbini. med. coll. vol 9, no 2, july-dec 2021 rana s et al. fatigue and sleep quality among staff nurses working in a tertiary care hospital during covid-19 pandemic jlmc.edu.np positively correlated (r=0.721, p<0.001) with chronic fatigue which was statistically proven. likewise, acute fatigue (r=-0.658, p<0.001) and chronic fatigue (r=-0.639, p<0.001) were moderately and negatively correlated with inter shift recovery which was also statistically significant. the mean global psqi score of the study group was 6.74. majority (60.9%) of them had poor sleep. sleep quality was statistically significant with education (p=0.003), pattern of shift (p<0.001), shift profile (p<0.001) and duration of current shift pattern (p=0.002) (table 3). scores on psqi (sleep quality) had moderate positive correlation with chronic fatigue (r=0.4, p<0.001) and acute fatigue (r=0.39, p=<0.001) scores whereas had moderate negative correlation with inter shift recovery (r=-0.41, p<0.001) score which was statistically significant (table 4). table 4: correlation between psqi (sleep quality) and ofer (fatigue) scores of the participants (n=151). psqi score (sleep quality) ofer score acute fatigue chronic fatigue inter shift recovery r=0.394 r=0.400 r=-0.411 p<0.001 p<0.001 p<0.001 discussion: this study aimed to examine fatigue and sleep quality of the staff nurses of lmcth during covid-19 pandemic. this study disclosed that participants experienced moderate to high level of acute fatigue and high level of chronic fatigue. they had low to moderate inter shift recovery. this showed that their inter shift recovery level in relation to acute and chronic fatigue is low. this finding is consistent with other studies.[15,16] a lebanese study describes that high level of both acute and chronic fatigue is an anticipated finding during crisis like covid-19 pandemic. also, worse fatigue and poorer inter shift recovery was found in nursing staffs working in covid-19 compared to non-covid-19 ward.[13] likewise, a study conducted in the usa showed that participants had high acute fatigue, moderate-tohigh chronic fatigue and low-to-moderate inter shift recovery.[2] in the present study, fatigue level is statistically significant with age, education, marital status, work experience, work area, pattern of shift, shift profile and duration of current shift pattern. this is in line with other studies.[16,17,18] the study discovered that there were moderate correlations among acute fatigue, chronic fatigue and inter shift recovery in predictable direction. these findings highlight the fact that accumulated acute fatigue may progress into chronic in the absence of sufficient inter shift recovery. the inverse relationship between fatigue and recovery was seen in negative correlation. positive correlation was seen between acute and chronic fatigue. this is congruent with the finding of another study where moderate strength of inter-correlation among chronic, acute fatigue and inter shift recovery was seen.[15] in the present study, 60.9% participants had poor sleep quality. this study confirms previous finding.[9] the global psqi of 6.74±3.877explains that participants had poor quality of sleep. this finding is supported by other studies.[6,9] the current study discovered that education, pattern of shift, shift profile and duration of current shift pattern were associated with sleep quality which is consistent with other studies.[8,9] shift work, job demands, exposure to hazards in work environments, and chronic fatigue were found to affect sleep quality in chinese nurses.[19] the present study discovered that psqi score had moderate positive correlation with acute and chronic fatigue scores and moderate negative correlation with inter shift recovery scores. the correlations were statistically significant. this is supported by a korean study.[6] conclusion: the covid-19 pandemic has overburdened the nursing workforce worldwide. staff nurses of lmcth are experiencing fatigue and having poor sleep. fatigue and sleep quality are related with education, pattern of shift, shift profile and duration of current shift pattern. acute fatigue, chronic fatigue and inter shift recovery are related. sleep quality and fatigue are also related. the nursing administration of lmcth can work on implementing different staffing model for inpatient staff nurses to reduce chronic fatigue and to promote enough recovery in between shifts. policies on taking measures to counteract fatigue can be implemented such as scheduling breaks for tea or lunch etc. reinforcing and monitoring implementation of policies, promoting supportive work environment j. lumbini. med. coll. vol 9, no 2, july-dec 2021 rana s et al. fatigue and sleep quality among staff nurses working in a tertiary care hospital during covid-19 pandemic jlmc.edu.np and developing collaborative team by the nurse managers can prevent fatigue among staff nurses. similarly, in-service education regarding practices to improve sleep can also be conducted. arranging easy accessibility of help to address problems of sleep and fatigue could improve the overall health of the staff nurses of lmcth. acknowledgment: the authors extend their gratitude to dr. peter winwood (ofer scale) and daniel j. buysse (psqi tool) for granting permission to use their instruments in this study. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. references: 1. mohdfauzi mf, mohdyusoff h, muhamad robat r, mat saruan na, ismail ki, mohdharis af. doctors’ mental health in the midst of covid-19 pandemic: the roles of work demands and recovery experiences. int j environ res public health. 2020;17(19):7340. pmid: 33050004 doi: https://doi.org/10.3390/ ijerph17197340 2. sagherian k, clinton me, abu-saad huijer h, geiger-brown j. fatigue, work schedules, and perceived performance in bedside care nurses. workplace health saf. 2017;65(7):30412. pmid: 27872407 doi:https://doi. org/10.1177/2165079916665398 3. josten ejc, ng‐a‐tham jee, thierry h. the effects of extended workdays on fatigue, health, performance and satisfaction in nursing. j adv nurs. 2003;44(6):643-52.pmid: 14651687 doi: https://doi.org/10.1046/j.03092402.2003.02854.x 4. winwood pc, lushington k, winefield ah. further development and validation of the occupational fatigue exhaustion recovery (ofer) scale. j occup environ med. 2006;48(4):3819. pmid: 16607192 doi: https://doi. org/10.1097/01.jom.0000194164.14081.06 5. alahmadi ba, alharbi mf. work-related fatigue factors among hospital nurses: an integrative literature review. nurse media journal of nursing. 2018;8(2):113-133. doi: https://doi. org/10.14710/nmjn.v8i2.19554 6. sim s, lee sb, bang m. relationship among sleep quality, fatigue, resilience, and nursing performance ability in shift work nurses. indian journal of public health research &development. 2019;10(11):4659-63. doi:https://doi. org/10.5958/0976-5506.2019.04341.9 7. jahrami h, bahammam as, algahtani h, ebrahim a, faris m, aleid k, et al. the examination of sleep quality for frontline healthcare workers during the outbreak of covid-19. sleep breath. 2021;25(1):503-11. pmid: 32592021 doi: https://doi.org/10.1007/s11325-020-02135-9 8. zhang l, sun dm, li cb, tao mf. influencing factors for sleep quality among shift-working nurses: a cross-sectional study in china using 3-factor pittsburgh sleep quality index. asian nurs res (korean soc nurs sci). j. lumbini. med. coll. vol 9, no 2, july-dec 2021 rana s et al. fatigue and sleep quality among staff nurses working in a tertiary care hospital during covid-19 pandemic jlmc.edu.np 2016;10(4):277-82. pmid: 28057314 doi: https://doi.org/10.1016/j.anr.2016.09.002 9. muzio md, diella g, simone ed, novelli l, alfonsi v, scarpelli s, et al. nurses and night shifts: poor sleep quality exacerbates psychomotor performance. front neurosci. 2020;14(0):579938. pmid: 33154716 doi: https://doi.org/10.3389/fnins.2020.579938 10. rasoulzadeh y, bazazan a, safaiyan a, dianat i. fatigue and psychological distress: a case study among shift workers of an iranian petrochemical plant, during 2013, in bushehr. iran red crescent med j. 2015;17(10):e28021. pmid: 26568862 doi: https://pubmed.ncbi. nlm.nih.gov/26568862/ 11. chien pl, su hf, hsieh pc, siao ry, ling py, jou hj. sleep quality among female hospital staff nurses. sleep disord. 2013;2013(0):283490. doi: https://doi.org/10.1155/2013/283490 12. shiffer d, minonzio m, dipaola f, bertola m, zamuner ar, dalla vecchia la, et al. effects of clockwise and counterclockwise job shift work rotation on sleep and work-life balance on hospital nurses. int j environ res public health. 2018;15(9):2038. pmid: 30231514 doi: https://doi.org/10.3390/ijerph15092038 13. sagherian k, steege lm, cobb sj, cho h. insomnia, fatigue and psychosocial well‐being during covid‐19 pandemic: a cross‐sectional survey of hospital nursing staff in the united states. j clin nurs. 2020;10.1111/jocn.15566. pmid: 33219569 doi: https://doi.org/10.1111/ jocn.15566 14. buysse dj, reynolds cf, monk th, berman sr, kupfer dj. the pittsburgh sleep quality index: a new instrument for psychiatric practice and research. psychiatry research. 1989;28(2):193213. doi: https://doi.org/10.1016/01651781(89)90047-4 15. mohdfauzi mf, mohdyusoff h, mat saruan na, muhamad robat r, abdul manaf mr, ghazali m. fatigue and recovery among malaysian doctors: the role of work-related activities during non-work time. bmj open. 2020;10(9):e036849. pmid: 32978189 doi: https://doi.org/10.1136/ bmjopen-2020-036849 16. somantri i, yuliati m, winwood p, adiningsih d. work-related fatigue among inpatient unit nurses. journal of nursing care. 2020;3(3):199205. doi:https://jurnal.unpad.ac.id/jnc/article/ view/22286/13871 17. yuan sc, chou mc, chen cj, lin yj, chen mc, liu hh, et al. influences of shift work on fatigue among nurses. j nursmanag. 2011;19(3):339-45. pmid: 21507104 doi: https://doi.org/10.1111/ j.1365-2834.2010.01173.x 18. tang c, liu c, fang p, xiang y, min r. work-related accumulated fatigue among doctors in tertiary hospitals: a cross-sectional survey in six provinces of china. int j environ res public health. 2019;16(17): 3049. pmid: 31443480 doi: https://doi.org/10.3390/ijerph16173049 19. li y, fang j, zhou c. work-related predictors of sleep quality in chinese nurses: testing a path analysis model. j nurs res. 2019;27(5):e44. pmid: 30933051 doi: https://doi.org/10.1097/ jnr.0000000000000319 jlmc.edu.np case report —–————————————————————————————————————————————— abstract: introduction: osteochondroma are benign tumors which arise from aberrant cartilage nodules within the periosteum. they can be either pedunculated or sessile and are more common in the extremities and rarely seen in spine. en-bloc excision is the preferred treatment. case report: we present a case of 20 year female, who came with a swelling and pain in lower back for two years which was diagnosed to be thoracic vertebra(d11) osteochondroma on x-ray and computed tomography. excision biopsy was done and confirmed it to be osteochondroma. there has been no recurrence even after 16 months of follow up. conclusion: although rare, osteochondroma of the vertebra should be kept in mind as a differential diagnosis when evaluating mass in spine. en bloc excision should be performed. keywords: osteochondroma • thoracic vertebra • excision —–————————————————————————————————————————————— j. lumbini. med. coll. vol 2, no 1, jan june 2014 ___________________________________________________________________________________ a lecturer b professor c department of orthopaedic surgery & traumatology, lumbini medical college, palpa corresponding author: dr. ruban raj joshi e-mail: rubanjoshi@hotmail.com how to cite this article: joshi rr, sundararaj gd, solitary osteochondroma arising from the dorsal vertebral spinous process: a case report. journal of lumbini medical college. 2014;2(1):25-7. doi: 10.22502/jlmc.v2i1.51. ruban raj joshia,c, gabriel david sundararajb,c solitary osteochondroma arising from the dorsal vertebral spinous process: a case report aching intermittent in nature, and aggravated by doing heavy work and relieved by analgesics. there was no history of previous trauma or surgery and the past medical history was unremarkable. clinical examination of her back revealed an elliptical mass 7.5 x 5.25 cm in size lateral to d9 to d12 vertebra on right side (fig 1). palpation showed that the swelling was firm to bony hard in consistency which seemed fixed to the underlying corresponding vertebrae and ribs. the swelling became more prominent as the patient bent forwards. overlying skin was normal. there were no similar swellings in any other parts of the body and remainder orthopedic examination was normal. neurological examination was unremarkable with normal mental state. there was mild tenderness with no deformity of the back. the erythrocyte sedimentation rate (esr) was 11 mm/hr and the white blood cell (wbc) count was normal. a plain radiograph showed an uneven elliptical paraspinal mass at the level of d10 to d12 vertebrae (fig. 2a, b). a plain ct scan revealed expansile lesion originating from the posterior elements (spinous process) of d11 vertebra with the lesion showing mixed density with central dense calcification. the normal marrow was seen between the mass and the normal vertebra and the tumor was not extending in the spinal canal (fig 3a, b). 3d reconstruction of the ct revealed exostosis arising introduction: osteochondroma otherwise known as "osseocartilaginous exostosis" are frequently seen on the metaphysis of the long bones, but they are rarely seen (2%) on the spinal column. vertebral osteochondromas usually arise from neural arch of cervical and thoracic vertebra and spinal cord compression is seen more often in hereditary multiple exostosis than in solitary lesion.1,2 here, we report a case of solitary osteochondroma arising from the spinous process of d11 vertebra without neurological deficit. case report: a 20 years old female student presented with low back pain and progressive swelling over the right lower back for two years. the pain was dull https://doi.org/10.22502/jlmc.v2i1.51 25 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 joshi rr. et al. solitary osteochondroma arising from the dorsal vertebral spinous process: a case report from the spinous process (fig. 3c). excision biopsy of the tumor was planned. under general anesthesia, patient was positioned prone. a 10 cm long longitudinal right para median incision was made centering on the tumor. trapezius muscle was dissected, paraspinal muscles were incised along the fibers to expose the tumor (fig 4). en bloc excision of the elliptical capsulated mass with well defined borders was carried out. tumor revealed a hard mass measuring 7.5 cm x 6 cm x 4 cm along with multiple grey white bony pieces (fig 5). histopathologically, the tumor was noted to have a cartilaginous cap centered by trabecular bone with endochondral ossification at the bone-cartilage interface which were consistent with a diagnosis of osteochondroma. postoperative stay was uneventful and patient got discharged after a week. after 16 months postoperatively, patient was asymptomatic and there was no recurrence. discussion: osteochondromas are common benign primary bone tumors that are thought to arise through a process of progressive enchondral ossification of aberrant cartilage of a growth plate as a consequence of congenital defect or trauma. osteochondromas rarely affect the spine; 1.3% to 4.1% of solitary osteochondromas arise within the spine, and approximately 9% of patients with multiple osteochondromas have spinal lesions.3-5 understanding embryological development of spine could also conjecture on other etiological hypothesis. the complete growth of the vertebral column is completed in adolescence by secondary ossification centers at the spinous process, transverse process, articular process, and end plate of vertebral body. these secondary ossification centers appear in children between the ages of 11 and 18 years and complete the ossification process in the cervical spine during the third decade of life, in the thoracic and lumbar spine during the end of second decade of life and in the sacrum during the third decade of life.1 the aberrant cartilaginous tissue of these secondary ossification centers could be the origin of osteochondroma. so, it can be hypothesized that more rapid ossification of these centers could give rise to aberrant cartilaginous tissues. osteochondromas arising in the upper segment of vertebral column could probably be explained by age fig 1: a diffuse lump over lower dorsal paraspinal region of right side fig 2(a, b): ap and lateral plain x-ray of the thoracic spine. a heterogeneous bony mass is seen in the lower thoracic spine fig 3: ct scan at the level of t10-11 showing an abnormal bony mass arising from the posterior arch of t11 having irregular cortical margins (a and b). the 3d ct reconstruction of this patient shows the osteochondroma of t11 vertebra comes from the spinous process (c) 26 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 joshi rr. et al. solitary osteochondroma arising from the dorsal vertebral spinous process: a case report likelihood of recurrence.7 malignant transformation is reported in 10-30% of hme as compared to 15% in solitary osteochondroma, so complete resection of these tumor is crucial.1 majority of surgically treated patients’ outcomes are good and malignant degeneration is uncommon.8 we present this case to highlight a successful resection of a solitary thoracic osteochondroma originating from the spinous process of thoracic veterbra. clinical message: veterbral osteochondroma is a rare condition, which can present with diversed presentations and locations. complete excison of osseous mass is a treatment of choice with lower risk of local recurrence . financial support and sponsorship: none. conflicts of interest: none. fig 4: per operative findings showing cartilaginous cap in the lesion fig 5: gross specimen of the lesion after total resection fig 6: photomicrograph of the osteochondroma (hematoxylin and eosin stain) showing a cartilaginous cap (*) covering the trabecular bone variations of ossification process in these centers.1 spinal involvement is more common in hereditary multiple osteochondroma (hme) and may present with radiculopathy and myelopathy. it usually affects the dorsolumbar vertebrae, while the solitary lesions commonly affect the cervical spine particularly c1 c2 vertebra.6 computed tomography(ct) is the diagnostic imaging of choice. complete excision of the cartilaginous cap is advocated to reduce the references: 1. fiumara e, scarabino t, guglielmi g, bisceglia m, angelo vd. osteochondroma of the l5 vertebra: a rare cause of sciatic pain. j neurosurg. 1999 oct;9(2 suppl):219-22. 2. govender s, parbhoo ah. osteochondroma with compression of the spinal cord. j bone joint surg (br) 1999;81(14):667-9. 3. marchand ep, villemure jg, rubin j, robitaille y, ethier r. solitary osteochondroma of the thoracic spine presenting as spinal cord compression. spine. 1986;11(10):1033-35. 4. mermer mj, gupta mc, salamon pb, benson dr. thoracic vertebral body exostosis as a cause of myelopathy in a patient with hereditary multiple exostoses. j spinal disord tech. 2002;15(2):144-8. 5. mikawa y, watanabe r, nakashima y, hayashida t. cervical spinal cord compression in hereditary multiple exostoses. report of a case and a review of the literature. arch orthop trauma surg. 1997;116(1-2):112-5. 6. murphey md, choi jj, kransdorf mj, flemming dj, gannon fh. imaging of osteochondroma: variants and complications with radiologic-pathologic correlation. radiographics. 2000;20(5):1407-34. 7. mamartzis d, marco ra: osteochondroma of the sacrum: a case report and review of the literature. spine. 2006(31):425-9. 8. lopez-barea f, hardisson d, rodriguez-peralto jl, sanchez-herrera s, lamas m. intracortical hemangioma of bone. j bone joint surg (am). 1998;80(11):1673-8. * 27 j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np nepal p, et al. readiness for self-directed learning among nursing students of lumbini medical college: a cross-sectional study ___________________________________________________________________________________ submitted: 09 october, 2021 accepted: 20 december, 2021 published: 25 december, 2021 aassistant professor, nursing program blecturer c-lumbini medical college teaching hospital, palpa, nepal. d-devdaha college of science and technology, rupandehi, nepal. corresponding author: parbati nepal e-mail: kirparu@gmail.com orcid: https://orcid.org/0000-0001-9879-5486_______________________________________________________ abstract introduction: self-directed learning is an independent learning approach and especially appropriate for adult learners where control over the learning is exerted by the learners than by teachers. methods: a descriptive cross-sectional study was conducted among 147 nursing students. all the students of 2nd and 3rd years proficiency certificate level (pcl) and 2nd, 3rd, and 4th-year bachelor in science (b.sc) nursing were selected purposefully. the level of readiness was assessed through internationally validated “self-directed learning readiness scale (sdlr)”. data were analyzed using descriptive and inferential statistics. the p-value was set at <0.05. results: the mean age of participants was 20.10±1.73 years and 55.1% of participants were from pcl nursing and 51.7% were from brahmin/chhetri ethnicity. nearly three quarter (72.3%) were hosteller. a majority (83.7%) of participants had a high level of readiness for self-directed learning with an overall mean score of 158.78±14.27. the mean score (60.42±6.99) of selfcontrol subscale was higher than the mean score of self-management (49.82±5.01) and desire for learning (48.53±5.47). the year of study (p<0.001), level of study (p<0.001), age (p<0.001), and grade obtained in previous level education (p<0.001) were statistically significant with the readiness level for self-directed learning. conclusion: nursing students had a higher level of readiness for self-directed learning, so the teachers need to adopt those learning strategies that help and encourage nursing students for independent learning which enhance student’s learning with better retention, good decision making, and confidence. keywords: nursing students; readiness; self-directed learning original research articlehttps://doi.org/10.22502/jlmc.v9i2.460 parbati nepal,a,c dipa adhikari b,d readiness for self-directed learning among nursing students of lumbini medical college and teaching hospital: a cross-sectional study how to cite this article:how to cite this article: nepal p, adhikari d. readiness for self-directed learning among nursing students of lumbini medical college and teaching hospital: a cross-sectional study. journal of lumbini medical college. 2021;9(2):6 pages. doi: https://doi.org/10.22502/jlmc.v9i2.460. epub: december 25, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: self-directed learning (sdl) is an art and science of helping adults to meet their learning needs and this learning approach is based on the concept called andragogy. here, the students direct their learning and the teacher just plays the role of facilitator. according to knowles “self-directed learning is defined as “ a process in which individuals take initiative, with or without help of others, in diagnosing their learning needs, formulating learning goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies and evaluating learning outcomes.”[1] this learner-centered approach operates based on the learners’ maturation in terms of their readiness to assume responsibility for his or her own learning.[2] in this approach, learners have the freedom to set their priorities for learning as to how they feel learning is important for them. the degree of self-control depends on the learner’s ability, personality character, and attitude. in sdl, learning can be done in an informal setting as well.[3] j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np nepal p, et al. readiness for self-directed learning among nursing students of lumbini medical college: a cross-sectional study the scope of nursing has expanded, and nurses are working in multifaceted health care settings. along with their changing scopes, various challenges emerging from advanced science and technology are unavoidable. the responsibility of nursing education is to prepare such nurses who can successfully combat the challenges of quality nursing services by developing independent learning, assertiveness, accountability, critical thinking, and worthy decision-making capacity. [4,5] being nursing students as the future health manpower, nursing educators need to adopt creative learning approaches like sdl with the primary aim of preparing such nurses who can provide quality service through critical thinking and good decision making.[5] to adapt and stimulate self-directed learning among nursing students, it is important to regularly investigate, and analyze their state of selfdirected readiness.[6] and, in the context of nepal, the educational system is largely based on teachercentered approach. so, the present study aimed to explore the nursing students’ state of readiness for self-directed learning. methods: a descriptive cross-sectional study design was adopted to investigate the nursing students’ readiness for self-directed learning. ethical approval was taken from the institutional research committee of lumbini medical college and teaching hospital (lmcth) (irc-lmc 01-d/021). this study was conducted among the nursing students of lmcth. there were total of 147 nursing students from the second and third year of proficiency certificate level (pcl) in nursing and second, third and fourth year of bachelor in science (b.sc) nursing, who were selected purposefully. participation was voluntary. first-year students of pcl and b.sc nursing and those who were absent during data collection time were excluded. the paper and pencil technique were used for data collection. all the students were gathered in their respective classrooms. after giving clear instructions and obtaining verbal consent, questionnaires were distributed to them. in the presence of the researcher, questionnaires were filled by participants and around 10 minutes were taken for completion. the data was collected in the first week of september 2021. the self-administered questionnaire used in this study consisted of two parts; part i: sociodemographic variables. part ii: self directed learning readiness (sdlr) scale to assess the readiness level of nursing students. it is an internationally validated and standard self-perception scale that was first developed and tested by fisher et al.[3,7] there is a total of 40 items grouped under three subscales; self-management (13), the desire for learning (12), and self-control (15). the responses were rated in a five-point likert scale format, where ‘1’ indicated strongly disagree, and ‘5’ indicated strongly agree. whereas, reverse scoring was done for 4 negative statements (i am poor at managing my time, i dislike studying; i am disorganized, and i am not in control of my life). the minimum score of total items was 40 and the maximum score was 200. the content validity of the instrument was established through the use of a modified reactive delphi technique using experts from the nursing field. the internal consistency for each component was estimated using cronbach’s coefficient alpha. the computed values of cronbach’s coefficient alpha for the total 40 items was 0.924 and self-management subscale, the desire for learning subscale and the self-control subscale were 0.85, 0.847 and 0.830 respectively.[7] a score of 150 or greater is indicative of students’ high level of readiness in self-directed learning.[3] after checking for completeness, the collected data were entered in microsoft excel 2007 and transformed in statistical package for the social sciences (spss) version 16 for statistical analysis. descriptive statisticsfrequency, percentage, mean, standard deviation, and range; and inferential statistics (chi-square and fisher’s exact test) were used for the analysis of data. the p-value was set at <0.05 for statistical significance. results: almost all (99.3%) of the participants were unmarried, whereas nearly three-fourth (72.8%) of them were hostellers. slightly more than three quarter (78.2%) of the participants were from nuclear family and 51.7% of them were the first child of their parents. a majority (93.2%) belonged to the hindu religion. regarding parent’s education, 47.6% of fathers and 53.8% of the mother had a secondary level of education. a majority (78.2%) of participants’ mothers were housewives, whereas, 34.7% of the father had their own businesses. the remaining profiles are depicted in table 1. j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np nepal p, et al. readiness for self-directed learning among nursing students of lumbini medical college: a cross-sectional study table 1. participants’ demographic profiles (n=147). characteristics n (%) age in years ≤20 82(55.8) >20 65(44.2) mean±sd=20.10±1.73, range=17-24 level of education pcl in nursing 81 (55.1) b.sc. in nursing 66 (44.9) year of study 2nd year 54 (36.7) 3rd year 63 (42.9) 4th year 30 (20.4) ethnicity brahmin/chhetri 76 (51.7) janajati 68 (46.3) dalit 3 (2.0) grade obtained in the previous level distinction 54 (36.7) first 86 (58.5) second 7 (4.8) voluntarily selection of profession yes 133 (90.5) no 14 (9.5) a majority (83.7%) of the participants had a high level of readiness for self-directed learning. the self-control subscale has the highest mean score (66.42) followed by self-management (49.82) and desire for learning (48.53). the overall mean score percent of sdlr was slightly more than three quarters (79.39). the results are shown in table 2 and table 3. table 2. participant’s level of readiness in self directed learning (n=147). variables n (%) high level of readiness (≥150) 123 (83.7) low level readiness (<150) 24 (16.3) there was a statistically significant relationship between the level of self-directed learning readiness with age (p<0.001), level of education (p<0.001), year of study (p<0.001), and grade obtained in previous level education (p<0.001). but there were no statistical significant relationship with voluntarily selection of profession (p=0.193), type of family (p=0.508), place of residence (p=0.154), ethnicity (p=0.109) and religion (p=0.368) as illustrated in table 4. discussion: it is crucial for nursing educators to search for the most effective and appropriate learning approaches for their students and it is determined by students’ readiness state to adopt any type of learning approach. therefore, this investigation was done to find out the self-directed learning readiness state of bachelor and proficiency certificate level nursing students of lmcth. the present study reported that the majority (83.7%) of nursing students had a high level of readiness. a study conducted in chitwan, nepal also reported the same finding.[3] similarly, studies from other countries also reported a high level of self-directed learning readiness among nursing students.[4,6,8,9] though there are varieties of learning approaches, nepal is still practicing teacher-directed learning style, but the findings of the present study indicated that nursing students of lumbini medical college and teaching hospital are independent learners. the study revealed that most of the participants possessed a high level of preparedness and willingness to adopt the sdl approach. nurses and nursing students need to be updated with changing knowledge, skills and technology to provide quality care to the health service consumers, so sdl is one of the most effective learning strategies that is essential for students of the medical field to be life-long learner. integration of sdl in the nursing curriculum would help deeper logical understanding, memorizing the content, and promoting the exchange of ideas.[10] table 3: mean score obtained by participants in subscale of sdlr (n=147). variables items range obtained score (range) mean score sd mean % self-management 13 13-65 38-63 49.82 5.013 80.88 desire for learning 12 12-60 18-60 48.53 5.479 60.42 self-control 15 15-75 26-73 60.42 6.990 80.56 overall 40 40-200 82-186 158.78 14.273 79.39 *sd= standard deviation j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np nepal p, et al. readiness for self-directed learning among nursing students of lumbini medical college: a cross-sectional study since sdl is an effective learning style for adult learners and self-control is a very essential component that has occupied a total of 15 out of 40 statements in the sdlr tool. self-control indicates independence and maturation in learning with minimum guidance only. the present study reported that nursing students had the highest level of the mean score (60.42±6.99) in self-control amongst all subscales of sdl. similar findings were reported from other studies as well.[3,4,6,8,9,11,12,13] but they had the lowest (48.53±5.48) mean score on subscale desire for learning which is consistent with other studies.[3,4,9,11] the study finding suggested that there is a need to change traditional teacher-centered learning with a more independent, self-controlled and student-centered learning style. similarly, course contents should be relevant for changing situations so that students can find relevancy and become enthusiastic in their learning. on the other hand, teachers could play significant role to provide effective learning environment so that students’ desire for learning could be promoted. present study explored that there are statistically significant differences between some socio–demographic characteristics like age (p<0.001), level of education (p<0.001), year of study (p<0.001), and the grade obtained in previous level education (p<0.001) with a level of readiness on sdl. whereas, other studies only found the statistical difference with age and level of education to level of readiness in self-directed learning. [3,6,14,15] table 4. associations between sdlr and selected demographic variables (n=147). variables level of readiness χ2 value p value high low n (%) n (%) age in years ≤20 77 (93.9) 5 (6.1) 14.204 <0.001 >20 46 (70.8) 19 (29.2) level of education pcl in nursing 80 (98.8) 1 (1.2) 30.079 <0.001 b.sc. in nursing 43 (65.2) 23 (34.8) year of study 2nd year 47 (87.0) 7 (13.0) 16.001 <0.001 3rd year 58 (92.1) 5 (7.9) 4th year 18 (60.0) 12 (40.0) ethnicity brahmin/chhetri 60 (78.9) 16 (21.1) 2.573 0.109 others (janajati/dalit) 63 (88.7) 8 (11.3) grade obtained in the previous level distinction 54 (100) 0 (0) 16.655 <0.001 others (first/second) 69 (74.2) 24 (25.8) present place of residence# home 6 (66.7) 3 (33.3) 0.165 out of home 117 (84.8) 21 (15.2) types of family nuclear 95 (82.6) 20 (17.4) 0.438 0.508 joint 28 (87.5) 4 (12.5) voluntarily selection of nursing profession# yes 114 (85.0) 20 (15.0) 0.174 no 10 (71.4) 4 (28.6) # fisher exact test j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np nepal p, et al. readiness for self-directed learning among nursing students of lumbini medical college: a cross-sectional study the study cannot escape from limitations. this study was conducted in only one setting so the findings of the study cannot be generalized. further, the study was self-responding so, along with the subjective interpretation, recall bias might be present. conclusion: self-directed learning readiness among nursing students of lmcth was high. the desire for learning subscale was lowest amongst other subscales. nursing educators can adopt this studentcentered learning approach by being supportive, encouraging and having positive attitude which creates a conducive environment to make students’ learning in-depth, creative and relevant. acknowledgment: ms. bandana pokharel, nursing program coordinator, lmcth. ms. chandra kumari garbuja, assistant professor, nursing program, lmcth. all the nursing faculties and nursing students of lmcth. conflict of interest: the authors declare that no competing interests exist. financial disclosure: funds for the study were not available references: 1.singh i. essentials of education: a textbook for nurses & other health professionals. 5th revised ed. published by mr. j.b. singh: kathmandu; 2012. 2.gyawali s, jauhari ac, ravi shankar p, saha a, ahmad m. readiness for self directed learning among first semester students of a medical school in nepal. journal of clinical and diagnostic research. 2011;5(1):20-3. available from: https://www.jcdr. net/articles/pdf/1130/1480_e(c)_f(j)_r(s)_ pf(a)_p(2023)_lowres.pdf 3.singh i, paudel b. readiness for self-directed learning among nursing students in a medical college, chitwan. journal of chitwan medicalcollege. 2020;10(31):27-30. available from: http://www.jcmc.cmc.edu.np/index.php/ jcmc/article/view/102/49 4.yang gf, jiang xy. self-directed learning readiness and nursing competency among undergraduate nursing students in fujian province of china. international journal of nursing science. 2014;1(3):255-9. doi: https://doi.org/10.1016/j. ijnss.2014.05.021 5.premkumar k, vinod e, sathishkumar s, pulimood ab, umaefulam v, prasanna samuel p, et al. selfdirected learning readiness of indian medical students: a mixed method study. bmc med educ. 2018;18(1):134. pmid: 29884155 doi: https:// doi.org/10.1186/s12909-018-1244-9 6.el seesy n, sofar sm, ibrahim ja, al-battawi i. self-directed learning readiness among nursing students at king abdulaziz university, saudi arabia. journal of nursing and health science. 2017;6(6):14-24. available from: https:// iosrjournals.org/iosr-jnhs/papers/vol6-issue6/ version-3/b0606031424.pdf 7.fisher m, king j, tague g. development of a self-directed learning readiness scale for nursing education. nurse educ today. 2001;21(7):516-25. pmid: 11559005 doi: https://doi.org/10.1054/ nedt.2001.0589 8.abuassi n, alkorashy h. relationship between learning style and readiness for self-directed learning among nursing students at king saud university, saudi arabia. international journal of advanced nursing studies. 2016;5(2):109-116. j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np nepal p, et al. readiness for self-directed learning among nursing students of lumbini medical college: a cross-sectional study doi: http://dx.doi.org/10.14419/ijans.v5i2.5993 9.kaur a, lakra p, kumar r. self-directed learning readiness and learning styles among nursing undergraduates. nursing and midwifery research journal. 2020;16(1):40-50. available from: https://www.proquest.com/openv iew/1737edd921174bf811f38e5166e6ec35/1?pqorigsite=gscholar&cbl=4722104 10.soliman m, al-shaikh g. readiness for selfdirected learning among first year saudi medical students: a descriptive study. pak j med sci. 2015;31(4):799-802. pmid: 26430406 doi: https://doi.org/10.12669/pjms.314.7057 11.smedley a. the self-directed learning readiness of first year bachelor of nursing students. journal of research in nursing. 2007;12(4):373-85. available from: https://research.avondale.edu.au/ nh_papers/8/ 12.adera gebru a, ghiyasvandian s, mohammodi n, kidane m. a self-directed in learning among undergraduate nursing students’ in school of nursing and midwifery, tums, tehran, iran. education journal. 2015;4(4):158-65. available from: https://article.sciencepublishinggroup.com/ html/10.11648.j.edu.20150404.13.html 13.malekian m, ghiyasvandian s, cheraghi ma, hassanzadeh a. iranian clinical nurses’ readiness for self-directed learning. glob j health sci. 2015;8(1):157-64. pmid: 26234971 doi: https:// doi.org/10.5539/gjhs.v8n1p157 14.alsufyani am, elissaaboshaiqah a, lmoussa m, baker og, aljuaid aa, alshehri. self-directed learning readiness of students in bridging nursing programs in saudi arabia a descriptive study. midwifery practice and nursing standard. 2020;2020(1):16-23. doi: https://doi. org/10.33513/mpns/2001-07 15.aljohani ka, fadila des. self-directed learning readiness and learning styles among taibah nursing students. saudi journal of health science. 2018;7(3):153-58. available from: https://www.saudijhealthsci.org/temp/ saudijhealthsci73153-5359606_145316.pdf lmc journal vol. 2.indd 70 original article l m coll j 2013; 1(2): 70-73 clinico-pathological study of ovarian tumors: a two years study at lmc & teaching hospital, tansen – 11, parvas, palpa jain s, jain sk and poudel a department of obstetrics & gynaecology, lmc tansen-11, parvas, palpa corresponding author: dr. sushila jain (md), lecturer in obstetrics and gynecology, lumbini medical college, tansen-11, parvas, palpa, nepal abstract ovarian neoplasm is the commonest condi on observed in gynecology prac ce. both non-neoplas c as well neoplas c ovarian tumors are common. in the present study neoplas c ovarian tumors were analyzed for their age of occurrence, site of ovary involved and histological typing. oophrectomy/hysterectomy and oophrectomy was performed on pa ent suff ering from ovarian tumors and the specimens were sent to pathology department lmc & teaching hospital for their histological study. the present study of 40 cases of ovarian neoplasm is from 2068/05/05 b.s. to 2070/05/30 b.s. the mean age of pa ent was 39 years with s.d of 1.25 years. the size of the tumor varies from 5 cm to 32.9 cm and weight varies from 41 gms to 350 gms. commonest tumor was mature cys c teratoma (52.5 %) followed by serous cyst adenoma (30%). not much diff erence was found for ovarian tumor regarding its site right and le ovary. only two cases of malignant ovarian neoplasm were found in this study, one case (2.5 %) was of immature cys c teratoma and another (2.5 %) was of serous cyst adenocarcinoma. keywords: introduction ovarian cysts, both neoplas c and non-neoplas c are quiet common. no age is immune on developing ovarian tumors. non-neoplastic cysts are mostly related to hormonal imbalance but neoplas c ones are due to some gene c and acquired causes. the tumors may arise from surface epithelium, germinal epithelium and stromal cells of the ovary. they are classifi ed on the basis of their origin. this study was carried out on clinically diagnosed ovarian tumors and its histological typing in lumbini medical college & teaching hospital. materials and methods the study comprised of 40 numbers of ovarian tumors diagnosed in the obstetrics & gynecology department in lmc & teaching hospital from 2068/05/05 b.s to 2070/05/30 b.s. a er obtaining clinical details regarding age and symptoms which were lower abdominal discomfort, dysmenorrhoea and irregular menstrual cycle. the opera ve procedure oophrectomy/hysterectomy with oophrectomy was done and specimens were subjected to department of pathology for their histological examina on. results in the present study 40 cases of clinically diagnosed ovarian tumors were analyzed for age group, site of the ovary involved and histological typing of neoplasm. from the above table it appears that the maximum number of 12 cases (30 %) was found in age group of 31-40 years followed by 10 cases (25%) in the age group 41-50 years. prac cally same incidences of 7 cases each (17.5%) were found in the age group of 21-30 years and 51-60 years. mean age group for ovarian tumor was found to be 39 years with s.d of 1.25 years. so far the site of ovarian tumor is concerned the commonest site was right ovary 21 cases (52.5%) and le ovary 17 cases (42.5%). bilateral ovarian involvement was found in only 2 cases (5%). most common ovarian tumor in present study was mature cystic teratoma 21 cases (52.5 %) followed by serous cyst adenoma 12 cases (30 %). mucinous cyst adenoma was found in 4 cases (10 %). one case (2.5 %) each was of brenner tumor (benign type), malignant serous cyst adenoma and immature cystic teratoma. discussion the mean age for ovarian tumor in the present study was 39 years with s.d of 1.25 years. the mean age for ovarian tumor of 38 years was reported by pudasaini et al1 and 33 years by ghimire et al.2 commonest age for ovarian neoplasm in the present study was 31-40 years and prac cally with the same incidence of 25 % with mean age group of 41-50 years. youngest age group for ovarian neoplasm in the present study was 10-20 years (5%). 71 s jain et al table 1: showing age groups of ovarian tumors s.n age group (in years) no. of cases percentage 1 11-20 2 5% 2 21-30 7 17.5% 3 31-40 12 30% 4 41-50 10 25% 5 51-60 7 17.5% 6 6170 2 5% total no. of cases 40 100 % table 2: ahowing the site of involvement s.n site no. of cases percentage 1 right 21 52.5 % 2 le 17 42.5 % 3 bilateral 2 5 % total 40 100 % table 3: showing the morphological types of ovarian neoplasm s.n morphology no. of cases percentage 1 serous cyst adenoma 12 30 % 2 serous cyst adenocarcinoma 1 2.5 % 3 mucinous cyst adenoma 4 10 % 4 brenner’s tumor (benign) 1 2.5 % 5 mature cys c teratoma 21 52.5 % 6 immature cys c teratoma 1 2.5 % total 40 100 % so far the site of ovary involved in ovarian neoplasm is concerned there was not much diff erence as compared to right ovary (52.5%) and le ovary (42.5%). bilateral ovarian neoplasms were seen in only 5 % of cases in the present study. bilateral ovarian tumors involvement was reported in 8.49 % of cases by ghimire et al but its higher incidence of 18.6 % was observed by pudasaini et al.1 benign ovarian tumors were common in present study (95 %). a similar incidence of 83.9 % was reported by jha and karki,3 87.3 % by pudasaini et al and 89.42 % by ghimire et al. somewhat lower incidence of 72.9 % was reported by gupta et al.4 germ cell tumor, mature cys c teratoma was commonest ovarian tumor 21 cases (52.5 %) in the present study. the mature cys c teratoma was also observed to be commonest tumor by jha et al, ghimire et al, thurlbeck wm et al,5 peterson wf,6 dhakal et al8 and sha et al.9 surface epithelial tumors consisting of serous cyst adenoma, mucinous cyst adenoma and benign brenner tumor were seen in 17 cases (42.5 %) in present study. similar observa on of 48.8 % has been reported by gupta et al, 52.5 % by jha and karki et al and 43.6 % by ghimire et al. yasmin et al7 has reported somewhat higher incidence of 76.5 %. fig. 1: immature cys c teratoma showing the glial ssue and choroid plexus, h&e stain 10x fig. 2: serous cyst adenocarcinoma showing sheets of epithelial malignant cells with papillary forma on. h&e stain 40x. fig. 3: mature cys c teratoma showing epidermis and appendages. h&e stain 10x fig. 4: benign brenner tumor showing islands of transi onal epithelium (walthard nests) h&e stain 10x 72 journal of lumbini medical college only two cases malignant ovarian tumor, one surface epithelial tumor mucinous cyst adenocarcinoma (2.5 %) and one case of germ cell tumor immature cys c teratoma (2.5 %) were observed in present study. incidence of malignant immature teratoma of 9.43 % was observed by ghimire et al. conclusion ovarian neoplasms were clinically seen from the age group of 15 – 60 years. majority of the ovarian tumors were unilateral. maximum numbers of ovarian neoplasm were benign germ cell tumor, mature cys c teratoma followed by benign surface epithelial tumor serous cyst adenocarcinoma. only two cases of malignant ovarian neoplasm were observed, one case was of immature cys c teratoma and another case was of serous cyst adenocarcinoma. references 1. pudasaini s, lakhey m, hirachand s, akhter j, thapa b. astudy of ovarian cysts in a ter ary hospital of kathmandu valley. nepal med coll j 2011; 13(1): 39-41 2. ghimire r, ghimre pg, goel rg. histopathological spectrum of ovarian mass lesions: a three years study at nepalgunj medical college –teaching hospital. j nepalgunj med coll 2012; 10(1): 22-5. 3. jha r and karki s. histopathological pa erns of ovarian tumors and their age distribu on. nepal med coll j 2008; 10(2): 81-5. 4. gupta and bisht d, agarwal ak, sharma vk. retrospec ve and prospec ve study of ovarian tumors and tumor -like lesions. ind j pathol microbiol 2007; 50(3): 525-7. 5. thurblbeck wm, scully re. solid teratoma of the ovary. a clinico-pathological analysis of 9 cases. cancer 1960; 13: 804-11. 6. peterson wf. solid, histologically benign teratoma of ovary. a report of four cases and review of literature. am j obstet gynecol 1956; 72: 1094-1102. 7. yasmins, yasmin a, asif m. clinicohistological pa ern of ovarian tumors in peshawor region. j ayub med coll abbo abad 2008; 20(4): 11-3. 8. dhakal hp, pradhan m. histological pa ern of gynecological cancers. j nepal med assoc 2009; 48 (176): 301-5. 9. sah sp, uprety d, rani s. germ cell tumors of ovary in clincopathological study of 121 cases from nepal. j obstet gynecol res 2004; 30(4): 303-8. lmc journal vol. 2.indd 83 clinical study of pemphigus in lumbini medical college mikrani ja, sharma u and thapa s department of dermatology and venereology, lumbini medical college, palpa, nepal corresponding author: dr. mikrani ja, lecturer, dept. of dermatology and venereology, lumbini medical college, palpa, nepal; e-mail: drjameelmikrani@gmail.com abstract background: pemphigus is a worldwide disease and varies in its clinical profi le and epidemiology in diff erent regions of the world. the disease is rare and few epidemiological data are available. objec ve: the purpose of this study was to evaluate the epidemiologic, clinical, and therapeu c features of pemphigus in lumbini medical college. methods: we retrospec vely inves gated a total of 70 pa ents with pemphigus. the parameters including age at diagnosis, sex, diagnos c methods and treatment outcome of the disease. results: the mean age at the onset was 41.3 years. the male-to-female ra o was 1.18:1. most of the pa ents were cured at the end of the treatment. rest were clinically improved. conclusion: pemphigus vulgaris (pv) is the most common clinical subtype in our centre. the disease is more frequent in the fi h decade of life and has a male predominance in our region. keywords: pemphigus, dermatological disease, epidemiology, clinical , therapeu c original article l m coll j 2013; 1(2): 83-85 introduction the term pemphigus refers to a group of autoimmune blistering diseases of the skin and mucous membranes characterized histologically by intraepidermal blister and acantholy c cells and immunopathologically by the fi nding of igg, iga and c 3 deposited on the surface of the kera nocytes.1,2,3,4 in the pa ent's serum, indirect immunofl uorescence demonstrates the presence of circulating pemphigus autoantibodies that bind to epidermis. the ter of circula ng an body correlates with disease course.5,6,7 pat h o ge n e s i s o f p e m p h i g u s i s t h e b i n d i n g o f autoan bodies to kera nocyte cell surface molecules. these intercellular or pemphigus an bodies bind to keratinocyte desmosomes and to desmosome-free areas of the kera nocyte cell membrane. the binding of autoan bodies results in blisters and a loss of cell-cell adhesion, a process termed acantholysis.8,9 pemphigus has the tendency to recurrent and its clinical symptoms is varied. prognosis is worse in patients with extensive lesion, especially when associated with infec on.10 therefore, the diagnosis and treatment has been one of the issues to focus on to the dermatologists. that is why we the choose pemphigus to study its features and treatment eff ect. we analyzed and summarized the clinical manifesta ons and the treatment of pemphigus to supply the reference of clinical diagnosis and treatment. material and methods all pa ents diagnosed as pemphigus from the out and in-pa ent department of dermatology and venereology of lumbini medical college were selected for the study. their records were reviewed retrospec vely. pa ents visi ng from 1st of june 2009 to 31st of may 2013 were included in the study. socio-demographic data and subtype of disease were studies. all the data was entered into microso excel and sta s cal analyses were performed by the spss17.0 so ware package and expressed with mean and standard devia on. results there were a total of 70 pa ents enrolled in the study. out of those, 38(54%) were male and 32(46%) were female. the extent of pa ent’s age was from 16 to 82 years old (mean 41.3 ± 28.5). disease was classifi ed into following types: 1. pemphigus vulgaris 2. pemphigus vegetans 3. pemphigus foliaceus 4. pemphigus erythematosus 5. iga pemphigus 6. herpe form pemphigus 7. paraneoplas c pemphigus there were 42 cases of pemphigus vulgaris accoun ng for 60% of all those cases. sixteen cases (22.8%) were diagnosed as pemphigus foliaceus. eight cases (11.4%) were of pemphigus erythematosus variety. there were 4 cases (5.8%) diagnoses as pemphigus vegetans. there 84 journal of lumbini medical college were no cases of iga, paraneoplas c and herpe form pemphigus. fig 1: sex distribu on therapeutic effect: pemphigus vulgaris: out of 42 cases, 32 were clinically cured and 8 cases were improved. pemphigus foliaceus: all the 16 cases were cured. pemphigus erythematosus: all 8 cases were cured. pemphigus vegetans: all 4 cases were cured as shown in table 2. table-1: types of pemphigus disease number percentage pemphigus vulgaris 42 60 pemphigus vegetans 4 5.8 pemphigus foliaceus 16 22.8 pemphigus erythematosus 8 11.4 iga pemphigus 0 0 herpe form pemphigus 0 0 paraneoplas c pemphigus 0 0 table 2: results a er treatment disease total cured improved pemphigus vulgaris 42 34 8 pemphigus vegetans 4 4 na pemphigus foliaceus 16 16 na pemphigus erythematosus 8 8 na iga pemphigus na na na herpe form pemphigus na na na paraneoplas c pemphigus na na na na= not available or non applicable discussion pemphigus is a worldwide disease and varies its presenta on, clinical profi le, and incidence in diff erent regions of the world. in general, the incidence ranges from 0.76 to 5 new cases per million per year.11 there was a male dominance in our study with m:f ra o of 1.18. overall, the sex ra o for pemphigus appears to be equivalent or close to equivalent. however, a few studies have found large imbalances in the sex distribu on, such as a study that found a 4:1 ra o of females to males with pemphigus foliaceus in tunisia and a study that found a 19:1 ra o of males to females in an endemic loca on in columbia.12,13 pemphigus vulgaris was the most common variety in our study. this result was comparable to those reported in the majority of the studies.12,13 treatment was very effective in early and limited diseases with 100% cure rate in many cases. some advanced cases were par ally improved. similar results were shown by studies.14,15,16 conclusions pemphigus is a common dermatological disease. it aff ects males more than females. pemphigus vulgaris is the most common clinical type of pamphigus, accoun ng for 60% of the pa ents, followed by pemphigus foliaceus, accoun ng for 22.8%. iga pemphigus, paraneoplas c andherpe form pemphigus are rare. the total cure rate is 88.6%. treatment is very eff ec ve for vegetans, foliaceus and erythematosus types. whereas it is eff ec ve for pemphigus vulgaris with cure rate of 81%. the eff ect of treatment in pa ents with mild to moderate condi on of pemphigus vulgaris, pemphigus foliaceus, pemphigus erythematosus and pemphigus vegetans was best, while in serious condi on of pemphigus vulgaris it was par al. references 8. scully c, challacombe sj. pemphigus vulgaris: update on e opathogesis, oral manifesta ons, and management. j crit rev oral biol med 2002; 13(5): 397-408. 9. fermandesnc, perezm. treatment of pemphigus vulgaris and pemphigus foliaceus: experience with 71 pa ents over a 20 year period. rev inst med trop 2001; 43(1): 33-6. 10. hertl m, eming r, veldman c. t cell control in autoimmune bullous skin disorders. j clin invest 2006; 116: 1159. 11. tsuruta d, ishii n, hamada t et al. iga pemphigus. clin dermatol 2011; 29: 437. 12. amagai m. pemphigus. in: dermatology, 3rd ed, bolognia jl, jorizzo jl, schaff er jv, et al.. (eds), elsevier, 2012. vol 1, p.461. 13. ishii k, amagai m, hall rp, et al. characterization of autoantibodies in pemphigus using antigen-specific enzyme-linked immunosorbent assays with baculovirusexpressed recombinant desmogleins. j immunol 1997; 159: 2010. 14. abasq c, mouquet h, gilbert d, et al. elisa tes ng of an -desmoglein 1 and 3 an bodies in the management of pemphigus. arch dermatol 2009; 145: 529. 15. kljuic a, bazzi h, sundberg jp, et al. desmoglein 4 in hair follicle diff eren a on and epidermal adhesion: evidence from inherited hypotrichosis and acquired pemphigus vulgaris. cell 2003; 113:249. 16. funakoshi t, lunardon l, ellebrecht ct, et al. enrichment 85 ja mikrani et al of total serum igg4 in pa ents with pemphigus. br j dermatol 2012; 167:1245. 17. herbst a, bystryn jc. pa erns of remission in pemphigus vulgaris. j am acad dermatol 2000; 42: 422. 18. kneisel a, hertl m. autoimmune bullous skin diseases. part 1: clinical manifesta ons. j dtsch dermatol ges 2011; 9: 844. 19. bastuji-garin s, souissi r, blum l, et al. compara ve epidemiology of pemphigus in tunisia and france: unusual incidence of pemphigus foliaceus in young tunisian women. j invest dermatol 1995; 104:302. 20. abrèu-velez am, hashimoto t, bollag wb, et al. a unique form of endemic pemphigus in northern colombia. j am acad dermatol 2003; 49: 599. 21. chams-davatchi c, esmaili n, daneshpazhooh m, et al. randomized controlled open-label trial of four treatment regimens for pemphigus vulgaris. j am acad dermatol 2007; 57: 622. 22. ioannides d, apalla z, lazaridou e, rigopoulos d. evalua on of mycophenolate mofe l as a steroid-sparing agent in pemphigus: a randomized, prospec ve study. j eur acad dermatol venereol 2012; 26: 855. 23. chams-davatchi c, mortazavizadeh a, daneshpazhooh m, et al. randomized double blind trial of prednisolone and azathioprine, vs. prednisolone and placebo, in the treatment of pemphigus vulgaris. j eur acad dermatol venereol 2012. drnaresh_forpdf.docx https://doi.org/10.22502/jlmc.v10i2.469 original research article antihypertensive drug use pattern in a tertiary care hospital of western region of nepal: a cross-sectional study nareshkarki,a,d kamal kandel,b,d pravinprasad,a,e jeevankhanalc,d abstract: introduction: assessing antihypertensive drug use pattern always plays an important role to mitigate the burden of hypertension and also helps doctors to prescribe the drugs rationally. this study was conducted to assess antihypertensive drug use pattern in a tertiary care hospital. methods: an observational crosssectional study was conducted in the internal medicine department of lumbini medical college and teaching hospital from july 2021 to december 2021 for the duration of five months after ethics approval. hypertensive patients who were prescribed one or more antihypertensive drugs irrespective of age and gender were included. socio-demographic profiles, clinical characteristics and antihypertensive drug use related data were collected. convenience sampling technique was used. categorical variables were expressed as frequency and percentage while continuous variables were reported as mean ± standard deviation. results: a total of 224 patients were included. the average number of antihypertensive drugs per patient was 1.7 ± 0.8. combination drug therapy (54.5%) was commonly used. calcium channel blockers (amlodipine) were commonly prescribed (66.5%). moreover, 98.7% and 41.5% patients were prescribed drugs from essential drug list of nepal (revised 2016) and in fixed dose combination respectively. use of combination drug therapy was higher among male patients (p = 0.003) and patients with stage ii hypertension (p < 0.001). conclusion: calcium channel blockers were commonly used as monotherapy and in combination therapy as well. in approximately all of the patients, antihypertensive drugs were used from the essential drug list of nepal which is an essential component of rational use of medicine. keywords: antihypertensive, calcium channel blockers, drug use, hypertension, tertiary care. submitted: december 07, 2021 accepted: june 22, 2022 published: january 2, 2023 aassistant professor, department of pharmacology blecturer, department of pharmacology cassociate professor, department of internal medicine (cardiology) dlumbini medical college and teaching hospital, tansen-7, palpa, nepal einstitute of medicine (tu), maharajgunj, kathmandu, nepal corresponding author: naresh karki, lumbini medical college & teaching hospital, tansen-7, palpa nepal email: karki007naresh@gmail.com orcid: https://orcid.org/0000-0002-8788-6443 introduction: hypertension is a serious public health problem and a major cause of deaths globally.[1] the adverse consequences of hypertension are increased risk of development of chronic kidney disease, cardiovascular disease, stroke and eye disease. the factsheet of who in 2019 reported that approximately one billion people throughout the world have hypertension.[2] of them, about two-third of the patients are how to cite this article: karki n, kandel k, prasad p, khanal j. antihypertensive drug use pattern in a tertiary care hospital of western region of nepal: a cross-sectional study. 2022;10(2):9 pages. doi: https://doi.org/10.22502/jlmc.v10i2.469 epub: january 2, 2023 j. lumbini med. coll. vol 10, no 2, jul-dec 2022 https://doi.org/10.22502/jlmc.v10i1 https://orcid.org/0000-0002-8788-6443 https://doi.org/10.22502/jlmc.v10i1.469 karki n, et al. antihypertensive drug use pattern in a tertiary care hospital of western region of nepal living in lowand middle-income countries.[2] similarly, the data of department of health services of nepal in 2020 also revealed that approximately one million of population are suffering from hypertension.[3] the use of antihypertensive drugs is the mainstay of treatment and they should be used on the basis of efficacy, safety and cost-effectiveness. inadequate treatment of hypertension with antihypertensive drugs may increase its complications and financial burden of treatment.[4] the risk of occurrence of hypertensive complications and subsequent mortalities can be minimized if patients are treated rationally with antihypertensive drugs.[4,5] the assessment of antihypertensive drug use in hospitals at regular time intervals always plays an important role to mitigate the burden of hypertension and may help healthcare providers prescribe the drugs rationally.[5,6] many studies have been published worldwide related to the pattern of use of antihypertensive drugs. some studies have been also conducted in low-income countries including nepal.[5,6,7] thus, this study attempted to add the data to previous studies with the general objective to provide an understanding of antihypertensive drug use pattern in a tertiary care hospital of the western region of nepal. whereas, the specific objectives were to identify antihypertensive drug use pattern, to assess socio-demographic and clinical characteristics of the patients, and to analyze the association of single drug and combination drug used for hypertension with socio-demographic and clinical characteristics of the patients. methods: a hospital based observational, cross-sectional study was carried out in the internal medicine out-patient department (opd) of lumbini medical college and teaching hospital (lmcth), tansen, palpa after approval letters were received from the institutional review committee (protocol no: irc-lmc 04-c/021) and the internal medicine department of lmcth. the duration of the study was five months from july 2021 to december 2021. the study included data of hypertensive patients who visited the internal medicine opd and were prescribed one or more antihypertensive drugs irrespective of age and gender. the study excluded data of hypertensive patients who were not prescribed any antihypertensive drug and the follow up patients who had been encountered by the researcher previously. the sample size calculated was 191 using the sample size formula n = z2p (1-p) / d2 [4,8], where n = minimum sample size required for accuracy in estimating proportions, z = standard normal value for 95 % confidence interval (1.96), p = proportion of the study population estimated to have hypertension from a previous study, which was 14.5% as per the study by adejumo et al.[4], d = margin of sampling error tolerated, 0.05 (5%). a convenience sampling technique was used for data collection. the required data were collected from the patients’ prescription forms and entered in the pre-designed case proforma. the case proforma consisted of socio-demographic characteristics of patients (age, gender, hospital number, domicile and ethnic group), clinical characteristics of patients (diagnosis, number of diagnosis, stage of hypertension, presence of complications and name of complications) and information related to antihypertensive drug use pattern (number of drugs used, class of antihypertensive drugs, name of antihypertensive drug, route of administration, use of monotherapy or combination therapy, number of drugs used in combination therapy, j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np karki n, et al. antihypertensive drug use pattern in a tertiary care hospital of western region of nepal table 1: american heart association classification of blood pressure blood pressure category systolic blood pressure (mm hg) diastolic blood pressure (mm hg) normal < 120 and < 80 elevated 120-129 and < 80 stage 1 hypertension 130-139 or 80-89 stage 2 hypertension ≥ 140 or ≥ 90 hypertensive crisis more than 180 and / or more than 120 table 2: anatomical therapeutic classification of antihypertensive drugs anatomical therapeutic classification (main group c : cardiovascular system) code class of drug c02ab centrally acting anti-adrenergics (methyldopa) c03 diuretics c07 beta blockers c08 calcium channel blockers c09 renin-angiotensinogen-angiotensin inhibitors c09a angiotensin converting enzyme inhibitors c09c angiotensin ii receptor blockers generic prescription, presence of fixed dose drug combinations and use of drugs from essential drug list of nepal). hypertension was classified as stage 1 hypertension, stage 2 hypertension and hypertensive crisis on the basis of american heart association classification of blood pressure as shown in table 1.[9] similarly, anatomical therapeutic classification (atc) of antihypertensive drugs was used for classifying drug groups in code as c02ab, c03, c07, c08 and c09 [10] as shown in table 2. moreover, essential drug list of nepal (revised 2016) was also used to find out the number of the antihypertensive drugs used from that list.[11]the data of the patients were kept confidential by using code numbers used in place of name and address of the patients. however, hospital numbers were j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np karki n, et al. antihypertensive drug use pattern in a tertiary care hospital of western region of nepal recorded to make sure that the data were original. data were entered in and analyzed by statistical package for social sciences (spss), version 18. basic socio-demographic variables, clinical characteristics and findings related to antihypertensive drug use were described. categorical variables were expressed as frequency and percentage while continuous variables were reported in terms of mean ± standard deviation (sd).the associations of socio-demographic characteristics and co-morbidities with the use of mono therapy or combination therapy were analyzed. for inferential statistics, independent t-test and chi-square test were used as appropriate. p value less than 0.05 was considered as statistically significant. results: a total of 224 patients were included, of which, 54% were male and 78.6% were above 50 years of age (table 3). the mean age of the patients was 59.7 ± 12.3 years. similarly, the mean age of the female and male was 60.3 ± 11.8 and 59.2 ± 12.7 respectively (t=0.674, df=220.202, p=0.501). the average number of antihypertensive drugs used per patient was 1.7 ± 0.8. in 55.8% of the patients, comorbidities were present. diabetes mellitus was the most common comorbidity present (38.4%) as shown in table 3. the majority of the patients belonged to stage i hypertension (63.4%). only, 25.9% patients were prescribed antihypertensive drugs in generic name (table 3) table 3: socio-demographic and clinical characteristics of hypertensive patients (n = 224) variables frequency (%) age (in years) 21-30 01 (0.4) 31-40 13 (5.8) 41-50 34 (15.2) 51-60 70 (31.2) 61-70 58 (25.9) >70 48 (21.5) gender female 103 (46) male 121 (54) presence of complications 125 (55.8) presence of diabetes 86 (38.4) stage of hypertension stage 1 142 (63.4) stage 2 82 (36.6) number of diagnosis one 67 (29.9) more than one 157 (70.1) generic prescriptions yes 58 (25.9) fixed dose combination yes 93 (41.5) prescription from essential drug list of nepal (revised 2016) yes 221 (98.7) j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np karki n, et al. antihypertensive drug use pattern in a tertiary care hospital of western region of nepal table 4: prescription pattern of monotherapy and combination therapy (n = 224) pattern of monotherapy and combination therapy number of prescriptions n (%) monotherapy 102 (45.5) combination therapy 122 (54.5) two drug-combination 86 (38.4) three drug-combination 27 (12.1) four drug-combination 9 (04.0) table 5: association of socio-demographic and clinical characteristics with monotherapy or combination therapy of hypertension (n = 224) characteristics monotherapy combination therapy statistics age (in years) ≤50 22 26 χ2=0.002, df=1, p=0.96 >50 80 96 gender male 44 77 χ2=8.926, df=1, p=0.003 female 58 45 number of diagnosis one 30 37 χ2=0.022, df=1, p=0.881 more than one 72 85 presence of complications yes 57 68 χ2=0.0004, df=1, p=0.983 no 45 54 presence of diabetes yes 48 38 χ2=5.946, df=1, p=0.015 no 54 84 stages of hypertension stage 1 84 58 χ2=29.011, df=1, p<0.001 stage 2 18 64 j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np karki n, et al. antihypertensive drug use pattern in a tertiary care hospital of western region of nepal nearly in all of the patient’s prescription forms (98.7%) drugs were prescribed from essential drug list of nepal (revised 16). in less than half of the patient’s prescription forms (41.5%) drugs were prescribed in fixed dose combinations (table 3). the majority of the patients were prescribed combination drug therapy (54.5%). regarding the combination drug therapy used, 38.4%, 12.1% and 4% of patients were prescribed two drugs, three drugs and four drugs respectively (table 4). in 66.5% of total patients, calcium channel blockers were used. amlodipine was the most commonly used drug followed by losartan. likewise, 66.5% of the patients were prescribed drugs from c08 class of anatomical therapeutic classification of antihypertensive drugs followed by c09. amlodipine 5 mg + losartan 50 mg (25.4%) was the most common fixed dose combination followed by losartan 50 mg + hydrochlorothiazide 12.5 mg (10.7%). use of antihypertensive drugs in combination therapy was more likely among male patients (χ2[n = 224, df =1] = 8.926,p = 0.003) and patients with stage ii hypertension (χ2[n = 224, df =1] = 29.011,p < 0.001) respectively as shown in table 5. discussion: the aim of our study was to assess the antihypertensive drug use pattern in a tertiary care hospital of western region of nepal. assessment of antihypertensive drugs is an essential tool to promote rational and appropriate use of drugs.[5,6] rational use of drugs is the process of appropriate use of drugs for prevention, diagnosis and treatment of disease.[6] they provide good contribution in reduction of morbidity, mortality and burden of treatment that may lead to medical, social and economic benefits.[6] in our study, hypertension is distributed commonly among male gender. few other studies also showed that the distribution of hypertension was common in male gender.[7,12,13,14,15,16].the possible reason for this finding may be that in nepalese society males are excessively exposed to some risk factors of hypertension like excessive smoking, excessive consumption of alcohol, stress and obesity. in few other studies, it was found that hypertension was similarly distributed to both gender.[5,6,9,17] our study also demonstrated that more than two-thirds of hypertensive patients were above 50 years of age. this similar finding was also found in other studies.[13,15,18,19,20] hypertension commonly belongs to the middle to elderly aged population.[12,18] the possible reasons are increased arterial stiffening leading to increase vasoconstriction, progressive declining of the capacity of kidney to excrete sodium and increased prevalence of diabetes mellitus that further enhances blood vessel injury and reduces renal function.[12] moreover, in this study, the average number of antihypertensive drugs used per patient was found to be approximately two. this value was similar to who standard value two.[21,22] it was also observed that combination drug therapy was commonly used. this finding was comparable with other studies.[4,5,6,14,18] while, few studies demonstrated that single drug was commonly used for hypertension treatment.[7,13,15,16,] hypertension was also associated with other comorbid diseases like diabetes, coronary artery disease, renal diseases and dyslipidemia. this could be a possible cause of the use of two or more drugs for better control of blood pressure in hypertensive patients with comorbid diseases. the synergistic action of two or more drugs increases efficacy and reduces frequency of adverse effects.[7] besides this, fixed dose combination of drugs also reduces doses of drugs and cost of treatment compared to when they are given separately.[7] however, in our j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np karki n, et al. antihypertensive drug use pattern in a tertiary care hospital of western region of nepal study it was found that the tendency of use of combination therapy was significantly lower in hypertensive patients with diabetes mellitus. related to anatomical therapeutic classification of antihypertensive drugs (atc), the highest numbers of drugs were used commonly from c08 class followed by c09. calcium channel blockers and renin-angiotensinogen-angiotensin inhibitors are represented by atc codes c08 and c09 respectively.[10] atc is a drug classification that “classifies the active ingredients of drugs according to the organ or system on which they act and their therapeutic, pharmacological and chemical property.”[10] it is an important tool to compare drug use at local, national or international level.[10] our study also showed that calcium channel blockers (amlodipine) were used in more than half of the patients included. the similar findings were found in other studies.[6,7,13,14,15,16,18] a possible reason for the common use of this drug is that the calcium channel blockers effectively lower the blood pressure to achieve the target level with better safety and tolerability profile. however, alkabi and busari et al. demonstrated that diuretics were preferred for treatment of hypertension.[4,5] calcium channel blockers control the blood pressure by producing coronary and / or peripheral arteriolar dilation via inhibition of voltage-gated l-type of calcium channels. they do not dilate veins. among calcium channel blockers, amlodipine (dihydropyridines) are commonly used worldwide. diuretics act by reducing re-absorption of sodium at different levels of nephrons. they are also the preferred drugs for hypertensive patients with renal disease. furthermore, our study also found that almost every patient was prescribed from the essential drug list of nepal (revised 2016). this finding showed that the practice of prescribing antihypertensive drugs by doctors was rational. cost effectiveness, improved drug use in terms of safety and effectiveness are the advantages of using medicines from international or national essential drug list.[21,22] however, if drugs are not used from essential drug list, it does not mean that the prescriptions are irrational because essential drug lists do not contain the medicines used for common and/or uncommon diseases. there are also some limitations in our study like small sample size, short duration of the study and convenience sampling technique. beside this, the study was not able to assess adherence of the patients to antihypertensive drugs. conclusion: in this study calcium channel blockers (amlodipine) were commonly used as combination drug therapy as well as single drug. the prevalence of use of calcium channel blockers was comparable with the findings of some other similar studies done in international settings. in almost all of the patients, antihypertensive drugs were used from the essential drug list of nepal which is an essential component of rational use of medicine. acknowledgement: department of internal medicine, lmcth. associate professor dr. vinod kumar verma, department of pharmacology, lmcth. dr. kyushu shah, lecturer, department of pharmacology, lmcth. mr. keshav raj bhandari, statistician, lmcth. mr. bhakti neupane, head of health insurance section, lmcth. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np karki n, et al. antihypertensive drug use pattern in a tertiary care hospital of western region of nepal references: 1. world health organization. a global brief on hypertension: silent killer, global public health crisis: world health day 2013. who. document number: who/dco/whd/2013.2, 2013. available 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https://www.cartercenter.org/resources/pdfs/health/ephti/library/lecture_notes/env_health_science_students/ln_biostat_hss_final.pdf https://www.cartercenter.org/resources/pdfs/health/ephti/library/lecture_notes/env_health_science_students/ln_biostat_hss_final.pdf https://www.cartercenter.org/resources/pdfs/health/ephti/library/lecture_notes/env_health_science_students/ln_biostat_hss_final.pdf https://www.cartercenter.org/resources/pdfs/health/ephti/library/lecture_notes/env_health_science_students/ln_biostat_hss_final.pdf https://www.acc.org/latest-in-cardiology/articles/2017/11/08/11/47/mon-5pm-bp-guideline-aha-2017 https://www.acc.org/latest-in-cardiology/articles/2017/11/08/11/47/mon-5pm-bp-guideline-aha-2017 https://www.acc.org/latest-in-cardiology/articles/2017/11/08/11/47/mon-5pm-bp-guideline-aha-2017 https://www.whocc.no/filearchive/publications/2022_guidelines_web.pdf https://www.whocc.no/filearchive/publications/2022_guidelines_web.pdf https://www.who.int/selection_medicines/country_lists/npl_eml_.pdf https://www.who.int/selection_medicines/country_lists/npl_eml_.pdf http://jlmc.edu.np karki n, et al. antihypertensive drug use pattern in a tertiary care hospital of western region of nepal 12. lionakis n, mendrinos d, sanidas e, favatas g, georgopoulou m. hypertension in the elderly. 2012;4(5):135-47. pmid: 22655162 doi: https://doi.org/10.4330/wjc.v4.i5.135 13. vashista k. study on drug utilization pattern of antihypertensive medication in tertiary care hospital of telangana, india. international journal of basic and clinical pharmacology. 2018;7(9):1770-4. doi: https://dx.doi.org/10.18203/2319-2003.ijb cp20183487 14. datta s. utilization study of antihypertensives in a south indian tertiary care teaching hospital and adherence to standard treatment guidelines. j basic clin pharm. 2016;8(1):33-7. pmid: 28104972. doi: https://doi.org/10.4103/0976-0105.195100 15. neupane gp. prescription pattern and drug utilization of antihypertensive agents at nepalgunj medical college hospital kohalpur, nepal. journal of clinical and experimental pharmacology. 2016;6(4):86. doi:http://dx.doi.org/10.4172/2161-1459. c1.014 16. pr r, hv a, shivamurthy mc. antihypertensive prescribing patterns and cost analysis for primary hypertension: a retrospective study. j clindiagn res. 2014;8(9):hc19-22. pmid: 25386458 doi: https://doi.org/10.7860/jcdr/2014/9567.48 90 17. liu ph, wang jd. antihypertensive medication prescription patterns and time trends for newly-diagnosed uncomplicated hypertension patients in taiwan. bmc health serv res. 2008;8(0):133. pmid: 18559115 doi: https://doi.org/10.1186/1472-6963-8-133 18. alkaabi ms, rabbani sa, rao pgm, ali sr. prescription pattern of antihypertensive drugs: an experience from a secondary care hospital in the united arab emirates. j res pharm pract. 2019;8(2):92-100. pmid: 31367644 doi: https://doi.org/10.4103/jrpp.jrpp_18_85 19. bakare oq, akinyinko mr, goodman o, kuyinu ya, wright ok, adeniran a, et al. antihypertensive use, prescription patterns, and cost of medications in a teaching hospital in lagos, nigeria. niger j clinpract. 2016;19(5):668-72. pmid: 27538558. doi: https://doi.org/10.4103/1119-3077.188709 20. paradkar sg, sinha sr. drug utilization among hypertensive patients in the outpatient department of medicine in a tertiary care hospital: a cross-sectional study. clinexphypertens. 2018;40(2):150-4. pmid: 28816547 doi: https://doi.org/10.1080/10641963.2017.13 46112 21. demeke b, molla f, assen a, melkam w, abrha s, masresha b, et al. evaluation of drugs utilization pattern using who prescribing indicators in ayder referral hospital, northern ethiopia. international journal of pharma sciences and research. 2015; 6(2):343-347. available from: http://www.ijpsr.info/docs/ijpsr15-06-02 -038.pdf 22. karki n, joshi r, shrestha b, prasad p. drug utilization pattern by using who core prescribing indicators in orthopaedics and obstetrics / gynecology departments of a tertiary care hospital. journal of lumbini medical college. 2019;7(1):18-23. doi:https://doi.org/10.22502/jlmc.v7i1.28 0 j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np https://pubmed.ncbi.nlm.nih.gov/22655162/ https://doi.org/10.4330/wjc.v4.i5.135 https://dx.doi.org/10.18203/2319-2003.ijbcp20183487 https://dx.doi.org/10.18203/2319-2003.ijbcp20183487 https://pubmed.ncbi.nlm.nih.gov/28104972/ https://doi.org/10.4103/0976-0105.195100 http://dx.doi.org/10.4172/2161-1459.c1.014 http://dx.doi.org/10.4172/2161-1459.c1.014 https://pubmed.ncbi.nlm.nih.gov/25386458/ https://doi.org/10.7860/jcdr/2014/9567.4890 https://doi.org/10.7860/jcdr/2014/9567.4890 https://pubmed.ncbi.nlm.nih.gov/18559115/ https://pubmed.ncbi.nlm.nih.gov/18559115/ https://doi.org/10.1186/1472-6963-8-133 https://pubmed.ncbi.nlm.nih.gov/31367644/ https://doi.org/10.4103/jrpp.jrpp_18_85 https://pubmed.ncbi.nlm.nih.gov/27538558/ https://doi.org/10.4103/1119-3077.188709 https://pubmed.ncbi.nlm.nih.gov/28816547/ https://doi.org/10.1080/10641963.2017.1346112 https://doi.org/10.1080/10641963.2017.1346112 https://doi.org/10.22502/jlmc.v7i1.280 https://doi.org/10.22502/jlmc.v7i1.280 http://jlmc.edu.np licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 9, no 2, july-dec 2021 ___________________________________________________________________________________ submitted: 04 november, 2021 accepted: 20 december, 2021 published: 30 december, 2018 a department of obstetrics and gynaecology, dhulikhel hospital, kathmandu university hospital, dhulikhel, kavre b associate professor c lecturer d medical officer eintern corresponding author: anjana dongol department of obstetrics and gynaecology, dhulikhel hospital, kathmandu university hospital kathmandu university school of medical sciences dhulikhel, kavre, nepal e-mail: anjanadongol@yahoo.com orcid: https://orcid.org/0000-0002-8942-4904_______________________________________________________ —–————————————————————————————————————————————— abstract: introduction: perimenopause is the time when ovaries gradually produce less estrogen. the menopausal symptoms in perimenopausal women cause severe disturbance in the women’s life. this study aimed to identify menopausal symptoms in perimenopausal women. methods: this was a hospital-based descriptive, cross-sectional study conducted among 243 women aged between 45 to 55 years.the categorical variables were presented as frequency and percentage. the associations between categorical variables were tested using chi square or fisher exact test. result: the total prevalence of menopausal symptoms was 91.8%. physical symptoms were identified to be prevailing symptom (n=184, 75.7%) followed by psychological (n=167, 69.5%). there were 136 (55.5%) women experiencing poor memory and 148 (60.9%) women having genitourinary symptoms. stress urinary incontinence (n=73, 30.04%) was predominantover urge (n=58, 23.8%), mixed (n=43, 17.6%) and prolapse (n=49, 20.1%) symptoms. vasomotor symptoms were experienced by123 (50.6%). excessive sweating (n=114, 46.9%) was leading over hot flush(n=113, 46.5%), night sweat (n=107, 44.03%) and palpitation (n=96, 39.5%). a total of 114 (46.9%) women were facing sexual symptoms. the common sexual symptom was dyspareunia 68 (27.9%). the menopausal rating scale (mrs) rating of overall symptoms showed women mostly suffer from mild symptoms during the perimenopausal period. conclusion: physical symptoms were identified to be predominating followed by psychological, genitourinary, vasomotor and sexual. however rating of symptoms using mrs showed majority of symptoms were mild. this study signifies the need to use the tool for assessment of severity of menopausal symptoms from the perimenopausal group. findings are noted in most of the cases of chronic lbp, degenerative changes being the most common and ranging from congenital to malignant lesions. keywords: menopause, menopause rating scale, perimenopause, symptoms original research articlehttps://doi.org/10.22502/jlmc.v9i2.467 dongol aa,b deoju sa,e, shikharakar sa,e rayamajhi sja,d pradhan na,c tripathi pa,c menopausal symptoms in premenopausal women among the cohort of gynecological patients attending outpatient department of dhulikhel hospital introduction: menopause is defined as the permanent cessation of menstruation. the diagnosis is made when individuals have amenorrhea for at least 12 months and there is a drop in the levels of estrogen how to cite this article: dongol a, deoju s, shikharakar s, rayamajhi sj, pradhan n, tripathi p. menopausal symptoms in premenopausal women among the cohort of gynecological patients attending outpatient department of dhulikhel hospital. journal of lumbini medical college. 2021;9(2):6 pages. doi: 10.22502/jlmc.v9i2.467. epub: 2021 dec 30. and progesterone, the two most important hormones in the female body.[1] the mean age of menopause is 51±2 years in the high-income countries and 49±2 years in the middleand low-income countries. ideally, menopause should occur by the age of 55 years.[2] studies conducted in nepal showed an average age of menopause as 48±2 years.[3,4,5] perimenopause as defined by the who and north american menopause society is a period two to eight years preceding and one year after the final menstruation. perimenopause, therefore occurs well before women officially hit menopause.[6] the menopausal symptoms include vasomotor https://orcid.org/0000-0002-8942-4904 dangol a. et al. menopausal symptoms in premenopausal women jlmc.edu.np symptoms (i.e. hot flushes, night sweating), abnormal uterine bleeding, psychological symptoms (i.e. depression, anxiety, irritability, poor memory), urogenital symptoms (i.e. loss of libido, dyspareunia, loss of bladder control) and other physical symptoms (i.e. bloating, musculoskeletal pain and fatigue). these symptoms may initiate during the perimenopausal period.[7] menopausal symptoms in perimenopausal and menopausal women can vary from mild to severe. they cannot be avoided, but can be managed successfully. with an increased life expectancy women are spending longer duration of their lives in menopause. maintaining a healthy life at this age becomes a major responsibility for the family and also for the nation. hence, this study aimed to identify various menopausal symptoms amongst nepalese women in perimenopausal groups seeking treatment in dhulikhel hospital. this study is then expected to create an awareness about menopause amongst the nepalese women and encourage them seek medical care for managing menopausal symptoms. methods: this was a hospital based, descriptive, cross-sectional study conducted at the out-patient department of obstetrics and gynecology in dhulikhel hospital. the sample size for the study was determined using cochrane formula: sample size (n) = (1.96)2 x p (1-p) / m2. taking the table 1. socio-demographic and behavioral characteristics of the study population (n=243) characteristics frequency (n) percent (%) mean age, in years (mean ± sd) 48.65±3.32 education uneducated and adult education 78 32.1 primary schooling 63 25.9 secondary schooling 73 30 higher secondary and above 29 11.9 menstrual cycle absent 39 16.04 regular 85 35 irregular 119 48.9 age at marriage (years) (mean±sd) 18.98±4.16 age at menarche (years) (mean±sd) 14.16±1.42 menopause in mothers and sibling(mean±sd) 48.85±3.87 parity nullipara 2 0.8 multipara 211 86.8 grand multipara 30 13.2 diet vegetarian 28 11.5 non-vegetarian 215 88.5 exercise no 194 79.8 yes 49 20.2 total 231 95.1 missing 12 4.9 smoking no 220 90.5 yes 23 9.5 alcohol no 201 82.7 yes 42 17.3 j. lumbini. med. coll. vol 9, no 2, july-dec 2021 dangol a. et al. menopausal symptoms in premenopausal women jlmc.edu.npj. lumbini. med. coll. vol 9, no 2, july-dec 2021 figure 1: categorization of major menopausal symptoms prevalence (p) as 0.14 with reference to the study dennerstein l et al.[8] the minimum total sample size calculated was 183. however, a total of 250 women of age between 45 to 55 years were included. women with a history of surgical menopause, chemotherapy or pelvic radiotherapy, those receiving hormone replacement therapy, suffering from psychiatric illness and those not willing to give consent were excluded from the study. a structured questionnaire was administered to collect information related to socio-demographic characteristics, obstetric, contraceptive, menstrual histories, awareness about menopause and various menopausal symptoms. after obtaining details about menopausal symptoms its severity was rated by using the menopausal rating scale (mrs).the data was entered into the microsoft excel and analyzed usingstatistical package for social sciences (spss) softwareversion 20.0. all the continuous variables were presented asmeans with standard deviation whereas categorical variables were presented as frequency and percentage. the associations between categorical variables were tested with chi square or fisher exact test. a p-value <0.05 was taken for statistical significance. results: a total of 250 women were enrolled on this study whereseven were excluded due to lack of needed information in the questionnaire. the mean age of the women participated in this study was 48.65±3.32 years. among all the participants 80 (32.9%) women were aware about the menopausal symptoms. the socio-demographic status is presented in table 1. the total prevalence of menopausal symptoms was 91.8%. there were only 20 (8.2%) participants without any symptoms. physical symptoms were identified to be predominating(n=184, 75.7%) followed by psychological (n=167, 69.5%) and genitourinary (n=148, 60.9%) symptoms. the categorization of major menopausal symptoms and its prevalence is presented in figure 1. the common vasomotor symptoms identified were sweating (n=114, 46.91%), hot flush (n=113, 46.5%) and night sweat (n=107, 44.03%). heart discomfort or palpitation was identified among 96 (39.5%) patients. within psychological symptoms, women experienced poor memory (n=136, 55.5%), irritability (n=109, 44.8%), sleep disturbance (n=92, 37.9%), feeling depressed and anxiety(n=79, 32.5%) as prevailing symptoms while other symptoms were feeling less accomplished (n=78, 32.09%) and having dissatisfaction with life (n=60, 24.6%). physical symptom assessments revealed that muscle and joint pain (n=138, 56%) were the main problems. the other symptoms were feeling fatigue (n=118, 48.5%), tingling sensation (n=110, 45.3%), flatulence (n=82, 33%), and breast tenderness (n=73, 30.04%). however, weight gain (n=49, 20%), dry skin (n=39,16%) and facial hair growth (n=17, 6.9%) were identified less. in genitourinary symptoms the assessment finding for pelvic organ prolapse was 49 (20.2%) and 68 (27.9%) having lax vagina. the different types of incontinence were identified to be of stress in 73 (30.04%), urge in 58 (23.9%), mixed dangol a. et al. menopausal symptoms in premenopausal women jlmc.edu.npj. lumbini. med. coll. vol 9, no 2, july-dec 2021 in 43 (17.7%) and fecal incontinence in 14 (5.7%). the common sexual symptom was dyspareunia in 68 (27.9%). there were 66 (27.2%) women experiencing dry vagina. only 13 (5.3%) women complained of decreased libido while 230 (94.6%) were having normal sexual desire. the bivariate analysis showed that menopausal symptoms had statistical significant association with premenstrual symptoms (p=0.007). however,they had no statistical association with diet (p=0.412) and education (p=0.897). the severity of menopausal symptoms experienced by perimenopausal women was assessed using mrs presented in table 3. discussion: this study assessed menopausal symptoms in women aged 45to 55 years. the symptoms checklist to identify the menopausal symptoms was utilized and then rated by the mrs to assess the severity of symptoms. the mrs is a validated tool for screening for the menopausal symptoms; it has also proved to be effective in finding the frequency and severity of symptoms. perimenopausal symptoms as shown from previous studies have racial and ethnic variations. studies reported that overall classical menopausal symptoms are shown to be higher in caucasians and lower in asians.[9,10,11] in our study, we found the prevalence of perimenopausal symptoms to be 91%. the physical symptoms (n=184, 75.7%) were identified to be predominating. the predominating result is comparable to other studies in nepal. however, these studies only identified symptoms and not the severity.[4,5] hot flushes, sweating, vaginal dryness and sleep disturbances are considered the main climacteric complains in western countries.[12] the menopausal symptoms may vary in peri-menopausal women. kakkar showed the symptoms vary according sociocultural and economic factors at this age. working women suffer more from psychological symptoms symptoms absent n (%) mild n (%) moderate n (%) severe n (%) very severe n (%) hot flushes, sweating (episodes of sweating) 125 (51.4%) 91 (37.4%) 22 (9.1%) 3 (1.2%) 2 (0.8%) heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness) 147 (60.5%) 78 (32.1%) 15 (6.2%) 2 (0.8%) 1 (0.4%) sleep problems (difficulty in falling asleep, difficulty in sleeping through, waking up early) 151 (62.13%) 71 (29.2%) 14 (5.7%) 7 (2.9%) 0 depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings) 164 (67.48%) 61 (25.1%) 13 (5.3%) 4 (1.6%) 1 (0.4%) irritability (feeling nervous, inner tension, feeling aggressive) 134 (55.1%) 80 (32.9%) 23 (9.5%) 6 (2.5%) 0 anxiety (inner restlessness, feeling panic) 164 (67.5%) 60 (24.7%) 16 (6.6%) 2 (0.8%) 1 (0.4%) physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness) 125 (51.4%) 88 (36.2%) 25 (10.3%) 4 (1.6%) 1 (0.4%) sexual problems (change in sexual desire, in sexual activity and satisfaction) 139 (57.2%) 69 (28.4%) 28 (11.5%) 6 (2.5%) 1 (0.4%) bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence) 155 (63.8%) 73 (30%) 13 (5.3%) 2 (0.8%) 0 dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse) 177 (72.8%) 54 (22.2%) 8 (3.29%) 4 (1.6%) 0 joint and muscular discomfort (pain in the joints, rheumatoid complains) 95(39.1%) 131 (53.9%) 12 (4.9%) 4 (1.6%) 1 (0.4%) table 3. rating of menopausal symptoms using ‘menopausal rating scale’(n=243) while non-working had somatic symptoms.[13] however, there is no statistical significance to support the evidence to kakkar’s study as most of the women participants were housewives and got no formal education or up to secondary education only. the other symptoms identified in this study apart from predominating physical were psychological (n=167, 69.5%) and genitourinary (n=148, 60.9%) vasomotor (n=123, 50.6%) and sexual (n=114, 46.9%). the research from nepal showed the commonest menopausal symptom identified as mood swing (80%) and irritability (68%).[3]whereas the other studies conducted in nepal showed the foremost symptom as loss of sexual desire (95%) and urinary symptoms (45%).[4,5] menopausal symptoms can vary in severity. the utilization of mrs in this study showed that the severity of symptoms were mostly in the form of mild to moderate (table 3). the factors that might have influenced the severity in nepalese settings may be due to the relatively more active agricultural occupation continuing even up to this age group that might be attributable to better outcomes in nepalese. the outdoor nature of their occupation also contributes to better vitamin d levels and lesser osteoporosis. majority of nepalese are nonvegetarians, however, even the vegetarians also have good amounts of phytoestrogen in the staple nepalese diet. phytoestrogens particularly isoflavone-rich soya foods are now believed to play a role in alleviating symptoms of menopause, maintaining bone density, reducing blood cholesterol levels and protecting against cancer development.[14,15] the pathophysiology behind the climacteric is multiple and interconnected.[1] however, the bivariate analysis showed that menopausal symptoms had statistical significant association with premenstrual symptoms. this supports the hormonal theory rather than other contributors. lack of estrogen invites issues such as cardiovascular, orthopedic, oncology and genitourinary problems. beside the most accepted hormonal theory, it is also attributed to physical and mental stress, genetic factors, or from aging. the influences from women’s psychology, lifestyle, body image, interpersonal relationships increase the risk of depression and anxiety in the menopausal patient. menopause, thus signifies the need for assessment of symptoms in perimenopausal group regularly. the optimistic results of our survey are suggested to be interpreted in light of some limitations of our study. firstly, being a single-centered study, our sample is not representative of nepalese women and is subject to limited external validity. however, our center is a referral center in the mid-northern region of nepal, which makes the study population a good representation of nepalese women. secondly, multiple subjectivities might have influenced the results. some degree of the retrospective nature of our study contributed to recall bias, which might have further worsened owing to the perimenopausal or age related poor memory at this age. in addition, inclusion of women presenting to the hospital with complaints other than menopausal problems may have caused apparently decreased prevalence as these participants may not have ever paid attention to the assessment of menopausal symptoms. thirdly, mrs is a self-administrated questionnaire; however, taking into account the substantial number of women lacking formal education in nepal, face-to-face interviews was applied in an attempt to minimize the reporting error. conclusion: menopausal symptoms varied in spectrum and severity amongst perimenopausal women. women suffered in the past from premenstrual symptoms were more likely to develop menopausal symptoms. physical symptoms were identified to be predominating followed by psychological, genitourinary, vasomotor and sexual. however rating of symptoms using mrs showed majority of suffered symptoms were in the range from mild to moderate. mrs can be considered a useful screening tool to assess for severity of menopausal symptoms. awareness about menopausal symptoms was identified to be less (32%). in order to identify the risk related with menopause this study signifies the need to use the tool for assessment of menopausal symptoms from the perimenopausal group on regular basis.identified severe symptoms thus can be managed timely. conflict of interest: none declared. financial disclosure: no funds were available. dangol a. et al. menopausal symptoms in premenopausal women j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np dangol a. et al. menopausal symptoms in premenopausal women jlmc.edu.np references: 1. howkins j, bourne g. perimenopause, menopause, premature menopause and postmenopausal bleeding. in: paduvidri vg, daftary sn, (ed.). shaw’s textbook of gynaecology. 14th ed. india: elsevier; 2008.p.37 2. gold eb. the timing of the age at which natural menopause occurs. obstet gynecol clin north am. 2011;38(3):425-40. pmid: 21961711 doi: https://doi.org/10.1016/j.ogc.2011.05.002 3. shrestha ns, pandey a. a study of menopausal symptoms and its impact on lives of nepalese perimenopausal and postmenopausal women. journal of kathmandu medical college. 2017;6(1):48. available from: https://www.researchgate.net/ publication/321060095 4. rajbhandari s, amatya a, giri k. relation of ethnicity and menopausal symptoms in nepal. journal of south asian federation of menopause societies. 2013;1(2):50-5. available from: https:// www.jsafoms.com/doi/jsafoms/pdf/10.5005/ jp-journals-10032-1012 5. marahatta rk. study of menopausal symptoms among peri and postmenopausal women attending nmcth. nepal med coll j. 2012;14(3):2515. pmid: 24047028 6. cheung am, chaudhry r, kapral m, jackevicius c, robinson g. perimenopausal and postmenopausal health. bmc womens health. 2004;4(suppl 1):s23. pmid: 15345086 doi: https://doi.org/10.1186/1472-6874-4-s1-s23 7. heinemann k, ruebig a, potthoff p, schneider hpg, strelow f, heinemann laj, et al. the menopause rating scale (mrs): a methodological review. health qual life outcomes. 2004;2(0):45. pmid: 15345062 doi: https://doi. org/10.1186/1477-7525-2-45 8. dennerstein l, dudley ec, hopper jl, guthrie jr, burger hg. a prospective population-based study of menopausal symptoms. obstet gynecol. 2000;96(3):351-8. pmid: 10960625 doi: https://doi.org/10.1016/s0029-7844(00)00930-3 9. rahman sa, zainudin sr, mun vl. assessment of menopausal symptoms using modified menopause rating scale (mrs) among middle age women in kuching, sarawak, malaysia. asia pac fam med. 2010;9(1):5. pmid: 20175982 doi: https://pubmed.ncbi.nlm.nih.gov/20175928/ 10. gold eb, block g, crawford s, lachance l, fitzgerald g, miracle h, et al. lifestyle and demographic factors in relation to vasomotor symptoms: baseline results from the study of women’s health across the nation. am j epidemiol. 2004;159(12):1189-99. pmid: 15191936 doi: https://doi.org/10.1093/aje/kwh168 11. pan ha, wu mh, hsu cc, yao bl, huang ke. the perception of menopause among women in tiawan. maturitas 2002;41(4):269-74. pmid: 12034513 doi: https://doi.org/10.1016/s03785122(01)00279-1 12. ayranci u, orsal o, arslan g, emeksiz df. menopausal status and attitudes in a turkish midlife female population: an epidemiological study. bmc women’s health. 2010;10(0):1. pmid: 20064263 doi: https://doi.org/10.1186/14726874-10-1 13. kakkar v, kaur d, chopra k, kaur a, kaur ip. assessment of the variation in menopausal symptoms with age, education and working/ non-working status in north-indian sub population using menopause rating scale (mrs). maturitas. 2007;57(3):306-14. pmid: 17408889 doi: https://doi.org/10.1016/j.maturitas.2007.02.026 14. somekawa y, chiguchi m, ishibashi t, aso t. soy intake related to menopausal symptoms, serum lipids, and bone mineral density in postmenopausal japanese women. obstet gynecol. 2001;97(1)109-15. pmid: 11152918 doi: https://doi.org/10.1016/s0029-7844(00)01080-2 15. rosett jw. menopause, micronutrient and hormone therapy. am j clin nutri. 2005; 81(5):1223-31. pmid: 15883456 doi: https:// doi.org/10.1093/ajcn/81.5.1223 j. lumbini. med. coll. vol 9, no 2, july-dec 2021 https://pubmed.ncbi.nlm.nih.gov/21961711/ https://doi.org/10.1016/j.ogc.2011.05.002 https://www.researchgate.net/publication/321060095 https://www.researchgate.net/publication/321060095 https://www.jsafoms.com/doi/jsafoms/pdf/10.5005/jp-journals-10032-1012 https://www.jsafoms.com/doi/jsafoms/pdf/10.5005/jp-journals-10032-1012 https://www.jsafoms.com/doi/jsafoms/pdf/10.5005/jp-journals-10032-1012 https://pubmed.ncbi.nlm.nih.gov/24047028/ https://pubmed.ncbi.nlm.nih.gov/15345086/ https://doi.org/10.1186/1472-6874-4-s1-s23 https://pubmed.ncbi.nlm.nih.gov/15345062/ https://doi.org/10.1186/1477-7525-2-45 https://doi.org/10.1186/1477-7525-2-45 https://pubmed.ncbi.nlm.nih.gov/10960625/ https://doi.org/10.1016/s0029-7844(00)00930-3 https://pubmed.ncbi.nlm.nih.gov/20175928/ https://pubmed.ncbi.nlm.nih.gov/20175928/ https://pubmed.ncbi.nlm.nih.gov/15191936/ https://doi.org/10.1093/aje/kwh168 https://pubmed.ncbi.nlm.nih.gov/12034513/ https://pubmed.ncbi.nlm.nih.gov/12034513/ https://doi.org/10.1016/s0378-5122(01)00279-1 https://doi.org/10.1016/s0378-5122(01)00279-1 https://pubmed.ncbi.nlm.nih.gov/20064263/ https://pubmed.ncbi.nlm.nih.gov/20064263/ https://doi.org/10.1186/1472-6874-10-1 https://doi.org/10.1186/1472-6874-10-1 https://pubmed.ncbi.nlm.nih.gov/17408889/ https://doi.org/10.1016/j.maturitas.2007.02.026 https://pubmed.ncbi.nlm.nih.gov/11152918/ https://doi.org/10.1016/s0029-7844(00)01080-2 https://pubmed.ncbi.nlm.nih.gov/15883456/ https://doi.org/10.1093/ajcn/81.5.1223 https://doi.org/10.1093/ajcn/81.5.1223 lmc journal vol. 2.indd 78 maternal mortality: sharing experience from banke district acharya s1 and shanta a2 1college of nursing, lumbini medical college, palpa, nepal, 2plan international nepal, nepalgunj, banke, nepal corresponding author: shusma acharya, lecturer, college of nursing, lumbini medical college, palpa, nepal abstract maternal mortality is a global burden, with more than 500,000 women during each year due to pregnancy and childbirth related complica ons.1 globally, 60-80% of maternal deaths are due to obstetric complica ons, these are hemorrhage, sepsis (infec on), obstructed labour and hypertensive disorder of pregnancy and complica ons of unsafe abor on.² objective: to iden fy the causes of maternal mortality in banke district. materials and methods: the study was conducted in banke district. descrip ve cross-sec onal study was adopted, during a period of one year from july 2011 to june 2012 at banke district in western region of nepal. non probability purposive sampling method was used for collec ng the data. both primary and secondary sources of data were taken for the study. results: the maximum number of maternal deaths was from madheshi and muslim community, most of them were illiterate. the main cause of maternal death was post partum hemorrhage. conclusion: nepal achieved an impressive reduc on in maternal mortality between 2001 and 2006, but maternal deaths s ll remains high. the trends of death from snake bite, suicide, epilepsy and physical assault are the new causes. keywords: infec on, maternal mortality, post partum hemorrhage. original article l m coll j 2013; 1(2): 78-79 introduction pregnancy and child birth is considered as a physiological process, but it is associated with certain risks to the life of both mother and newborn baby. at least 160 million women become pregnant every year around the world. out of them 15% women develop serious complica ons. reducing high maternal mortality is a priority agenda of the na onal and interna onal community, as evidenced by great interest in the millennium development goal (mdg5).3 nevertheless attaining millennium development goal-5 s ll remains a challenge to the world. many countries are unlikely to a ain many mdgs including that of maternal health, even though maternal health care has received par cular a en on from the developing countries of african and asian region. maternal mortality in nepal has drastically came down to 229 per hundred thousand live births.4 in 1998, government of nepal formulated the na onal reproduc ve health strategy with safe motherhood program to address reproduc ve health issues and developed na onal maternity guidelines, standards of midwifery practice, safe motherhood clinical protocol and management guideline. fi een year safe motherhood plan of ac on was developed in 2002. the long-term goal of the plan envisaged establishment of basic emergency obstetric care and comprehensive emergency obstetric care services in all district and skilled a endance at birth including increased access to emergency fund and transporta on.5 in spite of these en re programs, the burden is s ll high. direct causes of maternal death accounts for 71%. majority of maternal deaths occurred at home i.e 67.4%, 11.4% on the way and 21.2% in the health facility.5,6 methods a cross sec onal descrip ve study was used to conduct the study. non probability, purposive sampling method was used to collect the information. there were total 22 mothers expired due to diff erent causes in diff erent village development committee. in banke total 34 vdc namely bajapur, behari,kachanpur, manikapur, shamshergunj, sitapur, radhapur, bankatuwa, basudevpur,bhawanipur,binouna, fattepur,ganapur, hirminiya, holiya, udarapur,paraspur,puraini, rajahina, indrapur, jaispur, kamdi,karkado, katkuinjya, kohalpur, laxmanpur, matehiya, nepalgunj, narainapurpur, naubasta, raniyapur, saigaun and sonpur. data were collected through pre-tested interview schedule after taking of written permission of concerned authori es (district health offi ce, banke).data were tabulate through excel spreadsheet and analyzed by using simple analysis methods. results during one year study period from july 2011 to june 2012, there were total of 9705 deliveries during one year study period. 85.82% was hospital delivery. 14.18% was home delivery7. the number of female popula on in reproduc ve age group was 94793. there were 22 maternal deaths on 34 village development commi ee. the percentage of maternal mortality was very low when we take total number of delivery in banke i.e 0.226%. 79 the highest maternal deaths were reported from mathehiya village development commi ee (vdc). this vdc is situated in the east across rapti river and about 20 km from nepalgunj city. there is one sub-health post and no birthing centre. most of the me health workers were not available due to remoteness. among 22 maternal deaths 57% were form madheshi and muslim community. majority of 36.36% deaths occurred due to postpartum hemorrhage and 27% died due to infec on. the causes of maternal deaths were changing in new context. death from snake bite, suicide, epilepsy and physical assault were reported new trends of maternal deaths. discussion in nepal, the social status of women varies among diff erent ethnic group. all the 22 maternal deaths in this study indicates that women today have access to health facility. among 22 mothers, 57% were belonged madheshi and muslim, 14% from janja , 10% chhetri, 4% dalit and remaining 14% from others and newar 1%. in the study, 36.36% maternal death occurred due to postpartum hemorrhage, 27% due to infec on, 4.54% due to prolonged labor and abor on and rest due to indirect causes(not related to pregnancy). this fi ndings is consistent with fi ndings of maternal mortality and morbidity study 2009 which showed that maternal death due to hemorrhage 24%, abor on 7%, obstructed labor 6%, puerperal sepsis 5%.8 current study fi ndings is also consistent with study conducted in 1998, 47% maternal death was due to postpartum hemorrhage, 16% due to obstructed labour, 12% due to sepsis.9 the study indicated that majority of maternal death among 22 death was mainly in hospital i.e. 63.58%, 22.72% maternal death was in home and 13.63% death was on the way to hospital. similar study done by family health division nepal showed that maternal death in health facility was 41%, at home 40%, way of health facility 7%, way from facility to facility 5%, transit from facility to home 2% and in pharmacy 1%.10 similarly, another report by shrestha et al showed 67% women die at home, 11.4% on the way to health services, 14.4% in the hospital, 4.5% in private clinics and 2.3% at primary health care centre.9 another study was carried out on nobel medical college showed similar results.11 conclusion nepal achieved an impressive reduc on in maternal mortality between 2001 and 2006. provision of safe motherhood services even though maternal death remain high in this country. quality and quick services would be helpful in avoiding maternal mortality in many situa ons. otherwise expending a huge amount of money for maternal health service will be not meaningful. references 1. who (2001). managing complication in pregnancy and childbirth.whq/ibdoc.who.int/hq/2000/who_ rhr_00.7.pdf. 2. who (2008). a framework for implementing the reproduc ve health strategy in the south-east asia region. who. regional offi ce for south-east asia. new delhi. 3. bhandari tr, dangal g. maternal mortality: paradigm shi in nepal. nepal j obstet gynaecol 2012; 7(2): 3-8. 4. ministry of health and popula on (mohp) [nepal], new era, and icf interna onal inc.nepal demographic and health survey 2011. kathmandu, nepal: ministry of health and popula on, new era, and icf interna onal, calverton, maryland; 2012. 5. s a fe m o t h e r h o o d i n n e p a l [ o n l i n e ] . [ c i te d 2 0 1 3 november 30]. available from from: url:htpp:// w w w. s a f e m o t h e r h o o d . o r g . n p / p a g e s / d e f a u l t . php?func on=more_content&secid=74&con_id=44. 6. family health division, (1998). maternal mortality and morbidity study. kathmandu: 1998. 7. dpho [district public health offi ce] 2012. annual report 2011/2012. banke. 8. ministry of health and popula on (mohp) [nepal], new era, and icf interna onal inc. nepal demographic and health survey 2006. kathmandu, nepal: ministry of health and popula on, new era, and icf interna onal, calverton, maryland; 2007. 9. family health division, usaid, dfid, ssmp, new era,chrepa, (2009). nepal maternal mortality and morbidity study. summary preliminary fi ndings.2008/2009. kathmandu 10. shrestha rd. reproductive health national and international perspective.(1st edition). new dhulikhel prin ng press, dhulikhel, nepal 2008. 11. ghimire s. maternal mortality: paradigm shi in nepal. nepal j obstet gynaecol 2012; 7(2): 33-5. s acharya et al echocardiographic profile of patients with cardiomyopathy jeevan khanal,a,c tilchan pandey,b,c krishna godarb,c —–————————————————————————————————————————————— abstract: introduction: cardiomyopathies represent a heterogeneous group of diseases that often lead to progressive heart failure with significant morbidity and mortality. exact epidemiological data on cardiomyopathy in nepal are lacking. this study was done to observe the demographic and echocardiographic profile of patients with cardiomyopathy attending a medical college teaching hospital. methods: trans-thoracic two-dimensional echocardiographic study was performed by first author on all patients with cardiomyopathy over a period of six months. patients’ demographic and echocardiographic data were collected and analyzed using spss version 20 software. student t-test and chisquare test were applied where appropriate. results: a total of 60 patients were studied from october 2017 to march 2018. mean age of all participants was 56.38 years (sd = 13.86). mean age of males was significantly higher than that of females (60.96 yrs, sd = 13.61 versus 51.62 yrs, sd = 13.47) in dilated cardiomyopathy subgroup (p < 0.05). of all patients, 32 (53.33%) had dilated cardiomyopathy (idiopathic) and 13 (21.66%) had ischemic cardiomyopathy. conclusion: our study highlighted significant burden of dilated cardiomyopathy. dilated cardiomyopathy appeared in females at earlier age compared to males. potentially reversible cardiomyopathies like alcoholic and peripartum cardiomyopathies were also present which have a probability of cure if treated properly. keywords: alcoholic cardiomyopathy, dilated cardiomyopathy, echocardiography, ischemic cardiomyopathy —————————————————————————————————————————————— j. lumbini. med. coll. vol 6, no 2, july-dec 2018 original articlehttps://doi.org/10.22502/jlmc.v6i2.255 ___________________________ submitted: 23 march 2018 accepted: 20 june 2018 published: 12 july 2018 a consultant cardiologist b lecturer, department of medicine c lumbini medical college teaching hospital, palpa, nepal corresponding author: jeevan khanal e-mail: postatjk@gmail.com orcid: https://orcid.org/0000-0001-7845-5898 how to cite this article: khanal j, pandey t, godar k. echocardiographic profile of patients with cardiomyopathy. journal of lumbini medical college. 2018;6(2):x pages. doi: 10.22502/jlmc.v6i2.255. epub: 2018 july 12. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.____________________________ introduction: cardiomyopathy is a heterogeneous group of myocardial disorders associated with mechanical and/or electrical dysfunction that causes abnormal myocardial performance.[1] cardiomyopathies either are confined to the heart or are part of systemic disease conditions often leading to progressive heart failure.[2] within this broad definition, cardiomyopathies usually are associated with failure of myocardial performance, which may be mechanical or electrical prone to life-threatening arrhythmias. [3] the worldwide prevalence and incidence rate of heart failure related to cardiomyopathies are approaching epidemic proportion.[4] the primary cardiomyopathy group have dilated, restrictive and hypertrophic phenotypes. the secondary cardiomyopathies are those associated with known cardiac or systemic processes. these are referred to as specific cardiomyopathies named for the disease process with which they are associated.[5] dilated cardiomyopathy (dcm) is considered to be an important cause of heart failure and accounts for up to 25% of all cases of congestive heart failure (chf). [6] out of all these, dcm is the most common form https://doi.org/10.22502/jlmc.v6i1.182 j. lumbini. med. coll. vol 6, no 2, july-dec 2018 jlmc.edu.np khanal j. et al. echocardiographic profile of patients with cardiomyopathy comprising over 90% of all cases causing sudden cardiac death.[7] the framingham study has also reported 10% annual mortality rate for subjects having chf.[8] exact epidemiological data on cardiomyopathy in nepal are lacking. because of the high prevalence of chronic heart failure in the country and the increasing use of echocardiography, the incidence of cardiomyopathy is increasing. the present study was undertaken to analyze etiological and echocardiographic findings in patients with cardiomyopathy attending a medical college teaching hospital. methods: this was an observational study conducted over a period of six months (july 2017 to december 2017) at lumbini medical college teaching hospital (lmcth), palpa. ethical clearance for the study was taken from institutional review committee of the institute. inclusion criteria: • patients with cardiomyopathy • aged more than 15 years • undergoing echocardiogram exclusion criteria: • not consenting to the study admitted patients or those visiting the cardiology unit of outpatient wing of department of internal medicine were studied. proforma included demographic profile, clinical parameters, laboratory investigations, and echocardiographic findings. transthoracic twodimensional echocardiographic study was performed in accordance with the standard guidelines. echocardiography techinque: all patients were evaluated using m-mode and two-dimensional transthoracic echocardiography and color flow doppler examination using siemens acuson. the guidelines of american society of echocardiography were followed in obtaining measurements.[9] systolic dysfunction was characterized by reduced ejection fraction (ef) <55%. diastolic dysfunction was calculated by measuring e and a velocity across trans-mitral inflow velocity and tissue doppler imaging. diastolic dysfunction was characterized by (a) reduced early diastolic filling, (b) prolonged isovolumetric relaxation time, (c) increased atrial filling, (d) increased pre-ejection time and (e) reduced left ventricular ejection time. left ventricular hypertrophy (lvh) was defined by left ventricular posterior wall (lvpw) >10 mm and inter-ventricular septum (ivs) >10 mm by m-mode. dcm was labeled if enlarged left ventricle with decreased systolic function was present as measured by left ventricular ejection fraction (lvef); excluding ischemic, valvular, hypertensive or congenital causes. ischemic cardiomyopathy was labeled on the basis of documented history of previous myocardial infarction or acute coronary syndrome. hcm was defined by a thickened but nondilated left ventricle in the absence of another cardiac or systemic condition such as aortic valve stenosis, systemic hypertension. hocm was defined by thickened and nondilated left ventricle in the absence of other causes, such as hypertension or valve disease, with lvot obstructive gradient more than 30 mm of hg at rest. peripartum cardiomyopathy was characterized by features of dcm was present with onset in the last month of pregnancy or in the first five months after delivery. alcohol associated cardiomyopathy was labeled if features of dcm was present in patient with chronic alcoholism potentially reversible with abstinence from alcohol use. statistical analysis: statistical analysis of data was done using statistical package for social sciences (spsstm) version 20 software. all results were presented as frequency and percentages, and mean and standard deviation (sd). two means were compared with unpaired t-test. categorical variables were analyzed with chi-square or fisher exact test. a p value of less than 0.05 was considered significant. results: a total of 60 patients with diagnosis of cardiomyopathy were included in the study. mean age was 56.38 years (sd = 13.86). out of 60 patients, 34 (56.66%) were males with mean age of 61.11 years (sd = 11.36) and 26 (43.33%) were females with mean age of 52.79 years (sd = 16.28). there was significant statistical difference between genders in dcm subgroup (p < 0.05). baseline characteristics of the patients is shown in table 1. j. lumbini. med. coll. vol 6, no 2, july-dec 2018 khanal j. et al. echocardiographic profile of patients with cardiomyopathy jlmc.edu.np out of the total 60 patients with cardiomyopathy studied; 32 (53.33%) had idiopathic, 13 (21.66%) had ischemic cardiomyopathy. a total of 9 (15.0%) patients had alcoholic cardiomyopathy, 3 (5.0%) had peripartum cardiomyopathy (ppcm), 2 (3.33%) had hcm, 1 (1.66%) had hocm. in this study dcm was the most common cardiomyopathy (table 1). out of 32 patients diagnosed with dcm, 19 (59.37%) were males and 9 (40.62%) were females. out of 13 patients diagnosed with ischemic cardiomyopathy, 8 (61.53%) were males and 5 (38.46%) were females. out of 3 patients diagnosed with hcm, all (100%) were males. there were 3 female patients who were diagnosed with ppcm. all the 9 patient diagnosed with cardiomyopathy secondary to chronic alcohol consumption were males. out of 32 patients with dcm, 20 (62.5%) had table 1: baseline characteristics of patients with cardiomyopathy variables n (%) mean age in years (sd) p male female total population 60 (100%) 61.11 (11.36) 52.79 (16.28) dilated cardiomyopathy 32 (53.33%) 60.96 (13.61) 51.62 (13.47) <0.05 ischemic cardiomyopathy 13 (21.66%) 67.91 (12.89) 66.25 (11.46) 0.6 alcoholic cardiomyopathy 9 (15%) 52.32 (5.76) n/a hypertrophic cardiomyopathy 2 (3.33%) 49.33 (8.13) n/a hypertrophic obstructive cardiomyopathy 1 (1.66%) 44 n/a peripartum cardiomyopathy 3 (5.0%) 34.15 (6.24) n/a diastolic dysfunction (dd) as well, by echo criteria. total of 13 (100%) of ischemic cardiomyopathy, 100% of hcm and hocm, 11.11% of alcoholic cardiomyopathy patients had diastolic dysfunction. none of the patients with ppcm had diastolic dysfunction. total three (9.37%) out of 32 patients with dcm had left ventricular (lv) clot and 1 (3.12%) patient had echo-contrast in la/lv. the presence of lv clot in patients with dcm was significant statistically (p < 0.05). out of 32 patients with dcm, 26 (81.25%) patients had mitral regurgitation and 21 (65.62%) patients had tricuspid regurgitation (p < 0.05) (table 2). discussion: we compared the results of this study with various other studies. the dcm is frequently caused by coronary artery disease (cad) and hypertension. [10] dcm most commonly occurs in middle age. [11] in our study, mean age of patients with dcm was 60.96±61 years in male and 51.62±13.47 years in female. in another study by ahmad s et al,[12] the mean age was 51.39±17.7 years. in a study by pacheco oe et al,[13] ischemic cardiomyopathy was identified as the most common cause of dcm, representing 37% of the patient and 22% had idiopathic etiology. in contrast to it, idiopathic was most common (53.33%) and next to it was ischemic cardiomyopathy (21.66%). the incidence rate of six per hundred thousand person per year was reported in ischemic cardiomyopathy by mb cod et al.[14] of the 60 patients, 3 (5%) had peripartum cardiomyopathy. the mean age was 34.15±6.24 years in our study. ppmc has been reported mostly in women older 30 years.[15] the incidence of peripartum cardiomyopathy table 2: echocardiographic findings in patients with cardiomyopathy types of cardiomyopathy (n) lvef (±sd)% dd (%) clot (%) echocontrast (%) mr (%) tr (%) dilated cardiomyopathy (32) 28 (±7.7) 20 (62.5) 3 (9.37)* 1 ( 3.12) 26(81.25) 21(65.62)* ischemic cardiomyopathy (13) 36 (±9.5) 13 (100) 0 (0) 0 (0) 8(61.53) 3(23.07) alcoholic cardiomyopathy (9) 39 (±8.2) 1 (11.11) 0 (0) 0 (0) 2(22.22) 4(44.44) hypertrophic cardiomyopathy(2) 66 (±12.5) 2 (100) 0 (0) 0 (0) 0 (0) 0 (0) hypertrophic obstructive cardiomyopathy (1) 71 (±11.3) 1(100) 0 (0) 0 (0) 1(100) 0 (0) post-partum cardiomyopathy (3) 34 (±8.7) 0 (0) 0 (0) 0 (0) 0 (0) 1(33.33) * p-value < 0.05 j. lumbini. med. coll. vol 6, no 2, july-dec 2018 jlmc.edu.np khanal j. et al. echocardiographic profile of patients with cardiomyopathy is reported to be 1 in 4000 pregnancies.[16] in a study in pakistan, peripartum cardiomyopathy was reported to be 1 in 837 deliveries.[17] in our institution, 3 (5%) patients with cardiomyopathy, out of 60 study population, were admitted due to decompensated left heart failure. none of the patients with ppcm had diastolic dysfunction, lv clot and valvular regurgitation. we also noticed complications of cardiomyopathies on echocardiographic study. most common complications were intra-cardiac thrombi in 9.37%, spontaneous echo-contrast in 3.12%, mitral regurgitation in 81.25%, tricuspid regurgitation in 65.62%. in the present study, total 3 (5.0%) had hcm, 1 (1.66%) had hocm. 5% hcm in our study that included the clinical cases in our hospital, seems much less compared to the study by phadke r s et al, who reported 13.9% among the autopsy cases. [18] excess alcohol intake may be manifested by features of dcm. the incidence of alcoholic cardiomyopathy has been reported to be 21% to 32% of dcm.[19] it more commonly occurs in male.[20] we had 15% of dcm presenting with acm. all patients were male in our study. conclusion: present study highlights significant burden of idiopathic dilated cardiomyopathy and next to it was ischemic cardiomyopathy. dilated cardiomyopathy appeared earlier in females as compared to males (p<0.05). a total of 12 (20%) patients had potentially reversible cardiomyopathy like peripartum and alcoholic cardiomyopathy. the presence of lv clot and tricuspid regurgitation were significantly higher (p < 0.05) in patients with dilated cardiomyopathy. conflict of interest: none declared. source of funds: no fund was available. references: 1. mann dl, zipes dp, libby p, bonow ro, braunwald e. a braunwald's heart disease -textbook of cardiovascular medicine: dilated cardiomyopathy. 10th ed.philadelphia: elsivier saunders;2015, pp.1551-62. 2. elliott p, andersson b, arbustini e, et al: classification of the cardiomyopathies: a position statement from the european society of cardiology working group on myocardial and pericardial diseases. eur heart j 29:270, 2008. 3. maron bj, towbin ja, thiene g, et al. contemporary definitions and classification of the cardiomyopathies. circulation 2006;113:1807-16. 4. go as, mozaffarian d, roger vl. heart disease and stroke statistics-2013 update:a report from the american heart association. circulation 127:e6, 2013 5. rubin e. alcohol and the heart. n engl j med. 1979 ; 301 :28-33 6. anderson km, kannel wb. prevalence of congestive heart failure in framingham heart study subjects. circulation 1994;13:s107-s112 7. cohn jn, bristow mr, chien kr. report of the national heart, lung, and blood institute special emphasis panel on heart failure research. circulation 1997;95:766-70. 8. kalon k.l., keaven m. anderson, william b. kannel, william grossman, daniel levy. survival after the onset of congestive heart failure in framingham heart study subjects. circulation 1993;88:107-115. 9. feigenbaum h, armstrong wf, rayn t. dilated and hypertrophic cardiomyopathy. feigenbaum’s echocardiography, 7th asian edition 2010 philadelphia. wolters kluwer. 507–60. 10. randy wexler, terry elton, adam pleister, david feldman. cardiomyopathy: an overview. am fam physician. 2009; 79(9): 778–84. 11. praful jd, sachin mn.clinical profile of patients with dilated cardiomyopathy-a study of 50 cases. journal of research in medical and dental sciences. 2016; 4(3) 12. ahmad s, rabbani m, zaheer m, shirazi n. clinical ecg and echocardiographic profile of patients with dilated cardiomyopathy. indian j cardiol. 2005;8:25-9. 13. pacheco oe, novoa je, cox ra. dilated cardiomyopathy: a clinical review of patients evaluated at a tertiary care center in puerto rico. p r health sci j. 1995;14(4): 269–73. 14. codd mb, sugrue dd, gersh bj and melton lj. epidemiology of idiopathic dilated and hypertrophic cardiomyopathy. a population-based study in olmsted county, minnesota. 1975–1984. circulation. 1989; 80: 564–72. 15. hasan ah, qureshi a, ramejo bb, et al. peripartum cardiomyopathy characteristics and outcome in a tertiary care hospital. jpma. 2010: 60; 377–80. 16. ntobeko ba ntusi, ambroise wonkam, gasnat shaboodien, motasim badri, bongani m mayosi. frequency and clinical genetics of familial dilated cardiomyopathy in cape town: implications for the evaluation of patients with unexplained cardiomyopathy. s afr med j. 2011;101: 1–5. 17. haq nawaz, rehan ahmed, nasir ahmed, abdul rashid. frequency of echocardiographic complications of dilated cardiomyopathy at a tertiary care hospital. j ayub med coll abbottabad. 2011; 23(3): 51–5. 18. phadke r s, vaideeswar p, mittal b, deshpande j. hypertrophic cardiomyopathy: an autopsy analysis of 14 cases. j postgrad med. 2001; 47:165. 19. regan tj. alcohol and the cardiovascular system. jama, 1990;264:377-381. 20. ely m, hardy r, longford nt, wadsworth mej. gender differences in the relationship betweenalcohol consumption and drink problems are largely accounted for by body water. alcohol and alcoholism.1999;34:894-902. dipendra_for_pdf.docx https://doi.org/10.22502/jlmc.v10i2.482 original research article risk factors associated with frozen shoulder among nepalese population: a hospital-based comparative study dipendra singh chhetria,d, ruban raj joshib,d, sagar tiwaric,e abstract: introduction: frozen shoulder is one of the common musculoskeletal disorders characterized by pain and restriction of motion of the shoulder joint. it is also considered a common self-limiting regional skeletal problem. this study aimed to evaluate related risk factors for frozen shoulder. methods: this was a hospital-based comparative study involving 60 patients with a diagnosed frozen shoulder in the out-patient department as cases and 60 patients hospitalized during the same period with non-shoulder-related complaints as controls. a face-to-face interview was taken. univariate and multivariate logistic regression analyses were performed. results: a total of 120 consecutive subjects (60 patients with frozen shoulders and 60 controls) were taken. the mean age of cases was 54.7±3.21 years and that of controls was 42.08±2.74 years. among the frozen shoulder patients, 33.3% had diabetes and 15% had a history of thyroid disorder. multivariate logistic regression analysis showed age, diabetes mellitus, and thyroid dysfunction as independent risk factors for frozen shoulder (p<0.05). the frozen shoulder patients also had a higher prevalence of cardiac diseases and cervical spondylosis than the controls. no significant difference was found in body mass index, cholecystitis, history of surgical intervention, and uric acid level between the frozen shoulder group and the control group. conclusion: the study findings indicated that diabetes, thyroid disease, and advanced age have been significantly associated with increased frozen shoulders. keywords: frozen shoulder; musculoskeletal; risk factors. submitted: march 19, 2022. accepted: january 16, 2023. published: january 26, 2023. a lecturer, department of orthopedics b associate professor, department of orthopedics c medical epidemiologist dlumbini medical college and teaching hospital, palpa, nepal e bharatpur central hospital corresponding author: dipendra singh chhetri lecturer, department of orthopedics, lumbini medical college and teaching hospital. orcid:https://orcid.org/0000-0001-9367-9566 email: idipendrachhetri@gmail.com introduction: frozen shoulder is one of the common musculoskeletal disorders characterized by pain and restriction of motion of the shoulder joint. it is also considered the common self-limiting regional skeletal problem of unclear pathogenesis and is usually divided into primary and secondary causes. it usually how to cite this article: chhetri ds, joshi rr, tiwari s. risk factors associated with frozen shoulder among nepalese population: a hospital-based comparative study. j lumbini med coll. 2022;10(2):7 pages. doi: https://doi.org/10.22502/jlmc.v10i2.482 epub: january 26, 2023 j. lumbini med. coll. vol 10, no 2, jul-dec 2022 https://doi.org/10.22502/jlmc.v10i1 https://orcid.org/0000-0001-9367-9566 mailto:idipendrachhetri@gmail.com https://doi.org/10.22502/jlmc.v10i2.482 chhetri ds, et al. risk factors associated with frozen shoulder among nepalese population has an insidious onset and follows a protracted course, especially primary causes than secondary causes.[1] in a systematic review the point prevalence of shoulder pain among adults younger than 70 years was 7 to 27% and for adults older than 70 years was 13.2 to 26%.[2] the incidence of frozen shoulder in the general population is approximately 2 to 5% [3], but several conditions are associated with an increased incidence, including female gender, older age, diabetes mellitus (dm), cervical disc disease, prolonged immobilization, hyperthyroidism, stroke, or myocardial infarction, the presence of autoimmune diseases, and trauma. individuals between the ages of 40 and 70 years are more commonly affected.[4,5] frozen shoulder can be categorized into three stages: the first stage is a stage of pain, the second, the stage of stiffness, and the third, the stage of thawing which is usually self-limiting and resolves in 12 to18 months. [6] identifying the risk factors of a disease is important to gain an understanding of its etiology. the best treatment of frozen shoulder is prevention.[7] so the purpose of the present study was to examine the presumed risk factors and to warn about the disease progression and its early management. frozen shoulder presents with pain and stiffness in the shoulder which may lead to an inability to work and or to carry out household and leisure-time activities, therefore, this study precisely assesses the potential influence of several factors on frozen shoulder development and evaluate the possible relationship between these factors in elevating the risk for frozen shoulder in individuals. methods: this was a hospital-based comparative study in which cases and controls were taken from 2021 jan to 2022 jan. informed consent was obtained from each study participant. the sample size was calculated using the power and sample size program[8].we planned a study of independent cases and controls with one control per case. prior data indicate that the probability of exposure among controls is 0.07.[2,3] if the true probability of exposure among cases is 0.27 [2,3], we needed to study 54 cases and 54 controls to be able to reject the null hypothesis that the exposure rates for cases and controls were equal with a probability (power) of 0.8. the type i error probability associated with this test of the null hypothesis is 0.05. a total of 120 consecutive subjects (60 cases with frozen shoulder and 60 controls) were included. ethical approval was obtained from the institutional review committee of the institute (irc-lmc13-j/020). participants were taken from those with newly diagnosed frozen shoulders who presented to the outpatient department of orthopedics in lumbini medical college and teaching hospital (lmc-th). the inclusion criteria were: age more than 18 years; the presence of pain associated with active and passive restriction of glenohumeral motion with external rotation less than 50% of the normal side; normal radiograph and the shoulder ultrasound demonstrating no significant rotator cuff tear. the patients were excluded in case there was the presence of shoulder diseases like shoulder fracture, dislocations, impingement syndrome, supraspinatus calcific tendinitis, and rotator cuff injuries. for control, we included hospitalized patients without shoulder disease, frozen shoulder, and trauma history. j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np chhetri ds, et al. risk factors associated with frozen shoulder among nepalese population all the subjects were randomly interviewed using a common questionnaire set in proforma by two practicing doctors. they were trained to conduct the survey, with the written protocol. an in-person interview was conducted for all the participants and information on potential risk factors were collected. for body mass index (bmi), we used the who category for obesity (< 25, 25 to 29.9, 30 to 39.9, and ≥ 40).[9] and age range were categories (≤ 40 and > 40) years as median age group. statistical analysis: we used stata version 16.1 for statistical analysis. the quantitative results were expressed as frequency, percentage, and mean±standard deviation. we used the chi-square or fisher’s exact test where applicable to evaluate categorical variables. univariate logistic regression analysis was performed to assess the effect of each risk factor for frozen shoulder. furthermore, we performed a multivariate logistic regression analysis using those variables that were significant in the single-factor analysis. we used the forward direction to calculate the logistic model. possible interactions between risk factors were calculated using multivariate logistic regression models. a p-value of ≤0.005 was considered statistically significant. results: there were a total of 120 patients, 60 each in cases and controls. for those presented with frozen shoulder, the durations of symptoms were one, two, three, and four months among 38.33%, 30%, 23.33%, and 8.33% respectively. the mean age of the cases was 54.7±2.37 years and that of the controls was 42.08±2.49 years. the distribution of demographic variables and the risk factors of frozen shoulder namely: age, gender, diabetes mellitus (dm), bmi, thyroid dysfunction, history of cardiac disease, cervical spondylosis, cholecystitis, past surgery, uric acid are outlined in table 1. further, we divided the age range into two categories (≤ 40 and > 40) years. we performed a single-factor logistic regression analysis including all the mentioned risk factors of which the result is shown in table 2. no significant difference in gender (p=0.58), bmi (0.05), cervical spondylosis (p=0.69), cholecystitis (p=0.20), uric acid (hyperuricemia) (p=0.69), cardiac diseases like hypertension (p=0.08) among those with and without frozen shoulder. whereas age, dm, thyroid dysfunction showed a statistical significance (p values<0.009, <0.002, 0.04 respectively). these were further analyzed using multivariate logistic regression analysis, which showed that age, dm, and thyroid dysfunction were independent risk factors for frozen shoulder (table 3). discussion: this comparative study found that age, dm, and thyroid dysfunction were the risk factors associated with frozen shoulder significantly. in addition, we found several other predictive factors for the risk of frozen shoulder, namely gender, bmi, cardiac disease, cervical spondylosis, and hyperuricemia. the result of this study can help for a better understanding of the underlying risk factor of frozen shoulder. we found out that dm was an independent risk factor for the frozen shoulder with the risk nearly 12 times more than in the control group, which was consistent with the previous studies done by dias r et al.[10], miligrom c et al.[11],cho c-h et al.[12] and wei li et al.[4] above result and studies indicated that diabetes is by far the most common association with frozen shoulder. this may be due to high glucose causing collagen to be sticky resulting in movement restriction and stiffness which is also known as glycosylation[13].the study by moren et al. reported that painful stiff shoulders among diabetics had 90% of painful shoulders with restricted mobility and difficulty in daily j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np chhetri ds, et al. risk factors associated with frozen shoulder among nepalese population table 1: distribution of selected demographic variables and risk factors in frozen shoulder cases and controls. factors cases (n=60) controls (n=60) p value frequency (%) frequency (%) age <40 years 2 (3.33) 31 (51.66) <0.001 ≥40 years 58 (96.67) 29 (48.33) gender male 33 (55) 36 (60) 0.58 female 27 (45) 24 (40) bmi <25 16 (26.67) 22 (36.67) 0.09 25-29.9 34 (56.67) 35 (58.33) >30 10 (16.67) 3 (5) diabetes mellitus yes 20 (33.33) 2 (9.33) <0.001no 40 (66.67) 58 (96.67) thyroid dysfunction yes 8 (13.33) 2 (3.33) 0.048 no 52 (86.67) 58 (96.67) cardiac disease yes 5 (8.33) 1 (1.67) 0.094 no 55 (91.62) 59 (98.33) cervical spondylosis yes 4 (6.67) 3 (5) 0.69 no 56 (93.33) 57 (95) past surgery (other than shoulder surgery) yes 0 (0) 14 (23.33) no 60 (100) 46 (76.67) cholecystitis yes 4 (6.67) 8 (13.33) 0.22 no 56 (93.33) 52 (86.67) uric acid high 4 (6.67) 3 (5) na normal 56 (93.33) 57 (95) j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np chhetri ds, et al. risk factors associated with frozen shoulder among nepalese population table 2: univariate logistic regression analysis of the potential risk factors associated with a frozen shoulder between case and control groups. factor or 95% ci p value gender 1.22 0.59 to 2.53 0.58 age 30.99 6.93 to 138.62 <0.001 bmi 1.70 0.98 to 3.27 0.053 thyroid dysfunction 4.46 0.90 to 21.97 0.041 cardiac disease 5.36 0.61 to 47.3 0.08 cervical spondylosis 1.36 0.29 to 6.34 0.69 cholecystitis 2.15 0.61 to 7.57 0.20 hyperuricemia 1.36 0.29 to 6.34 0.69 dm 14.5 3.2 to 65.5 <0.001 or: odds ratio; ci: confidence interval; dm: diabetes mellitus table 3: multivariate logistic regression analysis factors or 95% ci p value age 1.03 1.01 to 1.07 0.009 diabetes mellitus 12.07 2.43 to 59.83 0.002 thyroid dysfunction 5.45 1.03 to 28.67 0.045 activity in the acute phase[14]. this signifies the need for early detection and prevention of frozen shoulder among patients with dm. considering those with thyroid dysfunction, the result of our study indicated that the individuals with thyroid dysfunction have around five times more risk of developing frozen shoulder than the control group which was to the previous studies done by miligron c et al.[11] and cakir m et al.[15]milgrom et al. reported that among those with frozen shoulder, 13.5% were with thyroid dysfunction. while it was 10.9% in a study conducted in an endocrinology clinic among 137 patients by cakir m et al.[15] wohlgethan et al.[16] also found a possible link between frozen shoulder and altered thyroid function. j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np chhetri ds, et al. risk factors associated with frozen shoulder among nepalese population in this study, the patients with cervical spondylosis were 1.4 times high likely of having frozen shoulders than the control group although not statistically significant. this result is consistent with the result of the hospital-based case-control study conducted in china where the prevalence of frozen shoulder was 23.6 % and 15.3% among those with cervical spondylosis and the control group respectively.[4] in this study regarding age, about 96% participated patients were above 40 years with a p-value less than 0.005 which is similar to other studies.[17,18] we found a significant relationship between frozen shoulder with some comorbidities. we performed a hospital-based case-control study and analyzed the potential risk factors associated with a frozen shoulder in western nepal. we found out overlapped as well as different patterns, comprising with other previous studies. this reflects the race-dependent effect on frozen shoulder. yet, the result of the present study should be considered with certain limitations. we carried out this study in small groups of 60 participants in each case and control. we could not include some of the suspected risk factors as mentioned in various articles like parkinson’s disease, stroke, hyperlipidemia, and dupuytren’s contracture. conclusion: this study showed that diabetes mellitus, thyroid disorder, and advanced age were associated with the frozen shoulder in western, nepal. however, more future prospective cohort studies will prove and simplify the association. conflict of interest: the authors declare that no competing interests exist. source of funds: none. references: 1. wang k, ho v, hunter-smith dj, beh ps, smith km, weber ab. risk factors in idiopathic adhesive capsulitis: a case 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https://pubmed.ncbi.nlm.nih.gov/26880627/ https://doi.org/10.1016/j.mehy.2016.01.002 https://doi.org/10.1016/j.mehy.2016.01.002 https://pubmed.ncbi.nlm.nih.gov/25107826/ https://doi.org/10.1016/j.math.2014.07.006 https://doi.org/10.1016/j.math.2014.07.006 http://jlmc.edu.np bacterial translocation as a cause of postoperative sepsis in surgical patients undergoing laparotomy neeraj thapa,a bhairav kumar hamal,b nagendra prasad yadav,c ghanshaym thapad —–————————————————————————————————————————————— abstract: introduction: bacterial translocation is the invasion of indigenous intestinal bacteria through the gut mucosa to normally sterile tissues and the internal organs. objective of the study is to examine the spectrum of bacteria involved in translocation in surgical patients undergoing laparotomy and to determine the relation between nodal migration of bacteria and the development of postoperative septic complications. methods: mesenteric lymph nodes (mln) culture was done in patients undergoing elective and emergency surgeries fulfilling the inclusion criteria. results: bacterial translocation was identified in 22 (44.8%) patients. the most common organism identified was escherichia coli (n=11, 50%). both enteric bacteria, typical of indigenous intestinal flora, and non-enteric bacteria were isolated. postoperative septic complications developed in four (11%) patients. septic morbidity was more frequent when a greater diversity of bacteria resided within the mesenteric lymph nodes. conclusion: bacterial translocation is associated with an increase in the development of postoperative sepsis in surgical patients. the organisms responsible for septic morbidity are similar in spectrum to those observed in the mesenteric lymph nodes. these data strongly support the gut origin hypothesis of sepsis in humans. besides, there is increased bacterial translocation in patients undergoing emergency procedures. keywords: bacteria • laparotomy • postoperative • sepsis • translocation —————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, department of surgery lumbini medical college teaching hospital, palpa, nepal b professor and head, department of surgery shree birendra chhauni hospital, kathmandu, nepal c surgeon, janakpur zonal hospital, nepal d assistant professor, nams, bir hospital, kathmandu, nepal corresponding author: dr. neeraj thapa e-mail: drneerajthapa@gmail.com how to cite this article: thapa n, hamal bk, yadav np, thapa g. bacterial translocation as a cause of postoperative sepsis in surgical patients undergoing laparotomy. journal of lumbini medical college. 2014;2(2):28-30. doi: 10.22502/jlmc.v2i2.53. ___________________________________________________________________________________ j. lumbini. med. coll. vol 2, no 2, july-dec 2014 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v2i2.53 introduction: bacterial translocation is defined as the passage of viable bacteria from the gastrointestinal (gi) tract through the mucosal epithelium to other sites, such as the mesenteric lymph nodes, spleen, liver and blood.1 this term also applies to the passage of inert particles and other macromolecules, such as lipopolysaccharide endotoxins across the intestinal mucosal barrier. in recent years ‘gut barrier function’ has been increasingly recognized which means the gut is also a metabolic and immunological organ that serves as a barrier against living organisms and antigens within its lumen. the fact that luminal contents in the caecum have a bacterial concentration of the order of 1012 organisms per ml of faeces, while portal blood and mesenteric lymph nodes are usually sterile, dramatically illustrates the efficacy of this barrier function.2 the idea that the alimentary tract, teeming with its own bacterial flora, could represent a source of sepsis referred as ‘gut origin of sepsis’ under certain conditions has interested clinicians for many years. many studies have been done and subsequently it has become clear that, in addition to gram-negative bacteria, endotoxin, gram-positive bacteria and fungi can pass through the mucosal barrier.3-7 subsequently it has become clear that, in addition to gram-negative bacteria, endotoxin, gram-positive bacteria and fungi can pass through the mucosal barrier which has been termed as 'bacterial translocation'.8 there is no doubt that bacterial translocation occurs in humans.9 it has a prevalence of about 28 j. lumbini. med. coll. vol 2, no 2, july-dec 2014 jlmc.edu.np thapa n. et al. bacterial translocation as a cause of postoperative sepsis in surgical patients undergoing laparotomy. 15% in elective surgical patients and occurs more frequently in patients with intestinal obstruction and those who are immunocompromised.9-11 many studies have established an association between gastrointestinal microflora and nosocomial infection supporting the concept of the gut as reservoir of bacteria and endotoxins.12,13 with increasing severity of illness, bacterial translocation occurs because of the inability of the host to deal adequately with the numbers of bacteria present.14 bacterial translocation occurs commonly to mesenteric lymph nodes so the culture of the same gives a valuable idea regarding the organisms responsible for sepsis.the purpose of our research was to observe the relationship between the bacterial translocation and the development of postoperative sepsis along with the observation of spectrum of organisms identified within the mesenteric lymph node culture and the rate of bacterial translocation depending upon the laparotomy done as elective or emergency basis. methods: a prospective observational study was conducted between june 2011 and may 2012 at general surgery clinic and emergency department of bir hospital and patan hospital following approval from the ethical review committee of the institutes. patients with preoperative sepsis and co-morbidities were excluded from the study. patients undergoing elective and emergemcy laparotomy were included in the study. surgery was performed by either consultants or registrars. perioperatively, enloarged mesenteric lymph nodes were excised with a sterile surgical blade and transported in seperate sterile containers with normal saline and sent for aerobic and anaerobic cultures. aerobic culture was done in blood agar at 37°c and reports were interpreted from third to fifth day. anaerobic culture was done in robertsons cooked meat media at 37°c. the report of anerobic culture was obtained at 5-7 days. the data was entered in microsoft excel and statistical analysis was done using spss (statistical package for social studies) version-13 software. various statistical tests were used and a 95% confidence interval and p <.05 were considered as statistically significant. results: in our study 49 patients were included out of which 26 (53.1%) were males and 23 (46.9%) were females. chi-square “goodness of fit” test was applied which showed that the difference was not statistically significant, x2(n=49) =.08, p=.78. both elective and emergency procedures were included. there were 41 (83.67%) of emergency and only 8 (16.33%) of elective procedures. mean age of patients was 41.94 years (sd=15.59). most common (71.4%) diagnosis in our study was peritonitis (table 1). mesenteric lymph node cultures were done to detect the bacterial translocation. culture was positive in 22 (45%) of the samples. the most common organisms cultured were escherichia coli 11 (22.4%) followed sno. diagnosis n(%) 1 peritonitis 35(71) 2 cholelithiasis 6(12) 3 colon carcinoma 4(8) 4 gastric carcinoma 2(4) 5 pancreatic carcinoma 1(2) 6 carcinoma gallbladder 1(2) table 1: frequency distribution of diagnosis. by proteus 5 (10.2%), bacteroides 3 (6%) and staphylococcus aureus 3 (6%). e. coli was found to be highest in age group of 41-60 years. culture was positive most frequently (n=16) in patients with peritonitis. bacterial translocation increased with age, mostly after 40 years; 16.33% of it was seen in the age group 41-50yrs. translocation of bacteria was more common (52%) in emergency cases as compared to elective cases (11%). postoperative sepsis was noted in 8% of patients who had bacterial translocation and this was statistically significant (table 2). discussion: those patients who had positive mesenteric lymph node culture had bacterial translocation and those with bacterial translocation developed sepsis in a few cases. not all patients with bacterial post-op sepsis yes no bacterial translocation yes 4 18 f=5.35 no 0 27 p=.02 table 2: relation between bacterial translocation and postoperative sepsis translocation developed sepsis but few of them who had decreased immunity owing to old age and emergent cases developed sepsis in our study. in a study conducted by macfie et al. which included 927 patients, age group ranged from 6077 years and the male to female ratio was similar to our study. there were more elective cases (80%). the most common diagnosis in their study was malignancy which consisted of 58.57% of total cases 29 thapa n. et al. bacterial translocation as a cause of postoperative sepsis in surgical patients undergoing laparotomy. jlmc.edu.npj. lumbini. med. coll. vol 2, no 2, july-dec 2014 which is unlike in our study. along with mesenteric lymph node culture nasogastric aspirates were sent for culture, which was not included in our study. the most common enteric organisms to be cultured in their study were e. coli (20%), lactobacillus spp. (14%), enterococcus spp. (12%), and enterobacter spp. (9%). the genus enterobacteriaecae (enteric gram negative facultative anaerobic rods) which includes e. coli and enterobacter species was present in 35% of positive cultures, which is similar to our study. postoperative sepsis was common in those with bacterial translocation (42.3%) which was similar to our study. 14 their study period was 13 years unlike ours, which included only laparotomies done within a year. in another study conducted by boyle, 448 patients were included with median age of 67 yrs. bacterial translocation occurred in 15.4% of patients in their study, whereas in our study bacterial translocation occurred in 44.8% of patients. the presence of distal intestinal obstruction at laparotomy was the strongest predictor of translocation and occurred in 41% of patients. age greater than 70 years and the necessity for urgent surgery were also associated with significantly increased translocation rates (both 21%) in their study. the most common organism cultured was e. coli (54%), which was the same in our study (22.4%). forty one percent of patients who had evidence of bacterial translocation developed sepsis compared with 14% of patients in whom no organisms were cultured.9 in our study 8% of patients who had evidence of bacterial translocation developed sepsis. a study in neonates defined microbial translocation as having occurred if organisms isolated from blood samples were also carried in the throat or rectum. they reported six infants with 15 episodes of septicaemia attributable to enteric organisms.15 availability of laboratories round the clock would have been an important factor and particularly in our study where most of the emergency cases were included. but it was not feasible in our study as culture was done during the working hours only. mesenteric culture is an important indicator of bacterial translocation and was employed in our studies but in other studies nasogastric aspirates have also been used. mesenteric lymph node culture gives a precise idea of organisms involving in sepsis. limitations of our study were small number of cases and a short duration of study. use of limited variables related to bacterial translocation which included unavailability of anaerobic culture at various times and use of only single method of mesenteric lymph node culture for the evaluation of postoperative sepsis. not all surgeries were performed by a single surgeon and the study was not carried out in a single institute. conclusions: based on the study conducted it can be concluded that the post-operative infections tend to be more in elderly patients and emergency cases particularly related to peritonitis. all the patients with bacterial translocation don’t develop sepsis but those patients who have developed sepsis have bacterial translocation indicated by positive mesenteric lymph node culture. another important conclusion that can be made is the gut origin of sepsis indicated by the growth of organisms in mesenteric lymph node culture similar to normal gastro-intestinal flora. references: 1. berg rd. bacterial translocation from the intestines. jikken dobutsu. 1985 jan;34(1):1-16. 2. simon g. the human intestinal microflora dig dis sci. 1986;31:147s–62s. 3. fraenkel a. ueber peritonaele infection. wein klin wochenschr. 1891;4(241):241,65,85. 4. flexner s. peritonitis caused by the invasion of the micrococcus lanceolatus from the intestine. john hopkins hosp bull. 1895;6:64-7 5. schweinburg f, frank h, frank e, heimberg f, fine j. transmural migration of intestinal bacteria during peritoneal irrigation in uremic dogs. proc soc exp biol med. 71:150–3. 6. schatten w, desprez j, holden w. a bacteriologic study of portal-vein blood in man. arch surg. 1955;71:404–9. 7. lemaire lc, van lanschot jj, stoutenbeek cp, van deventer sj, wells cl, gouma dj. bacterial translocation in multiple organ failure: cause or epiphenomenon still unproven. br j surg. 1997 oct;84(10):1340-50. 8. berg r, garlington a. translocation of certain indigenous bacteria from the gastrointestinal tract to the mesenteric lymph nodes and other organs in the gnotobiotic mouse model. infect immun. 1979;23:403. 9. o'boyle cj, macfie j, mitchell cj, johnstone d, sagar pm, sedman pc. microbiology of bacterial translocation in humans. gut. 1998 jan;42(1):29-35. 10. dietch e. simple intestinal obstruction causes bacterial translocation in man. arch surg. 1989;124:699-701. 11. sagar p, macfie j, sedman p, may j, mancey-jones b, johnstone d. intestinal obstruction promotes gut translocation in man. dis colon rectum. 1995;38:640-4. 12. macfie j, o'boyle c, mitchell cj, buckley pm, johnstone d, sudworth p. gut origin of sepsis: a prospective study investigating associations between bacterial translocation, gastric microflora, and septic morbidity. gut. 1999 aug;45(2):223-8. 13. marshall j, christou n, meakins j. the gastrointestinal tract:the undrained abscess of multiple organ failure. ann surg. 1993;218:111-9. 14. macfie j. current status of bacterial translocation as a cause of surgical sepsis. br med bull. 2004;71:1-11. 15. pierro a, van saene hk, donnell sc, hughes j, ewan c, nunn aj, et al. microbial translocation in neonates and infants receiving long-term parenteral nutrition. arch surg. 1996 feb;131(2):176-9. 30 comparative evaluation of 25µg and 50µg of travaginal misoprostol for induction of labor buddhi kumar shrestha,a,c sushila jain,a,c roshi maskey,b,c hasena banub,c —–————————————————————————————————————————————— abstract: introduction: to compare the efficacy and safety of 25g vs. 50g of intravaginal (posterior fornix) misoprostol for induction of labor in 100 patient from jan 2012 to dec 2012 at lumbini medical college. methods: one hundred pregnant lady requiring induction were randomly assigned to receive either 25 g (group a=50) or 50 g (group b=50) of intra vaginal misoprostol every 4 hrs till adequate contractions were achieved or maximum dose of 150 g was used. results: the onset of contraction was earlier in group b in 34 cases as compared to group a, where only 25 cases had earlier contraction ( p> 0.05). 38 cases (76%) in group b and 35 cases (70%) in group a delivered vaginally. induction to delivery interval was shorter(<12hrs) in group b in 15 cases and in 10 cases in group a. mean dose of misoprostol (94micrograms) for successful induction in group b was high compared to group a (75.5 microgram). requirement for oxytocin infusion was higher in group a, 26% vs. 15%. abnormal contractility pattern was seen in b group 24% cases compared to 14% cases in group a. apgar score < 7 at 1 min was seen in 26% neonates in group b and in only 10% neonates in group a. ruptured uterus did not occur in any group. conclusion: 50 g dose of misoprostol is more efficacious than 25 g dose as seen in our study. however it appears to be less safe both for mother and baby due to the high incidence of tachysystole, hyperstimulation and intrauterine passage of meconium. keywords: fornix • induction • intravaginal • labor • misoprostol ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer b medical officer c department of obstetrics and gynecology lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. buddhi kumar shrestha e-mail: drbkshrestha@jlmc.edu.np how to cite this article: shrestha bk, jain s, maskey r, banu hasena. comparative evaluation of 25µg and 50µg of intravaginal misoprostol for induction of labor. journal of lumbini medical college. 2013;1(1):46-7. doi:10.22502/ jlmc.v1i1.14. ___________________________________________________________________________________ j. lumbini. med. coll. vol 1, no 1, jan-june 2013 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v1i1.14 introduction: misoprostol is a new agent for labour induction. it was found that it had excellent cervical ripening and is uterotonic agent. though not usfda (united states federation for drug adminstration) approved it is being increasingly used in medical abortion, cervical repining before surgical abortion. however fda recognizes that in certain circumstances off label use of approved products are appropriate, rational, and accepted medical practice.1advandtage of misoprostol over other inducing agents include stability at room temperature, low cost, variety of routes and can be used in different dose. this study was planned to compare the efficacy and safety of 25g vs 50g intravaginally misoprostol for induction labour. methods: the study was carried out on pregnant lady (37 weeks or more of gestation) requiring induction of labour for any medical or obstetrical indication. the study duration was of 1 year and it was approved by the ethical committee of the hospital (lumbini medical college).women with singleton pregnancy at 37 or more weeks of gestation were included after informed consent. pregnant lady with favorable cervix (bishop score > 6), any contraindication to vaginal birth, previous c/s. and prom (premature rupture of membrane) were excluded from the study. the study included 100 cases pregnant females, out of which 50 cases received 25 g (group a) or 50 cases received 50 g (group b) misoprostol intravaginaly in posterior vaginal fornix. the drug was repeated every 4hrs till regular adequate uterine contractions were achieved or maximum up to 150 g of dose of the drug was used up. female with inadequate contractions or no uterine contractions despite of 150 g dose were augmented using oxytocin. various indication for induction were, postdated pregnancy 78%, oligohydromnios 12%, hypertension 10%. results: the induction to delivery interval was shorter in group b as shown in table 1.there was no difference between the both group with respect to mode of delivery (vaginal) 35 cases (70%) in group a and 38 cases (76%) in 46 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np shrestha b. et al. comparative evaluation of 25µg and 50µg of intravaginal misoprostol group b. the onset of contraction was earlier in group b in 34 cases as compared to group a, where only 25 cases had earlier contraction (p> 0.05). 38 cases (76%) in group b and 35 cases (70%) in group a delivered vaginally. induction to delivery interval was shorter (<12hrs) in group b in 15 cases and in 10 cases in group a. mean dose of misoprostol (94 µg) for successful induction in group b was high compared to group a (75.5 µg). misoprostol related side effect, especially gastrointestinal side effect (nausea, vomitting, diarrhea, fever, headache) were common with group b as compare to group a (30%vs 25%), which is not statically significant. failed induction in group a was seen in 7 cases and in 2 cases in group b. requirement for oxytocin infusion was higher in group a, 26% vs. 15% . abnormal contractility pattern was seen in b group 24% cases compared to 14% cases in group a, both statically not significant, as shown in table 2. apgar score < 7 at 1 min was seen in 26% neonates in group b and in only 10% neonates in group a as shown in table 3. of all the patient who underwent caesarian section, various indication for lscs(lower segment caesarian section) was irregular fhs(fetal heart sound), meconium stained liquor, failed induction. common indication for lscs was fetal distress,10 cases in group b and 8 cases in group a. revealed that low doses of misoprostol required more oxytocin augmentation as in our study (26%vs 15%, p>0.05).3 however, the cases with failed induction were more common in low dose misoprostol, these finding was consistent with one of the study of meydanliet et al.4 their study also reported that the proportion of women delivering vaginally with one dose of vaginal misoprostol was significantly greater in 50 g group (0/49 vs. 41/47;p>0.001) which was not studied in our cases. in a comparative study reported by has et al showed the rate of cesarian section due to fetal distress was higher with higher dose (28.6 vs. 10.3% p>0.05).5 this was comparable to our study (group b 20 % vs group a 16%). we observed that the incidence of normal contraclity pattern (tachysystole, hyperstumulation) was higher in 50 g (24% vs 14%, p>0.05%) was comparable with study by sanchez-ramos et al.6 minor side effects were common with higher dose but uterine rupture did not occur in both groups in our study. however, there are so many studies that have reported serious complication with the use of misoprostol. a systematic review by wsagner, 16 medico legal cases agreed with these findings, with uterine rupture in 7 cases and hypoxic encephalopathy in 14 cases.7 thomas et al reported rupture uterus in a primigravida patient after the use of 100 g of misoprostol (25 g given 4hrly).8 neonatal outcome was also adversely affected in females who received higher dose. babies with low apgar score, requiring admission were significantly higher in 50 g group. this was in concurrence with the observations made by has et al.5 contrary to this sanchez-ramos et al in their meta-analysis of five randomize clinical trials reported comparable neonatal outcomes with the two doses.6 conclusion: misoprostol is a effective agent for labour induction. complication remain a matter of concern. these can be minimized by judicious selection of misoprostol dose. 25g misoprostol appears to be safer than 50 g misoprostol due to high incidence of tachysystole, hyperstumulation and meconium in 50 g misoprostol. although this requires stastical correlation in larger series. references: 1. off-label drug use and fda review of supplemental drug applications: hearing before the subcommittee on human resources and intergovernmental relations of the committee on government reform and oversight, house of representatives. 104th congress, 2nd session, september12. washington: u.s. gp.o 1996;53-94. 2. farah la, sanchez-ramos l, rosa c, del valle go, gaudier fl, delke i, et al. randomized trial of two doses of the prostaglandin e1 analog misoprostol for labor induction. am j obstet gynecol. 1997;177:364–71. 3. hofmeyr gj, gulmezoglu am. vaginal misoprostol forcervical ripening and induction of labor. cochranedatabase syst rev 2003;(1): cd000941. 4. meydanli mm, caliskan e, burak f, narin ma, atmaca r. labor induction post-term with 25 micrograms vs 50 micrograms of intravaginal misoprostol. int j gynaecol obstet 2003;81:249-55. 5. has r, batukan c, ermis h et al. comparison of 25 and50 microgram vaginally administered misoprostol for preinduction of cervical ripening and labor induction.gynecol obstet invest 2002;53:16-21. 6. sanchez-ramos l, kaunitz am, delke j. labour induction with 25 g versus 50 g intravaginal misoprostol : asystematic review. obstet gynecol.2002;99(1):145-51. 7. wagner m. adverse events following misoprostol induction of labor. midwifery today int midwife. 2004;71:9-12. 8. 8. thomas a, jophy r, maskhar a . uterine rupture in primigravida with misoprostol used for induction of labor. bjoj . 2003;110:217-8. table 1: induction to delivery interval sno induction to delivery interval (hrs) group a (n = 35 group b (n = 38) 1 <12 10 15 2 12-24 15 16 3 >24 10 7 table 2: abnormal contractility pattern sno indication group a, n = 50 group b, n = 50 1 tachysystole 4(8%) 6(12%) 2 hypertonus 2(4%) 3(6%) 3 hyper stumulation 1(2%) 3(6%) total 7(14%) 12(24%) table 3: fetal outcome analysis sno outcome group a, n=50 group b, n=50 1 apgar <7 in 1 min 5 (10%) 13 (26%) 2 apgar >7 30 (60%) 25 (50%) 3 resuscitation 7 (14%) 9 (18%) 4 meconium 6 (12%) 9 (18%) 5 admission 7 (14%) 10 (20%) discussion: misoprostol the pge1 and analogue appears to be safe and effective but only the optimal dose needs to be determined. in our study induction delivery interval was shorter in group b as compared to group a. lisa et al, their study on 399 pregnant females reported shorter induction delivery interval in female who recieved 50 g of misoprostol (826 min vs. 970 min, p>0.02), few cases in both group required oxytocin augmentation as in our study.1,2 a cochrane review by hofmeyr also 47 samyog article corrected ds jan 10 for pdf.docx https://doi.org/10.22502/jlmc.v10i2.480 original research article students’ perception in learning human anatomy towards dissection or prosection samyog mahat,a,d sarun koirala,b,d sandip shah,c,d laxman khanalc,d abstract: introduction: cadaveric dissection has been used as a traditional method of teaching and learning for many years. with time, changes in medical curriculum has reduced the time for anatomy learning and seeking alternative methodology moving away from traditional learning. with the introduction of new methodology and technology the question arises whether it is still effective enough to follow the old traditional mode of teaching and learning. with ever changing medical education it is important to recognize students perceptive and attitudes toward the learning different method. therefore, this study aimed to determine students’ perception towards prosection and dissection in learning anatomy. methods: the first year medical students were included in the study. the study was carried after the series of lecture as per curriculum. the students were divided into four groups. each group dissected the cadaver followed by observation of the prosected cadaver explained by the faculty. questionnaires were prepared related to dissection and prosection and sent to the students using google form. the students' perception towards dissection and prosection was recorded. the results were tabulated and subjected to statistical analysis. percentage of students opting for dissection and prosection was calculated. results: the majority of students (82.5%) preferred dissection over prosection, 2.6% opted for prosection over dissection and 14.9% were still not sure which method of teaching and learning is favorable. conclusion: the study reflected the traditional method of dissection was more favorable to students while alternative methods can also provide better insight to learning. keywords: cadaver, dissection, prosection. submitted: february 24, 2022. accepted: november 20, 2022. published: march 9, 2023. alecturer, department of human anatomy badditional professor, department of human anatomy cassociate professor, department of human anatomy db.p. koirala institute of health sciences, dharan, nepal corresponding author: samyog mahat email: samyoganatomy@gmail.com orcid: https://orcid.org/0000-0001-8357-0436 introduction: for decades, cadaveric dissection has been used as a core teaching tool in delivering anatomy curriculum in medical schools.[1,2,3] traditional cadaveric dissection facilitates several educational benefits especially obtaining a three-dimensional perspective of human body structures and appreciation of anatomical variations.[4,5,6,7] how to cite this article: mahat s, koirala s, shah s, khanal l. students’ perception in learning human anatomy towards dissection or prosection. j lumbini med coll. 2022;10(2):7 pages. doi: https://doi.org/10.22502/jlmc.v10i2. epub: march 9, 2023. j. lumbini med. coll. vol 10, no 2, jul-dec 2022 https://doi.org/10.22502/jlmc.v10i2.480 mailto:samyoganatomy@gmail.com https://orcid.org/0000-0001-8357-0436 https://doi.org/10.22502/jlmc.v9i2.416 mahat s, et al. students’ perception in learning human anatomy towards dissection or prosection. cadaveric dissection aids in improving students' manual practicing skills including touch mediated perception of the body, use of basic instruments and hand-eye coordination relevant to a variety of basic clinical procedures, create ethical awareness and promote professionalism.[8,9,10,11] over the past decades, with considerable medical curriculum reform, conducting extensive cadaveric dissection has been debated due to its slow and tedious approach, limited availability of cadavers, the difficulties imposed by the ethical issues for their use, high costs, time intensity, requirement for highly skilled teachers and the emotionally challenging nature of cadaveric dissection.[2,10,12,13] with considerable transformation in anatomical teaching over the past decade, need for developing alternative methods of learning gross anatomy is clearly evident.[12,14] another alternative methods is combination of dissection and prosection or prosection alone.[15,16,17] prosection is a preserved specimen of cadaver after part of it is dissected by the demonstrator.[6] prosection requires less time and less financial burden.[6,7] with curriculum reform, the question of which method is better to teach gross anatomy remains to be addressed.[18] hence, the present study was conducted to address the students’ perception towards dissection and prosection in learning gross anatomy. methods: a cross-sectional descriptive study was conducted among the first year bachelor of medicine and bachelor of surgery (mbbs) students of b.p. koirala institute of health sciences from september to november 2021. the total number of students in the first year was hundred. all of the hundred respondents were included in the study after obtaining a written consent. a prior approval of institutional ethics committee was taken before commencement of the study (code no.: irc/2137/021). the respondents were briefed about the study and all those students who volunteered for study were included. the study was done after routine anatomy program lectures and practical class of upper and lower limbs. all the students were exposed to identical series of lecture. all students followed the same syllabus according to the curriculum of the institution. each series of lectures was followed by practical dissection class. practical classes were coordinated and conducted by anatomy faculties and staffs. during practical, students were divided into four subgroups and were exposed to dissection mainly followed by additional prosection in each table. each group was assigned to one cadaver for dissection and prosection. following dissection of body by students, dissected structures were demonstrated by the table teacher. in prosection method, students were asked to observe the cadaver while the table teacher dissected the body and demonstrated to the students. eleven questionnaires were designed for evaluation of the study program by likert style survey from previously published study.[6] structured questionnaire was based on multiple choice questions. google form was created for the questions and was distributed to the students through their respective email address during the period. response was taken from the students for the structured questionnaire prepared using google form. students were asked to response the listed questionnaire a-k shown in table1 using the five point likert scale. responses: 1 strongly disagree, 2-disagree, 3-not sure, 4-agree, and 5-strongly agree. the results were analyzed statistically using the spss 16.0 software. frequency and percentage were calculated. results: the questionnaire was responded by a total of 74 students. no prior experience with cadaveric specimens or dissection was experienced by the students before attending j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np mahat s, et al. students’ perception in learning human anatomy towards dissection or prosection. the sessions. the majority of the respondents (82.5%) ranked dissection based learning very high in terms of their anatomical learning when comparing with prosection, 2.6% students also favored prosection based learning while 14.9% of respondents were not sure which methodology to prefer. more than two-thirds (82.5%) of respondents stated their preference in prosection because of time management is better in comparison to dissection. the majority of respondents (>45%) disagreed or strongly disagreed with questionnaire that reflected positive perceptions of cadaveric prosection: -knowledge gained from prosection is more -interest generated towards subject is more with prosection -with prosection there is more scope for application of knowledge in future than with dissection -with prosection, there is better understanding of spatial orientation of body than with dissection majority of the students (69%) also agreed with the equal opportunity for everyone participation in prosection. comparing structural details better witnessed with prosection than with dissection, student agrees/strongly agrees (52.6%) better structural details in prosection. the frequency and percentage of students responded to each statement is shown in [table 1] figure 1 shows most common responses to each question and their respective frequency discussion: the current study showed relevant findings about student perceptions with regard to positive and negative aspects of prosection and dissection in learning anatomy. student’s assessment and feedback about different methodology of learning is useful in changing and improving medical education curriculum as changes is taking place globally to improve standards of education.[17] a change in methodology of teaching and learning modalities develops in response to student’s requirement and institution. majority of participants held positive perceptions about the effectiveness of cadaveric dissections in better understanding of anatomical structures and knowledge. our study also showed that student’s perception towards time management and equal opportunity is better in prosection as compared to dissection. our findings correlate with the previous study done by dissabandara et al. which showed that students perception towards dissection is time consuming, difficult in finding correct structures as compared to other forms of learning anatomy.[2] time consuming may be due to difficulty in finding structure at once during cutting the body. equal opportunity is not received by all the students in dissection may be due to students ratio is higher in comparison to inadequate availability of cadaver for dissection. a previous study done by topp et al. found that prosection provides greater insight into anatomical variations than dissection.[15] our study showed mixed perception of students towards different anatomical learning methods providing greater insight to anatomical variations. this may be due to different populations targets used in different studies. these study findings differed from the study conducted by rizzolo et al. which included student’s perception towards prosection helps more than dissection to reinforce and apply concepts learned from lectures.[19] our study demonstrated that about forty percent of students agree dissection can help them to reinforce and apply concepts learned from lecture. this difference in findings may be due to different setting used in the study. j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np mahat s, et al. students’ perception in learning human anatomy towards dissection or prosection. table 1: showing frequencies and percentage of students rating to questionnaire (n = 74) statements strongly agree n (%) agree n (%) not sure n (%) disagree n (%) strongly disagree n (%) a knowledge gained from prosection is more compared to dissection 2 (2.7%) 12 (16.2%) 26 (35.2%) 30 (40.5%) 4 (5.4%) b time management is good with prosection compared to dissection 12 (16.2%) 49 (66.3%) 11 (14.9%) 1 (1.3%) 1 (1.3%) c interest generated towards subject is more with prosection compared to dissection 2 (2.7%) 12 (16.2%) 14 (19.0%) 40 (54%) 6 (8.1%) d with prosection there is more scope for application of knowledge in future than with dissection 0 (0%) 8 (10.8%) 23 (31.1%) 35 (47.3%) 8 (10.8%) e prosection helps more than dissection to reinforce and apply concepts learned from lectures 0 (0%) 15 (20.3%) 28 (37.9%) 30 (40.5%) 1 (1.3%) f with prosection, there is better understanding of spatial orientation of body than with dissection 1 (1.3%) 27 (36.5%) 19 (25.8%) 25 (33.7%) 2 (2.7%) g everyone gets equal opportunity for participation in prosection 9 (12.2%) 42 (56.8%) 13 (17.6%) 8 (10.7%) 2 (2.7%) h with prosection, systems interrelation in the body is better understood 1 (1.3%) 26 (35.2%) 27 (36.5%) 17 (22.9%) 3 (4.1%) i prosection provides greater insight into anatomical variations than dissection 3 (4.1%) 26 (35.1%) 17 (22.9%) 24 (32.5%) 4 (5.4%) j structural details better witnessed with prosection than with dissection 4 (5.4%) 35 (47.2%) 15 (20.3%) 15 (20.3%) 5 (6.8%) k i prefer dissection over other forms of learning cadaver 24 (32.5%) 37 (50.0%) 11 (14.9%) 1 (1.3%) 1 (1.3%) j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np mahat s, et al. students’ perception in learning human anatomy towards dissection or prosection. figure1. most common responses to each question and their respective frequency in our study, 82.5% of students preferring dissection over prosection for learning anatomy whereas study conducted by dinsmore et al. showed only 8.5% of the responding students preferred traditional dissection; 78.8% chose examination of prosected materials with faculty.[16] this difference might be due to students not getting equal opportunity to dissect the cadaver. the study conducted by j.o. nnodim et al. showed that structures imprinted better on dissector’s mind, one learns to dissecta skill useful later in surgery while prosection is effective, very time-economical and all important structures are seen.[20] our study also showed similar results as students (55.8%) favoring prosection as there is more scope for application of knowledge in future than with dissection and 82.5% of students opting prosection as time management is good while learning with prosected cadaver compared to dissection. our findings correlates with the study conducted by smith et al. which demonstrated that majority of students agreed prosection helped them appreciate relationships between structures.[21] moreover, in our study 52.6% of students agreed that structural details is better witnessed with prosection than with dissection. study conducted by whelan et al. showed majority of students valued the ability to improve three dimensional and spatial knowledge of anatomy during the course of dissection.[22] our study also showed that nearly two-thirds of the students agreed that there is better understanding of spatial orientation of body in prosected body than with dissection, nearly two-thirds of participants disagreed with above statements whereas nearly one-fourth of participants were neutral to the statements. limitation of the study includes, bds students as well as second year mbbs students could have been included in the study. j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np mahat s, et al. students’ perception in learning human anatomy towards dissection or prosection. conclusion: use of traditional cadaveric dissection to facilitate teaching and learning is becoming difficult because of limited availability of cadaver, ethical issues, and students to cadaveric ratio. our study showed majority of student’s opted dissection over prosection as it is efficient in acquiring surgical skills and good clinical practice. although majority of participants sought the importance of dissection in many ways but students also disagreed towards sole method of delivering anatomy practical as prosection provided good insight to anatomical variation and time management was better than with other forms of methodology used in learning. therefore the introduction of diverse method is required to facilitate learning technique in laboratory. acknowledgement: department of anatomy, bpkihs, dharan, nepal conflict of interest: none of the authors have a conflict of interest. source of fund: no funds were available. references : 1. ghosh sk. human cadaveric dissection: a historical account from ancient greece to the modern era. anat cell biol. 2015;48(3):153-69. pmid: 26417475 doi: https://doi.org/10.5115/acb.2015.48.3.153 2. dissabandara lo, nirthanan sn, khoo tk, tedman r. role of cadaveric dissections in modern medical curricula: a study on student perceptions. anat cell biol. 2015;48(3):205-12. pmid: 26417481 doi: https://doi.org/10.5115/acb.2015.48.3.205 3. magee r. art macabre: resurrectionists and anatomists. anz j surg. 2001;71(6):377-80. pmid: 11409024 doi: https://doi.org/10.1046/j.1440-1622.2001. 02127.x 4. aziz ma, mckenzie jc, wilson js, cowie rj, ayeni sa, dunn bk. the human cadaver in the age of biomedical informatics. anat rec. 2002;269(1):20-32. pmid: 11891622 doi: https://doi.org/10.1002/ar.10046 5. ghosh sk. cadaveric dissection as an educational tool for anatomical sciences in the 21st century. anat sci educ. 2017;10(3):286-99. pmid: 27574911 doi: https://doi.org/10.1002/ase.1649 6. pushpa nb, deepa b, pushpalatha k. students’ perception on dissection and prosection in learning gross anatomy. international journal of anatomy, radiology and surgery. 2019;8(3):ao25-ao27. available from: http://www.ijars.net/articles/pdf/2505/41 534_ce[ra1]_f(shu)_pf1(ag_shu)_p fa(shu)_pb(ag_shu)_pn(shu).pdf 7. mcwatt sc, newton gs, umphrey gj, jadeski lc. dissection versus prosection: a comparative assessment of the course experiences, approaches to learning, and academic performance of non-medical undergraduate students in human anatomy. anat sci educ. 2021;14(2):184-200. pmid: 32539226 doi: https://doi.org/10.1002/ase.1993 8. moore na. to dissect or not to dissect? anat rec. 1998;253(1):8-9. pmid: 9556018 doi: https://doi.org/10.1002/(sici)1097-0185(1 99802)253:1%3c8::aid-ar6%3e3.0.co;2-z 9. ellis h. teaching in the dissecting room. clin anat. 2001;14(2):149-51. pmid: 11241750 doi: https://doi.org/10.1002/1098-2353(200103 )14:2%3c149::aid-ca1023%3e3.0.co;2-u 10. jeyakumar a, dissanayake b, dissabandara l. dissection in the modern medical curriculum: an exploration into student perception and adaptions for the future. anat sci educ. 2020;13(3):366-80. pmid: 31168930 doi: https://doi.org/10.1002/ase.1905 11. kinirons sa, reddin vm, maguffin j. j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np https://pubmed.ncbi.nlm.nih.gov/26417475/ https://pubmed.ncbi.nlm.nih.gov/26417481/ https://pubmed.ncbi.nlm.nih.gov/26417481/ https://pubmed.ncbi.nlm.nih.gov/11409024/ https://pubmed.ncbi.nlm.nih.gov/11891622/ https://pubmed.ncbi.nlm.nih.gov/27574911/ https://pubmed.ncbi.nlm.nih.gov/32539226/ https://pubmed.ncbi.nlm.nih.gov/9556018/ https://pubmed.ncbi.nlm.nih.gov/9556018/ https://doi.org/10.1002/(sici)1097-0185(199802)253:1%3c8::aid-ar6%3e3.0.co;2-z https://doi.org/10.1002/(sici)1097-0185(199802)253:1%3c8::aid-ar6%3e3.0.co;2-z https://pubmed.ncbi.nlm.nih.gov/11241750/ https://pubmed.ncbi.nlm.nih.gov/11241750/ https://pubmed.ncbi.nlm.nih.gov/31168930/ http://jlmc.edu.np mahat s, et al. students’ perception in learning human anatomy towards dissection or prosection. effects of alternating dissection with peer teaching and faculty prosected cadaver demonstrations in a physical therapy and occupational therapy gross anatomy course. anat sci educ. 2019;12(5):468-77. pmid: 30452788 doi: https://doi.org/10.1002/ase.1833 12. fruhstorfer bh, palmer j, brydges s, abrahams ph. the use of plastinated prosections for teaching anatomy--the view of medical students on the value of this learning resource. clin anat. 2011;24(2):246-52. pmid: 21322047 doi: https://doi.org/10.1002/ca.21107 13. jaiswal r, sathe s, gajbhiye v, sathe r. students perception on methods of anatomy teaching and assessment. international journal of anatomy and research. 2015;3(2):1103-8. available from: http://dx.doi.org/10.16965/ijar.2015.161 14. alexander j. dissection vs prosection in the teaching of anatomy. journal of medical education. 1970;45(0):600-6. 15. topp ks. prosection vs. dissection, the debate continues: rebuttal to granger. anat rec b new anat. 2004;281(1):12-4. pmid: 15558780 doi: https://doi.org/10.1002/ar.b.20037 16. dinsmore ce, daugherty s, zeitz hj. teaching and learning gross anatomy: dissection, prosection, or “both of the above?”. clin anat. 1999;12(2):110-4. pmid: 10089036 doi: https://doi.org/10.1002/(sici)1098-2353(1 999)12:2%3c110::aid-ca5%3e3.0.co;2-3 17. aziz m, kernick et, beck dallaghan gl, gilliland ko. dissection versus prosection: a comparison of laboratory practical examinations. med sci educ. 2020;30(1):47-51. pmid: 34457635 doi: https://doi.org/10.1007/s40670-019-00839 -6 18. kerby j, shukur zn, shalhoub j. the relationships between learning outcomes and methods of teaching anatomy as perceived by medical students. clin anat. 2011;24(4):489-97. pmid: 20949485 doi: https://doi.org/10.1002/ca.21059 19. rizzolo lj. human dissection: an approach to interweaving the traditional and humanistic goals of medical education. anat rec. 2002;269(6):242-8. pmid: 12467081 doi: https://doi.org/10.1002/ar.10188 20. nnodim jo. learning human anatomy: by dissection or from prosections? med educ. 1990;24(4):389-95. pmid: 2395432 doi: https://doi.org/10.1111/j.1365-2923.1990.t b02456.x 21. smith mj, wilkinson t. does a functional prosection provide a more effective method of learning the anatomy of the forearm and hand than a 3d online anatomy resource? mededpublish. 2018;7(3):1-12. doi: https://doi.org/10.15694/mep.2018.00002 08.1 22. whelan a, leddy jj, ramnanan cj. benefits of extracurricular participation in dissection in a prosection-based medical anatomy program. anat sci educ. 2018;11(3):294-302. pmid: 28881412 doi: https://doi.org/10.1002/ase.1724 j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np https://pubmed.ncbi.nlm.nih.gov/30452788/ https://pubmed.ncbi.nlm.nih.gov/21322047/#:~:text=the%20majority%20of%20students%20(94,of%20anatomy%20in%20real%20life. https://pubmed.ncbi.nlm.nih.gov/15558780/ https://doi.org/10.1002/ar.b.20037 https://pubmed.ncbi.nlm.nih.gov/10089036/ https://pubmed.ncbi.nlm.nih.gov/34457635/ https://pubmed.ncbi.nlm.nih.gov/20949485/ https://pubmed.ncbi.nlm.nih.gov/12467081/ https://pubmed.ncbi.nlm.nih.gov/28881412/ http://jlmc.edu.np aruna manuscript final for pdf.docx https://doi.org/10.22502/jlmc.v10i2.489 original research article prevalence of abnormal pap smear in pregnancy: a hospital-based study in western nepal aruna pokharela,d, arati shresthaa,d, deepak shresthab,d, shreyashi aryalb,d, archana tiwaric,d abstract: introduction: cervical carcinoma is the third most common malignancy worldwide. the world health organization in 2014 reported the crude incidence rate of cervical cancer in nepal as 24.2 per 100,000 women per year. this study was carried out with the aim of finding out the prevalence of cervical smear abnormality in pregnancy. methods: an observational study was conducted in the department of obstetrics and gynecology of a tertiary center for a period of one year from may 2021 to april 2022. all pregnant women up to 28 weeks of gestation who had national health insurance coming for antenatal check-up underwent pap smear test. the cytological results were reported based on the bethesda classification system 2001. results: of 200 pregnant women enrolled in the study, the pap smear report revealed that 32% of the study subjects had inflammatory smear showing candidiasis and bacterial vaginosis with reactive inflammatory changes. however, 66.5% of the subjects showed negative for intraepithelial lesion or malignancy and only 0.5% of subjects had signs related to carcinoma cervix in which the subject had a low-grade squamous intraepithelial lesion. no satisfactory sample was reported in 1% of the subjects. conclusion: pap smear during pregnancy not only gives the opportunity to screen but also helps to create awareness. keywords: carcinoma cervix, pap smear, pregnancy. submitted: 24 june, 2022 accepted:29 november, 2022 published: 20 january, 2023 alecturer, department of obstetrics and gynaecology. bassociate professor, department of obstetrics and gynaecology. cassociate professor, department of pathology. dlumbini medical college and teaching hospital, palpa, nepal. corresponding author: aruna pokharel department of obstetrics and gynaecology, lumbini medical college, palpa, nepal e-mail: aruna.pokharel549@gmail.com orcid: https://orcid.org/0000-0002-7592-5222 introduction: cervical carcinoma is the third most common gynecological malignancy.[1] there has also been an increased frequency of cervical intraepithelial neoplasia (cin) in pregnancy.[2] early detection and treatment of precancerous lesions can decrease the incidence and risk of cervical carcinoma. in addition to the prevalence of risk factors like low socio-economy, high parity, early how to cite this article: pokharel a, shrestha a, shrestha d, aryal s, tiwari a. prevalence of abnormal pap smear in pregnancy: a hospital-based study in western nepal. j lumbini med coll. 2022;10(2): 8 pages. doi: https://doi.org/10.22502/jlmc.v10i2. epub: 20 january, 2023 j. lumbini med. coll. vol 10, no 2, jul-dec 2022 https://doi.org/10.22502/jlmc.v10i2.489 mailto:aruna.pokharel549@gmail.com https://orcid.org/0000-0002-7592-5222 https://doi.org/10.22502/jlmc.v10i2 pokharel a, et al. prevalence of abnormal pap smear in pregnancy marriage in low and middle-income countries (lmics), lack of awareness about cervical cancer and poor screening also contribute to the high incidence and mortality due to cervical cancer.[3] according to a report by who in 2014, the crude incidence rate of cervical cancer in nepal was 24.2 per 100,000 women per year.[4] the american college of obstetrics and gynecologists (acog) recommends cervical cancer screening be done every three years from the age of 21 years till 65 years.[3] given the large number of follow up and even the first hospital visits during pregnancy, most pregnant women can be evaluated, identified and treated early in case of abnormal papanicolaou (pap) results. the accuracy of pap smear in pregnancy is almost similar to that of non-pregnant state.[2] in addition to carcinoma, inflammatory conditions during pregnancy can also be identified and treated accordingly for the ongoing pregnancy to be uneventful.[3] while in high-income countries, pap testing has become a routine in pregnant women, in lmics like ours, screening is still not that common due to lack of awareness, fear, misconception and even shyness. to this researcher’s best knowledge, there has been no published study done in pregnant nepalese women till date. hence, this study was undertaken to determine the prevalence of abnormal cervical smear and genital infections among antenatal women. methods: this was a hospital-based observational study conducted in the out-patient department (opd) of obstetrics and gynecology in lumbini medical college and teaching hospital (lmcth) over a period of one year from may 2021 to april 2022. the study was started after obtaining the approval from the institutional review committee (irc-lmc 03-b/021). all the pregnant women presenting to gynecology opd till 28 completed weeks of gestation having national health insurance were enrolled into the study. those with history of per vaginal bleeding or actively bleeding, known case of cin or cervical carcinoma and women who had a normal pap smear report within one year were excluded from the study. sample size: the sample size was calculated using the following formula: n = z2 p (1-p)/e2 where, n = minimum sample size, p = proportion of cervical smear abnormality, taken as 90% from the study of himabindu p et al.[5] z = 1.96 at 95% confidence interval level. e=margin of error=5% the minimum sample size calculated was 139. a total of 200 antenatal women were included in the study. all women coming for antenatal check-up up to 28 weeks were explained about the study and informed consent taken. data was collected using a preformed proforma which included information on the participants’ demographic characteristics, obstetric history, and past history of cervical cytology screening, if any. before the test all the participants were asked if they were aware about pap test. during examination, the participants were placed in dorsal position. after exposing the cervix using cusco’s self-retaining speculum, per speculum findings were noted. the ectocervix was sampled using an ayre’s spatula and smeared on a glass slide. it was immediately fixed with 95% ethyl alcohol, and sent to lab. it was evaluated and reported by the department of pathology according to modified bethesda classification, 2001 as negative for intraepithelial lesion or malignancy (nilm), inflammatory, atypical squamous cells of undetermined significance (ascus), low grade squamous intraepithelial lesion (lsil), high grade j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np pokharel a, et al. prevalence of abnormal pap smear in pregnancy squamous intraepithelial lesion (hsil), asc-h (atypical squamous cellscannot rule out high grade lesion) and atypical glandular cell (agc).[6] majority of the reports were collected by the participants themselves or their family members. some defaulter cases’ reports were collected by the researcher from the department of pathology. a healthy cervix was defined on the basis of naked eye observation of cervix on speculum examination. the cervix that looked pink, round, smooth with a central external os was said to be healthy. the microsoft excel program 2016 version was used for data entry and management. statistical package for social sciences (spss) 18.0 software (spss inc., chicago, il, usa) was used for statistical analysis. descriptive statistics was used for demographic data and expressed in frequency and percentage. results: the most common finding in per speculum examination was a healthy cervix observed in 155 (77.5 %) of the study participants and two (1%) had growth in cervix (fig. 1). fig. 1: distribution of study participants based on the per speculum examination (n=200) the pap smear report revealed that 64 (32%) participants had inflammatory smear showing candidiasis and bacterial vaginosis with reactive inflammatory changes. one (0.5%) participant had lsil. no satisfactory sample was obtained in two (1%) of the participants (table 1). j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np pokharel a, et al. prevalence of abnormal pap smear in pregnancy table 1: distribution of the study participants based on the pap smear report (n=198)* pap smear report frequency (%) nilm 133 (66.5) inflammatory smear 64 (32) lsil 1 (0.5) *no satisfactory result was obtained in two samples. in the age wise distribution of the study participants, it was seen that the majority of study participants, 69 (34.5%) were in the age group between 21 and 25 years with the minimum age of 17 years and maximum, of 40 years. the mean age was 25.3±5.2 years. in the parity wise distribution, it was seen that the majority of study participants, 139 (69.5%) were multigravida. majority of the study participants (n=68, 34%) at the time of presentation were between 21 and 25 weeks of gestation with the mean gestational age of 19.4±6.7 weeks. the minimum period of gestation at presentation was five weeks (table 2). table 2: distribution of the study participants based on their gestational age (n=200) gestational age (in weeks) frequency (%) 5-10 29 (14.5) 11-15 35 (17.5) 16-20 26 (13) 21-25 68 (34) 26-28 42 (21) in this study, it was observed that the majority of the study participants (n=156, 78%) were not aware about pap smear and only 44 (22%) knew about the procedure. it was observed that the lower the age of marriage, the higher the chance of inflammatory change of cervix. thirty (49.2%) participants had inflammatory smear who were married before 20 years. it was noticed that the incidence was gradually decreasing with women married later (table 3). table 3: distribution of the study participants based on their age at marriage and the pap smear report (n=198) pap smear report age at marriage (years) ≤20 (n=61) 21-25 (n=41) 26-30 (n=47) 31-35 (n=48)* >35 (n=3)* nilm 30 (49.2%) 21 (51.2%) 35 (74.5%) 45 (93.7%) 2 (66.7%) inflammatory smear 30 (49.2%) 20 (48.8%) 12 (25.5%) 2 (4.2%) 0 lsil 1 (1.6%) 0 0 0 0 *one participant each had an unsatisfactory pap smear report. j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np pokharel a, et al. prevalence of abnormal pap smear in pregnancy discussion: cancer cervix falls in the category of preventable and easily diagnosable cancers. the available gold standard screening test to detect pre-invasive cervical lesions which are treatable is pap smear. such lesions if not diagnosed and treated in time may progress to carcinoma. though a wide range of cancer cervix occurs in peri-menopausal age group, pre-malignant changes begin much earlier. that is why, current guidelines recommend pap smear is to begin from the age of 21 years in all sexually active women and to be done every three years and hpv dna co-testing every five years as screening method.[5] as pregnant women also fall under the same age group, pap smear testing in pregnancy helps not only in identifying pre-malignant lesions of cervix but also in diagnosing asymptomatic genital infections which if left untreated might even hamper pregnancy outcome.[6] this study contained women from age group 16 to 39 years. majority (34.5%) belonged to 21 to 25 years of age. similar result was seen in the study conducted by ethirajan s et.al in india.[3] majority of the women in this study were multigravida (69.5%) while majority were primigravida in other studies.[3,5] regarding awareness about pap smear, only 22% of women knew what it means and what it is used for, which is slightly better than the result of the study done in india.[3] however, this is in contrast to the study done by manikkam b.[8] in coimbatore where 80% of women and study done in istanbul showed that 83.9% women were aware about pap smear.[9] better literacy rate and developed health care facilities might be the reasons for this. many females complain of pain in the lower abdomen on and off which is even severe at times. so, performing pap smear at first antenatal visit to know the presence or absence of squamous intraepithelial lesion, candidiasis, bacterial vaginosis and all of which infections may be of risk to mother and fetus. this initial smear can be used as a baseline diagnostic tool to treat infections if present.[10,11] in this study, maximum (34%) women presented for their first antenatal visit at 21 to 25 weeks of gestation. though pregnancy does not hamper the false negative results rate, normal physiological changes occurring during pregnancy may result in difficult interpretation of pap smear. for example, commonly seen mucus plug during pregnancy due to hyperplasia of cervical glands due to increased estrogen and progesterone associated with overall increase in vaginal secretions may obliterate the visualization of cervix.[12] in this study, there was no difficulty in visualizing the cervix of the involved women, and, maximum (77.5%) had healthy cervix similar to the study done by priya s s et al.[2] only 1% study participants showed growth which seemed benign. they were counseled for regular follow up and further evaluation later. in the studies done in past, prevalence of abnormal cervical cytology varied from study to study.[2] ueda y et al. reported 3.68% in 2010 to 4.35% in 2013 in japan, 4.8% was reported in 2018 in thailand by phaliwong p et al., 4.9% in 2019 in italy by martinelli m et al. and 16% in africa in 2020 by obeid da et al.[13,14,15,16] the prevalence of abnormal pap smear in pregnancy could be as high as 6-7% depending upon the population undergoing screening.[17] in present study, 0.5% of study population had lsil which is almost similar to the study done by manikkam b.[8] where 1% of women had premalignant lesion in pap smear with 0.5% being ascus and njaojaruwong et al.[15] with prevalence of abnormal cytology 0.4%. in contrast to the pap report of present study, study done by rasheed fa et al. in nigeria, out of 161 pregnant women, six had ascus, 11 had lsil and three had hsil.[18] but liquid based cytology was used in that while j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np pokharel a, et al. prevalence of abnormal pap smear in pregnancy conventional pap with ayre’s spatula was done in this study which might have led to this difference. in the present study, out of 30% of inflammatory smear, 4% were of bacterial vaginosis, 10% of candida infection while remaining were nonspecific inflammatory smears. in lmics like ours, where the awareness regarding pap smear and its importance has just begun to rise, where still most of the population rely on insurance to do necessary investigations, screening during pregnancy has a huge role in identifying at risk cases. identifying and treating at risk cases and infected cases, not only improves pregnancy outcome but also decreases the morbidity and mortality due to cancer cervix. it also serves as an excellent tool to educate and aware the female and her members encouraging them for regular pap screening for themselves and community. the study has a few limitations. as this study has small sample size and also only women up to 28 weeks of gestation are included, many cases might have been missed. rather than conventional pap smear, liquid based cytology and hpv dna are more sensitive but are not available here. conclusion: incidence of cancer cervix has been increasing every year and timely identification of pre malignant lesions could reduce this. in countries like ours, where many women do not undergo routine cervical screening, antenatal period during which women visit hospital, provides excellent opportunity to screen. as pap smear is not only of diagnostic but therapeutic importance, community should be made aware about this and encouraged to test. conflict of interest: the authors declare no competing interests exist. source of funding: none declared. references: 1. cioroba t, botezatu r, ciobanu am, gica c, demetrian m, cimpoca-raptis ba, et al. cervical cancer – a real medical challenge when diagnosed during pregnancy. romanian medical journal. 2022;69(suppl2):42-6. available from: https://rmj.com.ro/articles/2022.s2/rmj_ 2022_suppl2_art-09.pdf 2. priya ss, shankar r. pap smear in pregnancy: a hospital based study. international journal of reproduction, contraception, obstetrics and gynecology. 2018;7(12):4924-8. doi: https://doi.org/10.18203/2320-1770.ijrcog 20184941 3. ethirajan s, srinidhi r, jayashree k. pap smear in antepartum women: an opportunity to screen and create awareness. journal of reproduction, contraception, obstetrics and gynecology. 2018;7(10):4093-6. doi: https://doi.org/10.18203/2320-1770.ijrcog 20184134 4. world health organization. comprehensive cervical cancer control: a guide to essential practice – 2nd ed. geneva: world health organization; 2014. available from: https://apps.who.int/iris/bitstream/handle/ 10665/144785/9789241548953_eng.pdf 5. himabindu p, kanwal a, pg v. pap smear in antenatal women routine screening in low resource settings. iosr journal of dental and medical sciences. 2015;14(4):4-5. available from: https://www.iosrjournals.org/iosr-jdms/pa pers/vol14-issue4/version-1/b014410405. pdf 6. kujur p, joshi c. application of the 2014 bethesda system for reporting of cervical/ vaginal cytological lesions. journal of evolution of medical and dental sciences. 2015;4(98):16366-71. doi: http://dx.doi.org/10.14260/jemds/2015/24 19 j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np https://rmj.com.ro/articles/2022.s2/rmj_2022_suppl2_art-09.pdf https://rmj.com.ro/articles/2022.s2/rmj_2022_suppl2_art-09.pdf https://doi.org/10.18203/2320-1770.ijrcog20184941 https://doi.org/10.18203/2320-1770.ijrcog20184941 https://doi.org/10.18203/2320-1770.ijrcog20184134 https://doi.org/10.18203/2320-1770.ijrcog20184134 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journal of biomedical and advance research. 2014;5(1):47-9. doi: https://doi.org/10.7439/ijbar.v5i1.551 13. rasheed fa, yakasai ia, takai iu, yusuf i, ibrahim um. cervical cytopathological changes in pregnancy: an experience from a low resource setting. ann afr med. 2021;20(3):212-21. pmid: 34558451 doi: https://doi.org/10.4103/aam.aam_47_20 14. ueda y, yagi a, nakayama t, hirai k, ikeda s, sekine m, et. al. dynamic changes in japan’s prevalence of abnormal findings in cervical cytology depending on birth year. sci rep. 2018;8(1):5612. pmid: 29618795 doi: https://doi.org/10.1038/s41598-018-23947 -6 15. phaliwong p, pariyawateekul p, khuakoonratt n, sirichai w, bhamarapravatana k, suwannarurk k. cervical cancer detection between conventional and liquid based cervical cytology: a 6-year experience in northern bangkok thailand. asian pac j cancer prev. 2018;19(5):1331-6. pmid: 29802695 doi: https://doi.org/10.22034/apjcp.2018.19.5.1 331 16. martinelli m, musumeci r, rizzo a, muresu n, piana a, sotgiu g. et. al. prevalence of chlamydia trachomatis infection, serovar distribution and co-infections with seven high-risk hpv types among italian women with a recent history of abnormal cervical cytology. int j environ res public health. 2019;16(18):3354. pmid: 31514378 doi: https://doi.org/10.3390/ijerph16183354 17. obeid da, almatrrouk sa, alfageeh mb, al-ahdal mna, alhamlan fs. human papillomavirus epidemiology in populations with normal or abnormal cervical cytology or cervical cancer in the middle east and north africa: a systematic review and meta-analysis. j infect public health. 2020;13(9):1304-13. pmid: 32564935 doi: https://doi.org/10.1016/j.jiph.2020.06.012 j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np https://pubmed.ncbi.nlm.nih.gov/31791846/ https://doi.org/10.1016/j.sxmr.2019.09.005 https://doi.org/10.1016/j.sxmr.2019.09.005 https://doi.org/10.18203/2320-1770.ijrcog20150699 https://doi.org/10.18203/2320-1770.ijrcog20150699 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https://doi.org/10.3390/ijerph16183354 https://pubmed.ncbi.nlm.nih.gov/32564935/ https://doi.org/10.1016/j.jiph.2020.06.012 http://jlmc.edu.np pokharel a, et al. prevalence of abnormal pap smear in pregnancy 18. lertcharernrit j, sananpanichkul p, suknikhom w, bhamarapravatana k, suwannarurk k, leaungsomnapa y. prevalence and risk assessment of cervical cancer screening by papanicolaou smear and visual inspection with acetic acid for pregnant women at a thai provincial hospital. asian pac j cancer prev. 2016;17(8):4163-7. pmid: 27644678 j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np https://pubmed.ncbi.nlm.nih.gov/27644678/ http://jlmc.edu.np factors associated with pre-hospital delay before reperfusion therapy in patients with st-segment elevation myocardial infarction ram chandra kafle,a navaraj paudel,b girija shankar jha,a dibya sharma,c vijay madhav alurkard —–————————————————————————————————————————————— abstract: introduction: cardiovascular disease remains the main cause of death in the world, and myocardial infarction represents the main contributor to this mortality. timely restoration of myocardial blood flow with reperfusion therapy is crucial. pre-hospital delay is a major obstacle for early reperfusion therapy and has negative impact on mortality and left ventricle function. methods: a prospective study was carried in cardiology unit of a medical college from august 2013 to december 2017. cases of acute st segment elevation myocardial infarction that have undergone thrombolysis were recruited. results: out of 450 patients with st elevation myocardial infection (stemi), delayed presentation was seen in 288 (64%) for >6 hrs and 108 (24%) patients for >12 hrs. the duration from onset of symptoms to the presentation in the emergency room (pre-hospital delay) was 12.66 hrs (sd=14.19, range = 30 min to 72 hrs). the door to needle time was 54 min (sd=24) the major factors for pre-hospital delay were misinterpretation of symptoms (59%) and transportation problems (31%). conclusion: misinterpretation of symptoms remain the most common cause of delayed presentation. health education for public awareness can reduce the delay. extension of thrombolytic therapy to district hospital and primary health center level after basic training for medical officer with checklist and collaboration in form of telemedicine with referral cardiac center may have major impact on morbidity and mortality reduction in acute stemi patients with early reperfusion therapy. keywords: chest pain, myocardial infarction, pre-hospital delay, thrombolysis —————————————————————————————————————————————— j. lumbini. med. coll. vol 6, no 2, july-dec 2018 original articlehttps://doi.org/10.22502/jlmc.v6i2.228 ___________________________ submitted: 20 may 2018 accepted: 24 august 2018 published: 16 september 2018 a assistant professor, department of cardiology, manipal college of medical sciences (mcoms), pokhara b associate professor, department of cardiology, mcoms, pokhara c assistant professor, college of nursing, mcoms d professor, department of cardiology, mcoms, pokhara corresponding author: ram chandra kafle e-mail: drkafle30@gmail.com orcid: https://orcid.org/0000-0002-9840-8009 how to cite this article: kafle rc, paudel n, jha gs, sharma d, alurkar vm. factors associated with pre-hospital delay before reperfusion therapy in patients with st-segment elevation myocardial infarction. journal of lumbini medical college. 2018;6(2):5 pages. doi: 10.22502/jlmc. v6i2.228. epub: 2018 september 16. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.____________________________ introduction: non-communicable disease (ncd) is a leading cause of death worldwide. according to the world health organization (who), "40 million of the 56 million global deaths in 2015 were due to ncds". moreover, "48% of ncds deaths in low and middle-income countries in 2015 occurred before the age of 70".[1] cardiovascular disease remains the main cause of death worldwide, and myocardial infarction represents the main contributor to this mortality. annually, more than three million people suffer or die from st elevation myocardial infarction (stemi) worldwide.[2] treatment of patients with acute myocardial infarction (mi) is time related.[3] delay of every minute after stemi is associated with increasing mortality and morbidity. [4] prehospital delay is a major contributor to the morbidity and mortality in mi.[5] a landmark study by de luca et al. showed that every 30 minutes https://doi.org/10.22502/jlmc.v6i1.182 j. lumbini. med. coll. vol 6, no 2, july-dec 2018 jlmc.edu.np kafle rc. et al. factors associated with pre-hospital delay before reperfusion therapy prolongation in treatment delay was associated with a relative risk for 1-year mortality of 1.075. [6] timely restoration of myocardial blood flow in stemi optimizes myocardial salvage and reduces morbidity and mortality.[7,8] several factors contribute to pre-hospital delay such as age, gender, educational status, and clinical and psychological factors.[9] the total prehospital delay period consists of two components: time taken by patients to recognize that their symptoms are serious and to contact medical help (decision time) and the time taken from requesting help to hospital admission (home-to-hospital delay). despite quality improvement efforts to decrease the system delay in starting reperfusion treatment, some percentages of patients receive therapy outside the recommended time interval even in developed countries.[10] while the extent and the determinants of this delay have been well researched in the developed countries, it remains yet to be systematically identified in various developing countries like nepal, and nepalese studies are few in this regard. this study was carried out to determine pre-hospital delay and associated factors in patients with acute stemi. methods: a hospital based prospective observational study was carried out in stemi patients from august 2013 to december 2017. the study was conducted in cardiology unit, department of internal medicine, manipal college of medical sciences, phulbari-11, pokhara. the diagnosis of stemi was done based on 2013 acc/aha guideline and thrombolytic agents were given according to patient party preference after they were given the option of both streptokinase (stk) and tenecteplase (tnk). thromboytic agents were given in patients presented within 12 of chest pain or had clinical or electrocardiographic evidence of ongoing ischemia when given beyond 12 hrs. hypertension was defined according to jnc-7 criteria , diabetes mellitus based on 2013 ada guideline and dyslipidemia based on 2013 acc/aha guideline. in all patients, time of delay was established since the onset of symptoms associated with myocardial infarction and the arrival to the emergency department whether they received medical care elsewhere or not. the cases of stemi who were eligible for thrombolysis were included in this study. stemi cases not eligible for thrombolysis, who had undergone primary angioplasty or unable to tell exact timing of chest pain and who presented without chest pain but having angina equivalent symptoms were excluded from the study. in all patients, clinical evolution follow-up was made until discharge. the data was collected as per the attached proforma. semi structured questionnaire was used to interview the patient. collected data were entered into a master chart prepared in microsoft excel 2007 which was checked, verified and converted into spss 18 version for statistical analysis. descriptive statistics like mean, percentage, frequency, standard deviation was used to describe characteristics of collected data. chi-square was applied to find association between prehospital delay with socio-demographic characteristics and cardiac risk factors. p value less than 0.05 was considered statistically significant. the study was approved by the ethical review committee (erc) of manipal college of medical sciences, nepal. the participants were informed about the purpose of the project, their right to decline participation and to withdraw at any stage of the study. verbal consent was obtained from the participants. the confidentiality was maintained by removing personal identifiers and information was only used for purpose of the study. results: altogether 450 stemi-diagnosed patients were interviewed from august 2013 to december 2017 giving a response rate of 100%. mean age of the patients was 60 yrs (sd=13.02). there were 319 (70.89%) male and 131 (29.11) female patients. mean duration of prehospital delay was 12.66 hrs (sd=14.19). in nearly one fourth of the cases, delay was more than 12 hrs as shown in table 1. several risk factors of mi were present in the patients. their frequency and percentages are shown in table 2. more than 2/3rd were smoker and majority (52%) had hypertension. more than half (54.7 %, n=246) of the patients were treated with tenecteplase as a thrombolytic agent whereas 45.3% (n=204) were treated with streptokinase. mean door to needle time was 54 minute (sd=24). j. lumbini. med. coll. vol 6, no 2, july-dec 2018 kafle rc. et al. factors associated with pre-hospital delay before reperfusion therapy jlmc.edu.np age-group with bonferroni correction revealed that the relationship was significant with the age group more than 65 yrs. this suggests that the people above 65 yrs of age were more likely to be brought to hospital earlier (within 12 hrs) as compared to other younger age groups. table 4 shows the major factors for pre-hospital delay. the most common factor was misinterpretation of symptoms as acid peptic disease (apd) followed by transportation problems. table 1: prehospital delay in the study population (n=450) duration n % < 1 hr 3 0.67 1 to 6 hrs 159 35.33 7 to 12 hrs 180 40 >12 hrs 108 24 table 2: exposure of mi patients to risk factors (n = 450) characteristics n % smoking yes 312 69.3 no 138 30.7 hypertension yes 234 52 no 216 48 diabetes mellitus yes 72 16 no 378 84 dyslipidemia yes 72 16 no 378 84 alcohol yes 102 22.7 no 348 77.3 association between pre-hospital delay and various factors is shown in table 3. it shows that there was a significant association of prehospital delay with age-group and sex of the patient but not with cardiac risk factors like diabetes, hypertension, hypercholesterolemia, smoking, and alcohol intake. further analysis of relationship between delay and table 4: factors causing pre-hospital delay (n=450) factors n % misinterpreted as apd 266 59.1 transportation delay 140 31.1 inter-hospital delay 31 6.9 reperfusion decision delay 13 2.9 discussion: more than fifty percentage of the patients age ranges from 45-65 yrs with mean of 60 yrs (sd=13.02) which is similar to the study by perkins-porras l. et al,[11] beig jr. et al,[12] and ribeiro s. et al,[13] where mean age was 59 (sd=11.2), 57.6 (sd=10.5), and 62 yrs (sd=13.64) respectively. whereas, a study conducted in china reported the mean age of the patient was found to be 65.68 yrs (sd=12.68).[14] characteristics prehospital delay stats< 12.66 hrs n (%) ≥ 12.66 hrs n (%) age (yrs) < 45 39(81.3) 9(18.8) x2 = 6.3, df = 2 p = 0.04345 65 180(78.9) 48(21.1) > 65 120(69)* 54(31)* sex female 78(60.5) 51(39.5) x2 = 21.51, df = 1 p < 0.001male 261(81.3) 60(18.7) smoking habits yes 240(76.9) 72(23.1) x2 = 1.38, df = 1 p = 0.24no 99(71.7) 39(28.3) hypertension yes 174(74.4) 60(25.6) x2 = 0.25, df = 1 p = 0.62no 165(76.4) 51(23.6) diabetes yes 54(75.0) 18(25.0) x2 = 0.005, df = 1 p = 0.94no 285(75.4) 93(24.6) dyslipidemia yes 57(79.2) 15(20.8) x2 = 0.68, df = 1 p = 0.41no 282(74.6) 96(25.4) * statistically significant cell table 3: association between prehospital delay and different risk factors (n = 450) j. lumbini. med. coll. vol 6, no 2, july-dec 2018 jlmc.edu.np kafle rc. et al. factors associated with pre-hospital delay before reperfusion therapy nearly 1/4th (24%) of the patients duration of pain (prehospital delay) was >12 hrs and mean duration was 12.66 hrs (sd=14.19) which is similar to the study from mexico.[15] while a study conducted in china confirmed about the mean delay of 23.58 hrs (sd=85.09) which is relatively higher than the present study.[14] the present study revealed the median duration of prehospital delay is eight hrs which is comparatively higher than other studies where lesser median delay times were reported in korea (2.5 hrs),[16] beijing (2.3 hrs),[17] and chennai (three hrs).[18] the present study highlights the door to needle time was 54 min (sd=24) which is comparable to the study from south india and beijing which depicted the median door-to-needle time were 75 and 82 min respectively.[19,20] however, few studies showed significantly lower door to needle time i.e 40 min and 34 min respectively.[12,21] the current study enlightened the most commonly used thrombolytic agent was tenecteplase (tnk) 54.7%. nevertheless, the study conducted in mexico confirmed streptokinase as a most commonly used lytic agents in 67% of cases.[15] age has been shown to be a determinant of increased prehospital delay in many studies;[22,23] the present study also showed significant association between age-group and prehospital delay. there was significant association between sex of the patient and prehospital delay which is analogous with the result acquired in several studies by ribeiro s. et al, taghaddosi m. et al, angerud kh. et al with a higher proportion of female with longer pre-hospital delay.[13,22,23] the reason being females could not directly activate the transportation system and they had to first inform their husband or family in most cases and then only process of transportation started. while divergent result was obtained in a study by banos-gonzalez et al,[15] farshidi h. et al,[24] and george l. et al,[25] where no significant association was found between sex and prehospital delay. there were no significant associations with other cardiac risk factors such as diabetes, hypertension, hypercholesterolemia, smoking habits similar to the study from london.[11] in contrast to this, some studies have reported the presence of diabetes was associated with increased delay.[12, 25] the major factors for pre-hospital delay were misinterpretation of symptoms (59%) and transportation delay (31%) due to difficult geographical location and non-availability of ambulance or other vehicles alike to the results from mumbai with misinterpretation of symptoms (45%) and transportation problems (27%).[21] a study conducted in london figured out the decision time constituted 60% of the total pre-hospital delay period, home-to-hospital delay accounted for 40%.[11] limitations: this study has some limitation. although every effort was made to interview patients soon after admission, data may have been affected by recall bias. we could not assess other component of pre-hospital delay like cardiovascular history, patient's attribution of symptoms, clinical and proximal factors, and time of admission, symptom onset and call for assistance. only the cases of acute st segment elevation myocardial infarction that have undergone thrombolysis were recruited. only survivors could be interviewed thus factors that influenced delay in individuals who did not survive acs may not have been captured. conclusion: majority of cases in our study presented out of window period of six hours. misinterpretation of symptoms remain the most common cause of delayed presentation. health education for public awareness can reduce the delay. extension of thrombolytic therapy to district hospital and primary health centre level after basic training for medical officer with checklist and collaboration in form of telemedicine with referral cardiac 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2016;152(4):495-502. pmid: 27595253 16. park yh, kang gh, song bg, chun wj, lee jh, hwang sy, oh jh, park k, kim yd. factors related to prehospital time delay in acute st-segment elevation myocardial infarction. journal of korean medical science. 2012 aug 1;27(8):8649. doi: 10.3346/jkms.2012.27.8.864 pmid: 22876051 17. song l, yan hb, yang jg, sun yh, hu dy. impact of patients' symptom interpretation on care-seeking behaviors of patients with acute myocardial infarction. chinese medical journal. 2010 jul;123(14):1840-5. pmid: 20819565 18. rajagopalan re, chandrasekaran s, pai m, rajaram r, mahendran s. pre-hospital delay in acute myocardial infarction in an urban indian hospital: a prospective study. the national medical journal of india. 2001;14(1):8-12. pmid: 11242708 19. george l, ramamoorthy l, satheesh s, saya rp, subrahmanyam dk. prehospital delay and time to reperfusion therapy in st elevation myocardial infarction. journal of emergencies, trauma, and shock. 2017 apr;10(2):64. doi: 10.4103/0974-2700.201580 pmid: 28367010 20. song l, yan hb, yang jg, sun yh, liu ss, li c, hu dy. factors associated with delay of reperfusion-decision for patients with st-segment elevation myocardial infarction. zhonghua xin xue guan bing za zhi. 2010 apr;38(4):301-5. pmid: 20654072 21. khan a, phadke m, lokhandwala yy, nathani pj. a study of prehospital delay patterns in acute myocardial infarction in an urban tertiary care institute in mumbai. journal of the association of physicians of india. 2017 may;65:24-7. pmid: 28598044. publisher full text 22. taghaddosi m, dianati m, bidgoli jf, bahonaran j. delay and its related factors in seeking treatment in patients with acute myocardial infarction. arya atherosclerosis. 2010;6(1):35-41. pmid: 22577411. publisher full text 23. angerud kh, brulin c, naslund u, eliasson m. longer pre-hospital delay in first myocardial infarction among patients with diabetes: an analysis of 4266 patients in the northern sweden monica study. bmc cardiovascular disorders. 2013 dec;13(1):6. doi: 10.1186%2f1471-226113-6 pmid: 23356233. publisher full text 24. farshidi h, rahimi s, abdi a, salehi s, madani a. factors associated with pre-hospital delay in patients with acute myocardial infarction. iranian red crescent medical journal. 2013 apr;15(4):312-6. doi: 10.5812%2fircmj.2367 pmid: 24083004. publisher full text 25. mathews r, peterson ed, li s, roe mt, glickman sw, wiviott sd, saucedo jf, antman em, jacobs ak, wang ty. use of emergency medical service transport among patients with st-segment–elevation myocardial infarction: findings from the national cardiovascular data registry acute coronary treatment intervention outcomes network registry–get with the guidelines. circulation. 2011 jul 12;124(2):154-63. doi: 10.1161/ circulationaha.110.002345 pmid: 21690494. references: https://doi.org/10.1186/s12992-015-0119-7 https://doi.org/10.1016/s0140-6736(08)61237-4 https://doi.org/10.1016/s0140-6736(08)61237-4 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lumbini medical college sahadev prasad dhungana,a,b ms poudel,a,b bishal kc,a,b shamsuddina,b —–————————————————————————————————————————————— abstract: introduction: medicine is one of the noblest of all professions and is one of the rapidly expanding fields with increasing number of private medical colleges in the past few years. several international studies over the years have explored perceptions and preferences of students in choosing a career in medicine. this study was done with the objective to assess students’ views regarding selection of medicine as a career. methods: a survey study was conducted at lumbini medical college teaching hospital (lmcth) where 300 students of both sexes were asked to fill a structured questionnaire. results: all medical students mentioned that they selected the medical profession because of personal interest. of them, 285 (95%) students believed this profession offers services to humanity. however, 240 (80%) students felt that their family had an influence in their career selection. among discouraging factors, 234 (78%) students mentioned that medical training is difficult and prolonged, 210 (70%) students said that the course is too expensive, 225 (75%) students felt that there is too much competition while 186 (62%) students expressed that doctors have excessive working hours and lack social life. major factors in choosing lmcth as study destination were compulsion because of failure to enroll at other colleges 180(60%), easy access to admission 120 (40%), cheaper than other medical colleges 165 (55%) and location near to hometown 24 (8%). some of the discouraging factors were limited facilities 210 (70%), insufficient faculty members 270 (90%), newly established college and uncertain future 90 (30%). conclusion: study concluded that reasons for joining medical profession are primarily based on personal interest, respect and honor, family influence and service to humanity; however, long working hours, prolonged training, expensive study, discourages many students. keywords: medical profession • encouraging • discouraging factors ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer b department of medicine lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. sahadev prashad dhungana e-mail: spdhungana@rediffmail.com how to cite this article: dhungana sp, poudel ms, kc b, shamsuddin. why a medical career and what are the pros and cons of medical profession: beliefs of students at lumbini medical college. journal of lumbini medical college. 2013;1(1):10-2. doi:10.22502/jlmc.v1i1.4. ___________________________________________________________________________________ j. lumbini. med. coll. vol 1, no 1, jan-june 2013 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v1i1.4 introduction: medicine is the applied science or practice of the diagnosis, treatment and prevention of disease.1 it is one of the noblest of all professions, takes its name from the latin word 'ars medicina', which means the art of healing.2 in nepal, it is widely sought after and is one of the rapidly expanding fields with increasing number of private medical colleges in the last few years. several international studies over the years have explored perceptions and preferences of students in choosing a career in medicine. also, sometimes medical students and graduates face the dilemma of remaining in or leaving the profession.3 the most important determinants of career choice in previous studies appeared to be personal interest, opportunity, flexible working hours and part-time practice. in the recent past, it has been observed that students mostly from a middle class background and having an outstanding academic record at high schools are able to get admission in medical colleges. the professional beliefs of burgeoning medical students have been studied in a number of other countries.4-6 in most of the studies of developed countries, the majority of respondents reported that their interest in interaction with people, a wide range of job opportunities, fact 10 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np dhungana sp. et al. why a medical career and what are the pros and cons of medical profession that medicine is a highly-appreciated profession and their desire to acquire more knowledge greatly influenced their decision to enter medicine.7 moreover, today’s students are reported to have different work priorities and personal motivations, both of which impact learning.8,9 how well the findings from international studies generalize to students at nepal medical schools is unclear due to likely differences in culture, institutional practices, health systems and medical practice. our study evaluates the perceptions and preferences of nepalese students regarding career selection. the aim of our study was to investigate the merits and demerits of medical profession as visualized by the medical students in their career selection. the reasons that influence students to choose medicine and their association with a satisfying career will be established. methods: a survey study based on convenience sampling was done at lumbini medical college teaching hospital, palpa nepal, where 300 students of both sexes from pre-clinical (first and second year) and clinical science (third and fourth year) were included; 150 from pre-clinical and 150 from clinical side. they were asked to fill a structured questionnaire and the results were analyzed using microsoft excel. all potential responders were clearly advised that participation in this survey was voluntary and anonymous. results: out of the 350 questionnaires distributed, 300 were returned completed and 20 were incompletely filled up. characteristics of students are given in table 1. average age of respondents was 20.2 years and majorities were males 186(62%). 252(84%) of students were from urban areas of different parts of nepal. 294(98%) of students secured at least first division at school leaving certificate and intermediate level. majority 240(80%) of the students’ mothers were working as housewives (table 1) and majority of the fathers were engaged in business of various kinds. participants were asked to indicate their responses regarding their selection of medicine as a career (fig 1). of the 300 students, 100% students considered that they had a personal interest in studying medicine. 240 (80%) students were of the opinion that their families influenced them to become doctors, whereas the factor of "respect and honor" inspired 258 (86%) students in choosing their profession. 66 (22%) students had doctors in their families. 66 (22%) students believed that there was a great financial reward for doctors. interestingly, about one quarter 69 (23%) students believed that they were studying medicine as a means to go abroad. a greater proportion of students (92%) were satisfied with their medical profession and 261 (87%) students expressed their willingness to reselect medicine if they were given a second chance. among discouraging factors, 270 (90%) of students said that study is too expensive and 246 (82%) of table 1: characteristics of students included in study (n=300) no. of pre-clinical students 150 no. of clinical students 150 age (years), median (range) 18-23 male 186 (62%) hometown urban-252(84%), rural 84 (28%) schooling of students boarding school-288(96%) community school-12(4%) college private288 (96%) government-12 (4%) parents profession mother housewife-240(80%), others60 (20%) father business-165(55%) government post-66 (22%) health professional 45(15%) farmer-15 (5%) others-9 (3%) students felt that it is difficult and prolonged training whereas 240(80%) students believed that there is too much competition in medicine. excessive working hours of doctors discouraged 120 (40%) students whereas 60 (20%) students believed that doctors have no social life. surprisingly, 36 (12%) of the students thought that medicine offers less financial rewards.15 (5%) of the students had the impression that doctors run after money and parents are losing faith in doctors. students were asked about future plan after completion of study and the response were that they will work in urban area 180 (60%), work in rural area 168 (56%), join government service 60 (20%), respect medical ethics and run after money 282 (94%), have academic interest and join teaching institution 33 (11%), go abroad 15 (5%), earn as much as money by any possible means 9 (3%) and establish their own hospital 9 (3%). major factors in choosing lmc as study destination were compulsion because of failure to enroll at other colleges for 180 (60%), easy access to admission for 120 (40%), cheaper than other medical colleges for 165 (55%) and located near hometown for 11 dhungana sp et al results were analyzed using microso� excel. all poten� al responders were clearly advised that par� cipa� on in this survey was voluntary and anonymous. results out of the 350 ques� onnaires distributed, 300 were returned completed and 20 were incompletely fi lled up. characteris� cs of students are given in table 1. table 1: characteris� cs of students included in study at lumbini medical college and teaching hospital (n=300) no. of pre-clinical students 150 no. of clinical students 150 age (years), median (range) 18-23 male 186 (62%) home town urban-252(84%), rural 84 (28%) schooling of students boarding school-288(96% community school-12(4%) college private288(96%), government-12 (4%) parents’ profession mother father housewife-240(80%), others60 (20%) business-165(55%) government post-66 (22%) health professional-45 (15%) farmer-15 (5%) others-9 (3%) average age of respondents was 20.2 years and majori� es were males 186(62%). 252(84%) of students were from urban areas of different parts of nepal. 288(96%) of students had schooling and college study from boarding school and private ins� tu� on respec� vely. 294(98%) of students secured at least fi rst division at school leaving cer� fi cate and intermediate level. majority of students’ mother are working as housewife 240(80%) and fathers are engaged in business of various kinds 162(54%), government job 66(22%) and health profession 45(15%). participants were asked to indicate their responses regarding their selec� on of medicine as a career (diagram 1). of the 300 students, 100% students considered that they had a personal interest in studying medicine. 240(80%) students were of the opinion that their families infl uenced them to become doctor, whereas the factor of "respect and honor" inspired 258(86%) students in choosing their profession, 66(22%) students had doctors in their families. 66(22%) students believed that there was a great fi nancial reward for doctors. interes� ngly about one quarter, 69(23%) students believed that they were studying medicine as a means to go abroad. a greater propor� on of students (92%) were sa� sfi ed with their medical profession and 261(87%) students expressed their willingness to reselect medicine if they were given a second chance. among discouraging factors, 270(90%) of students said that study is too expensive. 246(82%) of students felt that it is diffi cult and prolonged training. 240(80%) students believed that there is too much compe� � on in medicine. excessive working hours of doctors discouraged 120 (40%) students whereas 60(20%) students believed that doctors have no social life. surprisingly, 36(12%) of the students thought that medicine off ers less fi nancial rewards.15(5%) of the students had the impression that doctors run a� er money and pa� ents are losing faith on doctors. students were asked about their plan in future a� er comple� on of study. they are of the opinion that they will work in urban area 180(60%), work in rural area 168(56%), join government service 60(20%), respect medical ethics and run a� er money 282(94%), have academic interest and join teaching ins� tu� on 33(11%), go abroad 15(5%), earn as much as money by any possible means 9(3%), establish own hospital 9(3%). major factors in choosing lmc as study des� na� on were compulsion because of failure to enroll at other colleges 180(60%), easy access to admission120 (40%), cheaper than other medical colleges 165(55%), located near to hometown 24(8%). some of the discouraging factors were limited facili� es 210(70%), insuffi cient faculty members 270(90%), newly established college and uncertain future 90(30%). when asked about the areas which can be improved at lumbini medical college, majority students responded that there are insuffi cient faculty members 270(90%), limited facili� es like place and quality of food, playing ground, library facili� es, internet service, and improper administra� ve management. 225(75%) students responded that they will recommend their rela� ves to choose medicine as a career. 252(84%) students feel unsecured about joining post graduate training a� er comple� on of mbbs. 240(80%) students feel diagram 1: factors for choosing medicine as a profession (n-300) fig 1: factors for choosing medicine as a profession (n-300) 11 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 dhungana sp. et al. why a medical career and what are the pros and cons of medical profession jlmc.edu.np 24 (8%) students. some of the discouraging factors were limited facilities 210 (70%), insufficient faculty members in 270 (90%), newly established college and uncertain future for 90 (30%) students. when asked about the areas which can be improved at lumbini medical college, majority students responded that there are insufficient faculty members 270 (90%), limited facilities like place and quality of food, playing ground, library facilities, internet service, and improper administrative management. 225 (75%) students responded that they will recommend their relatives to choose medicine as a career. 252 (84%) students feel insecure about joining post graduate training after completion of mbbs. 240 (80%) students feel that mbbs curriculum is tougher than expected. 36 (12%) of students feel pressured from their parents to earn amount of money spent during their study. 100% students opined that hard work, guidance from teachers and punctuality are required to be a good mbbs graduate. students would choose kathmandu medical college 105 (35%), kathmandu university school of medical sciences 84 (28%), manipal medical college 36 (12%) if they had opportunity to do so. discussion: medical profession is said to be a noble one and has its own merits and demerits. doctor's professional life is filled with care for people, interaction with people from different backgrounds, challenges, knowledge and wisdom. according to a report of royal college of physicians, the core values of the medical profession are integrity, compassion, altruism and excellence that are glued to a set of values including team work and continuous improvement.10 the top ranking reason why almost all students chose medicine as a career was based on personal interest, service to humanity and respect and honor. studies done in the west reported that 70% of the males and females chose this profession because they had high interest in it.11 in our study, 300 (100%) students considered that they had a personal interest in studying medicine. a high proportion of students 225 (75%) were encouraged by their families which showed that family support/ pressure was a major factor in influencing young minds which has also been reported by ehsan et al, in his study.12 surprisingly, for only 66 (22%) students, monetary reward was one of the considerations. hence, from our study, we could clearly make out that students still believed in the core values of this profession and money was not their only priority. 246 (82%) medical students put up the argument that medicine was too tough with stressful life, excessive work load and long working hours which left very less time for family and friends. according to our study, 39 (13%) of students mentioned that they would not go into medicine again as compared to an american study in which 66 (22%) of the respondents expressed their reluctance.13 66 (22%) students were of the opinion that medicine offered less financial reward and security. medicine is regarded as a noble career as during their education, medical students work as health coaches, advising and helping people about basic health issues, solving their everyday problem, thereby enjoying respect and honor.14 efforts can be made to reduce long working hours and improve salaries. the salaries of doctors of our country can be increased. doctors are the most highly paid professionals in america with residents of radiology and anesthesia earning $350,000 and $275,000 annually, respectively.15 this fascinates our doctors and unfortunately our country loses brilliant brains to america, europe and australia. well structured medical curriculum and organized training programs along with proper numeration and incentive to doctors may encourage doing noble deeds and reducing malpractice. conclusion: this study suggests that the reasons for joining medical profession are primarily based on personal interest, respectful living, family influence and service to humanity. however, though a respectable profession but training is expensive, difficult with long working hours and less financial reward. a high proportion of medical students was dissatisfied by their profession and did not want to reenter if they were given a second chance of career selection; however, as the students enter the clinical years, their level of interest increases. in order to make medicine attractive, sustainable efforts are required which provide promising opportunities to medical students and doctors. references: 1. oxford english dictionary. definition of ‘’medicine’’. 2. partridge e. the etymology of medicine. med world. 1956;84:144-7. 3. kaze links mr, nazar t, molnar p. remaining in or leaving the profession: the view of medical students. orv he_ l. 2008;149:843-8. 4. dall’alba g. medical practice as characterized by beginning medical students. advances health sci edu. 1898;3:101-8. 5. draper c, louw g. what is medicine and what is a doctor? medical students’ perceptions and expectations of their academic and professional career. med teach. 2007;29:100-7. 6. garcia-huidobro d, nunez f, vargas p et al. undergraduate medical students’ expectative of their desired profile as medical doctors. revista medical de chile. 2006;134:947-54. 7. rosenfeld jc, sefcik s. utilizing community leaders to teach professionalism. curr surg. 2003;60:222-4. 8. horton r. medicine: the prosperity of virtue. lancet. 2005;366:1985-7. 9. redman ds, straton bj, young c, paul. determinants of career choices among women and men medical students and interns. med edu. 2009;28:361-71. 10. syed eu, siddiqi mn, dogar i et al. attitudes of pakistani medical students towards psychiatry as a prospective career: a survey. acad psychiatry. 2008;32:160-4. 11. bickel j, brown aj. generation x: implications for faculty recruitment and development in academic health centers. acad med. 2005;80:205-10. 12. howell lp, servi g, bonham a. multigenerational challenges in academic medicine: ucdavis’s responses. acad med. 2005;80:527-32. 13. teitelbaum hs, ehrlich n, travis l. factor’s affecting specialty choice among osteopathic medical students. acad med. 2009;84:718-23. 14. wagner pj, jester dm, mosley gc. medical students as health coaches: acad med. 2002;77:1164-5. 15. ebell mh. future salary and us residency fill rate revisited. jama. 2008;300:1131-2. 12 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 6, no 2, july-dec 2018 ___________________________________________________________________________________ submitted: 16 october, 2018 accepted: 17 december, 2018 published: 27 december, 2018 a lecturer, department of psychiatry b associate professor and head, department of psychiatry c lumbini medical college and teaching hospital, pravas, palpa corresponding author: bhaskkar sharma e-mail: vasker63@yahoo.com orcid: https://orcid.org/0000-0001-8031-6926_______________________________________________________ —–————————————————————————————————————————————— abstract: introduction: the co-occurence of substance abuse and mental illness is well known. alcoholics are reported to be three times more likely to suffer from another psychiatric disorder. this study aims to observe the prevalence of psychiatric comorbidity in alcohol dependent patients in our setup. methods: this was a hospital based crosssectional observational study conducted over a period of three months. consecutive patients presenting to the outpatient section of psychiatric department who met the dsm-iv-tr criteria for alcohol dependence were included in the study. they were interviewed using structured clinical interview for dsm-iv-tr (scid i&ii) to assess for comorbidity. data was analyzed using statistical package for social sciences (spss tm) software. mann whitney u test and chi square or fisher's exact tests were used for statistical analysis. results: out of 31 patients enrolled, 14 (45.16%) had psychiatric comorbid conditions all of which were axis i disorders. anxiety disorder (35.71%) was the most frequent associated disorder followed by depressive disorder (28.57%). the alcohol dependent patients with comorbidity was significantly younger (mean age=35.71+13.60 years) in comparison to those without comorbidity (mean age=42.59+11.15 years). other socio-demographic parameters were comparable between the two groups. patients with history of past psychiatric illness and medication were less likely to have comorbidity, which was statistically significant. conclusion: psychiatric comorbidity is common in alcohol dependent people. anxiety disorder and depression were more prevalent entities. those with past illness and medications were less likely to have comorbidities. keywords: alcohol dependent, comorbidity, psychiatric original research articlehttps://doi.org/10.22502/jlmc.v6i2.266 bhaskkar sharmaa,c anup devkotaa,c suresh chandra pantb,c psychiatric comorbidities in patients with alcohol dependence syndrome in a tertiary care center: a cross-sectional study introduction: the co-occurrence of substance abuse and mental illness has been known for long. alcoholics are reported to be three times more likely to suffer from another psychiatric disorder.[1] studies have shown that out of two billion alcohol users worldwide 76.3 million (7.63%) have at least one additional disorder caused by their habit. [2,3,4] alcohol use disorders can also mimic or potentiate most other psychopathological symptoms. [5] there has been an increase in the incidence of dual diagnosis in recent years. people with dual diagnosis are more likely to experience disabilities of varying dimensions and severity in comparison to those with a single diagnosis. chronicity and treatment resistance are reported to be the hallmarks of dual diagnoses.[6] studies have shown high association of psychiatric comorbidity with alcohol dependence cases in different settings.[7,8] the superimposition of comorbid psychiatric disorders in those with alcohol dependence adds to the burden on the health care system. in addition, comorbid psychiatric disorders in alcohol dependence are associated with prolonged hospital stay, poor treatment outcomes, higher relapse rates, suicide, homelessness, and how to cite this article: sharma b. devkota a. pant sc. psychiatric comorbidities in patients with alcohol dependence syndrome in a tertiary care center: a cross-sectional study. journal of lumbini medical college. 2018;6(2):5 pages. doi: 10.22502/jlmc.v6i2.266. epub: 2018 dec 27. https://orcid.org/0000-0001-8031-6926 sharma b. et al. psychiatric comorbidities in patients with alcohol dependence syndrome jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 negative impact on family.[9] alcohol is one of the commonest drugs of abuse in nepal. yet, published literature on alcohol dependence and comorbidities is scarce in nepal. moreover, findings of the western studies may not be applicable in our culture. this study was therefore carried out to observe the prevalence of psychiatric comorbidity in alcohol dependent patients in our setup. methods: this was a hospital based cross-sectional observational study carried out in the department of psychiatry, lumbini medical college and teaching hospital (lmcth). it was conducted over a period of three months from august 2018 to october 2018. consecutive patients presenting to the out-patient section of department of psychiatry for the first time and those referred from other departments who met the dsm-iv-tr criteria for alcohol dependence were included in the study. ethical approval was obtained from the institutional review committee of lmcth (irclmc) prior to commencement of the study (irclmc 02-e/018). informed written consent was taken from the participants and complete confidentiality was maintained. the participants were interviewed by consultants using structured clinical interview for dsm-iv-tr (scid i&ii) to assess for comorbidity. a detailed psychiatric work up was done. sociodemographic information was recorded in a semistructured preformed proforma. clinical information noted were history of past psychiatric illness, comorbidity and history of any medications. detailed history of alcohol habits was taken from the patient and reliability ensured with the attending family member. data were entered to microsoft excel spread sheet and imported to statistical package for social sciences (spsstm) software version 20 for statistical analysis. quantitative data were presented in mean+sd and qualitative data in frequency and percentages. we used mann whitney u test for the analysis of continuous variables and chi-square test or fisher's exact test for categorical variables. p value <0.05 was considered statistically significant. results: a total of 31 patients meeting the criteria for alcohol dependence attended the psychiatric out-patient during the study period. out of them, nine patients were internal referrals from other departments. the mean age+sd of the study population was 39.48+12.59 years. 80.6% of them were males and 87.1% were married. 19.35% patients were unemployed. there were 41.93% of farmers and 16.12% migrant laborers working abroad. among 31 patients, 14 (45.16%) patients were found to have comorbid psychiatric illness. the axis-i comorbidity was found in 45.16% patients. axis-ii comorbidity (personality disorders) was not seen in any (table 1). anxiety disorder (35.71%) was the most frequent axis i disorder followed by depressive diagnosis frequency (%) axis i only 14 (45.16) axis ii only 0 (0) both 0 (0) nil 17 (54.83) table 1. comorbidity profile in alcohol dependent patients (n=31) disorder (28.57%) associating as a comorbidity in our study population. the cohort of alcohol dependent patients with comorbidity was significantly younger (mean age=35.71+13.60 years) in comparison to that without comorbidity (mean age=42.59+11.15 years). however this difference was not statistically significant (p=0.064). similarly, other sociodemographic factors as marital status, employment, education and socioeconomic status did not have any effect on the presence of comorbidity. patients with past psychiatric illness showed tendency to have no comorbidity while those who did not have any psychiatric illness were more likely to have comorbid conditions. similarly those who axis-i diagnosis frequency ( %) anxiety disorder 5 (35.71) depressive disorder 4 (28.57) psychotic disorder 2 (14.28) seizure disorder 2 (14.28) conversion disorder 1 (7.1) table 2. common axis i diagnosis (n=14) sharma b. et al. psychiatric comorbidities in patients with alcohol dependence syndrome jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 had history of past medication were more likely to have no comorbidity (table 4). discussion: (p=0.064). alcohol dependence syndrome (ads) and psychiatric comorbidity were more prevalent in males. this is likely because of higher prevalence variables with comorbidity (n=14) without comorbidity (n=17) statistics age in years, mean + sd 35.71+13.60 42.59+11.15 mann whitney u=165.5, n=31, p=0.064 gender male 12 (38.70%) 13 (41.93%) p=0.664* female 2 (6.45%) 4 (12.9%) marital status single 3 (9.7%) 1 (3.22%) p=0.304* married 11(35.48%) 16 (51.61%) employment employed 13 (41.93%) 12 (38.71) p=0.185* unemployed 1 (3.22%) 5 (16.12%) education below slc 9 (29.03%) 10 (32.26%) x2=0.097, df=1, n=31, p=0.756slc and above 5 (16.12%) 7 (22.58%) socioeconomic status low class 5 (16.12%) 8 (25.80%) x2=0.406, df=1, n=31, p=0.524middle class 9 (29.03%) 9 (29.03%) table 3. socio-demographic comparison between alcohol dependent patients with and without comorbidity (n=31) variables with co-morbidity (n=14) without co-morbidity (n=17) statistics past psychiatric illness yes 2 (6.45%) 11 (35.48%) x2=8.016, df=1, n=31, p=0.005no 12 (38.70%) 6 (19.35%) past medication yes 2 (6.45%) 13 (41.93%) x2=11.888, df=1, n=31, p=0.001no 12 (38.71%) 4 (12.9%) table 4. clinical comparison between alcohol dependent patients with and without comorbidity (n=31) lmcth is a tertiary care center catering to the mental health need of a large catchment area encompassing a number of surrounding districts. the present study aimed to observe the prevalence of psychiatric comorbidity in alcohol dependent cases attending the out-patient section of psychiatric department. the mean age of patients in our study was comparable to another study.[10] similar to the study by vohra ak et al.[11] the comorbid group in our study was much younger (mean age= 35.71+13.60 years) in comparison to the patients without comorbidity (42.59+11.15 years). however, this difference in mean was not statistically significant of ads, its better awareness and superior status of males.[10] 87.1% of the enrolled patients were married. as in another study, this might be because married people have better family support and care hence are brought for treatment.[10] in our study the comorbidity rate was 45.16 % of which all were axis i disorders. this prevalence is similar to that of the studies by chaudhary s. et al.[9] (46.59%) and singh a. et al.[12] a french hospital based study by nubukpo p. et al.[13] also reported a similar prevalence of 42.12%. however, this figure is lower than that of the studies by vohra ak et al.[11] and kumar v. et al.[14] in which the prevalence were 76.6% and 64.8% respectively. * fisher's exact test sharma b. et al. psychiatric comorbidities in patients with alcohol dependence syndrome jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 disparity in the sample size and use of diagnostic criteria could explain this variation in the findings. the absence of axis ii disorders in our sample could also be a contributing factor for this lower figure. moreover, patients in our part of the region tend not to open up regarding their psychiatric or mental issues which leads to a significant chunk of such illness going undetected. the most frequent axis i disorder in this study was anxiety disorder (35.71%) followed by depressive disorder (28.57%). similar were the findings in the study done by shakya dr et al.[10] however, in other studies depressive disorder was more prevalent comorbid condition.[11,14] this contrast could be due to geographical or ethnic variation of the study participants. the findings of this study also implicate that focusing on simultaneous treatment of these comorbid anxiety or mood disorders will result in a better outcome in patients with alcohol dependence. the co-occurrence of psychotic disorders in our study sample was low (14.28%) which is in congruence with other studies.[12,15] however some other studies have reported much higher prevalence ranging from 11% to 25%.[14,16] this is because patients with established or suspected severe psychotic disorders directly present to higher facilities as this center is not a specialized psychiatric hospital. the present study demonstrates that patients who were diagnosed with some psychiatric illness in the past were less likely to have co-morbidity (6.45% vs. 35.48%), which was statistically significant. likewise, those who had undergone medical treatment for psychiatric or non-psychiatric illness were less suffering from co-morbidity (6.45% vs. 41.93%). this is most likely because these patients tend to be more compliant and motivated, selfconscious regarding their mental health, and more cautious about the presence of psychiatric comorbid conditions. limitations: the sample size of our study was small. only the patients presenting to the out-patient department were included and no controls were taken. further, this being a facility based study, the generalizability of the study is limited. conclusion: psychiatric co-morbidity is common in people with alcohol dependence. this study suggested a significant prevalence of psychiatric comorbidity in alcohol dependent patients. anxiety disorder was the most common comorbidity while no axis ii disorder was observed. patients with comorbidity were younger compared to their counterparts. those with past psychiatric illness and medications were less likely to suffer from comorbidity. conflict of interest: none declared. financial disclosure: no funds were available. sharma b. et al. psychiatric comorbidities in patients with alcohol dependence syndrome jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 references: 1. winokur g. family history studies: viii. secondary 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[publisher full text] 15. kattukulathil s, kallivayalil ra, george r, kazhungil f. psychiatric comorbidity in alcohol dependence: a cross-sectional study in a tertiary care setting. kerala journal of psychiatry. 2015 dec 12;28(2):156-60. [publisher full text] 16. shantna k, chaudhury s, verma an, singh ar. comorbid psychiatric disorders in substance dependence patients: a control study. industrial psychiatry journal. 2009;18(2):84–87. pmid: 21180482 doi: 10.4103/09726748.62265. 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policy 1. journal of lumbini medical college journal (jlmc) is a biannually scien� fi c medical journal published in english by lumbini medical college in palpa, nepal. the journal is printed in two column format. its publica� on is supported by patron fee, commercial adver� sement. 2. subjects covered include all aspects of health and diseases including clinical and experimental studies and medical educa� on (in the form of original full papers, short communications, critical reviews, editorial commentaries, conference summaries and book reviews). 3. manuscripts in english from inves� gators/authors from any ins� tu� ons in any country are considered. the results and ideas contained therein should be original. 4. three sets of manuscript (one original and two copies) accompanied by a covering le� er signed by fi rst author should be submi� ed to the editor, journal of lumbimi medical college (jlmc), lumbini medical college, tansen 11, pravas, palpa, nepal; email: lmcpalpa@gmail.com. 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editor and editorials: the pa� ern should be the same as the of standard journal ar� cle but with men� on of research notes, short communica� on, le� er to the editor and editorials accordingly in the parenthesis (a� er the � tle) uga s, morimoto m, saito t, rai sk. surface ultrastructure of heterophyes heterophyes (trematoda: hetrophyidea) collected from a man (research note) j helminthol soc was 1998; 65: 119-22. c. corporate author in journal: ghana vast study team. vitamin a supplementa� on in northern ghana: eff ects on clinical a� endance, hospital admissions and mortality. lancet 1993; 343: 7-12. note: supplement volume or issue of a journal should be indicated by “suppl” in parenthesis after the publica� on year [for example, brit med j 1990 (suppl); 13: 121-5] d. personal author in book: oslen ow. animal parasited – their life cylces and ecology. 3rd ed. bal� ore-london –tokyo: univ park press 1974; 16: 194. e. editor(s), compiler(s) as authors: firkin f, chesterman n, penington d, bryan r, editors. de gruchy’s clinical haematology in medica prac� ce (5th ed.) oxford: blackwell science 1989. f. corporate author in book: verginia law founda� on. the medical and legal implica� ons of aids. charlo� esville: the founda� on 1987. g. chapter in book: -nimmannitya s. dengue and dengue haemorrhagic fever. in cook g, editor. manson’s tropical diseases (5th ed._ london: wb saunders 1996: 721-9. h. scien� fi c and technical report: who. control of the leishmaniasis 1990, technical report series 793. i. papers accepted for publica� on: hirai k, takagi e, okuno y, nagata k, tamura t, rai sk, shrestha mp. status of polyunsaturated fa� y acids in serum of persons aged 10-72 in nepal. nutr res (in press). 7. tables: tables should be typed in separate page and should be typed in double space. tables should not be typed in double space. tables should not be submi� ed as photographs. tables should be numbered consecu� vely in the order of their fi rst cita� on in the 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be reported in metric units. temperature should in degree celsius. 10. abbrevia� ons: only the standard abbrevia� ons should be used. abbrevia� ons should be avoided in the title and abstract. 11. reprints: reprints will be available on request made in advance at the � me of acceptance of manuscript. for the charge, author (s) should contact the editor. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 6, no 2, july-dec 2018 ___________________________________________________________________________________ submitted: 11 november, 2018 accepted: 17 december, 2018 published: 29 december, 2018 a lecturer, department of radiodiagnosis b associate professor and head, department of radiodiagnosis c associate professor and head, department of orthopaedics d lumbini medical college and teaching hospital, pravas, palpa corresponding author: rupesh sharma e-mail: roopskarma@gmail.com orcid: https://orcid.org/0000-0002-3422-6150_______________________________________________________ —–————————————————————————————————————————————— abstract: introduction: chronic low back pain (lbp) is a common cause of disability worldwide. magnetic resonance imaging (mri) is an excellent non-invasive imaging modality for morphologic evaluation of the lumbar spine in patients with chronic low back pain because of its high contrast resolution and lack of ionizing radiation. this study was done to see the patterns of mri changes in patients with chronic low back pain in a tertiary care center in western nepal. methods: this was a cross-sectional study conducted on patients presenting with chronic low back pain. eleven mri parameters were noted and analyzed. chi square test and fisher’s exact test were employed to see the associations between the various mri findings. results: a total of 108 patients were evaluated during the study period. mri changes were noted in over 95% of the cases. degenerative changes were the most common cause of low back pain, disc bulge being the most common mri finding. a significant association was found between radiculopathy and decreased lumbar lordosis and vertebral endplate changes. conclusion:mri is an invaluable tool in the evaluation of chronic lbp because of its high resolution and lack of ionizing radiation. significant mri findings are noted in most of the cases of chronic lbp, degenerative changes being the most common and ranging from congenital to malignant lesions. keywords: low back pain, mri, radiculopathy, ls spine original research articlehttps://doi.org/10.22502/jlmc.v6i2.273 rupesh sharmaa,d awadhesh tiwarib,d rajeev dwivedic,d pattern of lumbar mri changes in patients with chronic low back pain in a tertiary care center introduction: low back pain (lbp) is defined as the pain below the costal margin and above the inferior gluteal fold, with or without radiculopathy, and is called chronic if persists for three months or more. [1] globally, lbp ranks the highest in terms of disability and sixth in terms of overall burden with point prevalence of 9.4%.[2]in nepal, the overall prevalence of lbp is 57.1% and that of chronic lbp is 16.4%.[1] the differential diagnoses of lbp include mechanical lbp (most common, 97%), nonmechanical lbp (1%) and visceral disease (2%). of the mechanical lbp, about 70% includes sprain and strain and 10% includes degenerative changes.[3] magnetic resonance imaging (mri) is an excellent non-invasive imaging modality for morphologic evaluation of lumbar spine because of its high contrast resolution and lack of ionizing radiation. [4,5] it is a routinely prescribed investigation for chronic lbp worldwide and in nepal likewise. a number of spine changes including vertebral, disc and paravertebral changes have been found to be associated with chronic lbp and are best depicted in mri. however, very few studies on mri findings of chronic lbp have been published based on nepalese population. this study was therefore undertaken to study the patterns of lumbar mri changes in nepalese population attending lumbini medical college and teaching hospital (lmcth), palpa with chronic lbp. how to cite this article: sharma r, tiwari a, dwivedi r. pattern of lumbar mri changes in patients with chronic low back pain in a tertiary care centre journal of lumbini medical college. 2018;6(2):5 pages. doi: 10.22502/ jlmc.v6i2.273. epub: 2018 dec 29. https://orcid.org/0000-0002-3422-6150 sharma r. et al. pattern of lumbar mri changes in patients with chronic low back pain jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 methods: this was a cross-sectional study based on convenience sampling, comprising of patients attending lmcth, palpa with complaint of lbp for at least three months.the sample size was calculated taking into consideration the prevalence of chronic lbp of 16.4% in nepal with a 10% margin of error, which totaled to a minimum of 53 cases. the study, after being approved by the institutional review committee (irc-lmc),was carried out over a period of 12 months from september 2016 to august 2017 comprising a total of 108 cases. only the patients with lbp for at least three months and referred to the department of radiodiagnosis for mri lumbo-sacral (ls) spine were enrolled, after informed consent. patients with general contraindications to mri such as presence of prosthetic heart valves, metallic clips and implants, claustrophobia and those with past history of surgical procedures in the spine were excluded from the study. the mri studies were done in the department of radiodiagnosis, lmcth using a 0.35 tesla siemens magnatomtm mri scanner by a qualified technician. axial, coronal and sagittal images in t1 weighted, t2 weighted and short t1 inversion recovery (stir) sequences were routinely done with gadolinium-enhanced study whenever deemed necessary. the data recorded for analysis included demographics, clinical findings and mri findings. the clinical findings included the duration and presence or absence of radiculopathy. mri findings primarily included a total of 11 variables, viz. ls angle, lumbar lordosis, intervertebral disc (ivd) signal, disc size, disc bulge, disc herniation, annular tear, vertebral endplate changes, vertebral foraminal narrowing, spinal canal narrowing and ligamentum flavum thickness. other lesions such as neoplastic, congenital, traumatic and infective lesions were recorded when present. apart from the altered ls angle and lumbar lordosis, rest of the findings represent the degenerative changes.[6] ls angle >45 degrees was considered as increased.[7] lumbar lordosis was calculated as per the modified cobb’s angle and considering the superior endplates of l1 and s1 vertebrae.[8] loss of ivd signal was considered when the t2 signal intensity of the disc was lost. endplate changes were categorized as per modic changes.[9] the displacement of disc tissue beyond the edges of ring apophysis was defined as the herniation if it was <50% and termed as bulge if >50%. disc herniation was further divided as protrusion, extrusion and sequestration. the herniated disc was labelled as protrusion if the width of the base was larger than the largest diameter of the disc material beyond the normal margin and it was labelled as extrusion otherwise. if the extruded part of the disc lost the continuity with the parent disc, it was then called as sequestration. spinal canal diameter of at least 13 mm was considered normal. the data were entered to excel spreadsheet and analyzed using statistical package for social sciences (spsstm) version 16. the descriptive results were presented in terms of mean, standard deviation, frequency and percentage. chi square test and fisher’s exact test were employed for the analysis of categorical data. p value of less than 0.05 was considered statistically significant. results: altogether 142 patients underwent mri ls spine during the study period, out of which 34 were excluded because the duration of lbp was less than three months. thus a total of 108 patients with chronic lbp were included. the age of the patients ranged from 12 to 82 years with a mean age (±sd) of 44.5 years (±16.3). a total of 56 (51.9%) males and 52 (48.1%) females constituted the study population. radiculopathy was present in 52 (48.1%) patients. 83.3% 6.5% 4.6% 2.8% 0.9% 5.6% 0 10 20 30 40 50 60 70 80 90 degenerative changes neoplastic congenital infection trauma normal findings fig. 1. spectrum of spinal pathologies in mri findings of patients with chronic lbp the most common pathology was degenerative changes (83.3%) followed by neoplastic lesions (6.5%) and congenital conditions (4.6%) (fig 1). some of the patients had more than one spinal sharma r. et al. pattern of lumbar mri changes in patients with chronic low back pain jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 table 1. mri findings of ls spine in the study population (n=108) pathology. the most common mri finding was disc signal change (83.3%) followed by disc bulge (77.8%) and foraminal narrowing (76.9%)(table 1). in this study, disc protrusion was the most common type of disc herniation (table 1). out scoliosis was the most common congenital lesion followed by lumbosacral transitional vertebra and tarlov cyst. we also observed significant association between radiculopathy and loss of lumbar lordosis, endplate changes, spinal and foraminal narrowing (table 2). similarly, ligamentum flavum thickening was found to be significantly associated with foraminal narrowing, spinal canal narrowing and decreased disc size (table 3). ligamentum flavum thickening was not found in age less than 26 years and the incidence of lumbar lordosis was more in females. discussion: with an overall increase in life expectancy and more patients attending tertiary care hospitals in recent days for lbp, mri has become an important diagnostic tool for the evaluation of ls spine. this study was done to evaluate the pattern of mri changes in cases of chronic lbp. more than 95% of the patients with chronic lbp had some form of abnormal mri findings in ls vertebra. the most common finding was degenerative changes (83.3%), similar to many other studies. [10,11,12,13] disc signal change was the most common finding (83.3%), followed by some form of prolapsed intervertebral disc (pivd), namely diffuse disc bulge (77.8%) and disc herniation (38.9%) in that mri findings no. of cases percentage disc signal change 90 83.3 disc bulge 84 77.8 foraminal narrowing 83 76.9 loss of lumbar lordosis 55 50.9 spinal canal narrowing 53 49.1 disc herniation (n=42) protrusion extrusion sequestration 27 25 13 12 2 1.9 decreased disc size 38 35.2 increased l-s angle 25 23.1 annular tear 23 21.3 thickened ligamentum flavum 18 16.7 endplate change 17 15.7 variable mri finding statistics radiculopathy loss of lumbar lordosis x2 (df=1, n=108) =6.306, p=0.012 endplate changes x 2 (df=1, n=108) =6.518, p=0.038 foraminal narrowing x2 (df=1, n=108) =17.026, p<0.001 spinal canal narrowing x2 (df=1, n=108) =4.459, p=0.035 table 2. associations between radiculopathy and mri findings variable mri finding statistics ligamentum flavum thickening foraminal narrowing p=0.011* spinal canal narrowing x2 (df=1, n=108) =4.631,p=0.031 decreased disc size x 2 (df=1, n=108) =6.366,p=0.012 table 3. associations between ligamentum flavum thickening and mri findings * fisher's exact test. of these, postero-lateral herniation was the most common and foraminal was the least common. sharma r. et al. pattern of lumbar mri changes in patients with chronic low back pain jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 order. this observation is similar to that by ansari et al.[13] in a study based on nepalese population. in another study from india, disc bulge was the most common form of pivd followed by disc herniation; posterolateral herniation being the most common type.[10]however in a study done in ethiopia the most common form of pivd was disc herniation followed by disc bulge.[11] this difference may be because of the difference in the population studied. ogon et al.[14]reported a significant association between ivd signal change and chronic lbp which supports our observation of disc signal change being the most common mri finding. in a study done by rachel a et al.[15], significant mri findings were found in patients with radiculopathy as was seen in our study. ligamentum flavum is intimately related to the spinal canal posteriorly (fig 2). age related degenerative changes and mechanical stress have been implicated as the possible mechanisms for thickening of ligamentum flavum.[16] in our study, the ligamentum flavum thickening was found to be significantly associated with spinal canal and foraminal narrowing which was also shown in a study by saleem et al.[17] the most common neoplasia was vertebral hemangioma seen in five cases (4.6%) which is similar to another large scale study done in nepal. [12] the youngest patient in our study was a 12 years boy, a known case of leukemia, with lbp for eight months. mri finding was however unremarkable. scoliosis was the most common congenital spinal condition in this study similar to a study done in india.[10] this study was done in a single center using a 0.35 tesla mri machine. however, 1.5 tesla mri has now become the standard in which the image resolution is relatively better with higher signal-tonoise ratio (snr). thus a larger population based multi-centre study with 1.5 tesla (or higher) mri will be a better study. also since studies have shown abnormal mri findings in cases with no lbp[18], a case-control study would yield a better study result. conclusion: mri is an invaluable tool in the evaluation of chronic lbp because of its high resolution and lack of ionizing radiation. significant mri findings are noted in most of the cases of chronic lbp, degenerative changes being the most common and ranging from congenital to malignant lesions. conflict of interest: none declared. financial disclosure: no funds were available. fig 2. mri t2 axial showing a left paramedian disc protrusion at l4-5 ivd level causing narrowing of left neural foramina. sharma r. et al. pattern of lumbar mri changes in patients with chronic low back pain jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 references: 1. chou r. low back pain (chronic). bmj clinical evidence. 2010 oct 8;2010:1116.pmid:  21418678 [publisher full text] 2. hoy d, march l, brooks p, blyth f, woolf a, bain c, et al. the global burden of low back pain: estimates from the global burden of disease 2010 study. annals of the rheumatic diseases. 2014 jun 1;73(6):968–74. pmid: 24665116 doi:10.1136/annrheumdis-2013-204428 3. deyo ra, weinstein jn. low back pain. new england journal of medicine. 2001 feb 1;344(5):363–70. pmid: 11172169 doi: 10.1056/nejm200102013440508 4. suthar p, patel r, mehta c, patel n. mri evaluation of lumbar disc degenerative disease. journal of clinical and diagnostic research. 2015 apr;9(4):tc04-09. pmid: 26023617 doi: 10.7860/jcdr/2015/11927.5761 [publisher full text] 5. hong sh, choi j-y, lee jw, kim nr, choi j-a, kang hs. mr imaging assessment of the spine: infection or an imitation? radiographics. 2009 apr;29(2):599–612. pmid:19325068 doi: 10.1148/rg.292085137 6. modic mt, ross js. lumbar degenerative disk disease. radiology. 2007 oct;245(1):43–61. pmid: 17885180 doi: 10.1148/radiol.2451051706 7. okpala f. measurement of lumbosacral angle in normal radiographs: a retrospective study in southeast nigeria. annals of medical health and science research. 2014;4(5):757–62. pmid: 25328789 doi: 10.4103/21419248.141548 [publisher full text] 8. been e, kalichman l. lumbar lordosis. the spine journal. 2014 jan;14(1):87–97. pmid: 24095099 doi: https://doi. org/10.1016/j.spinee.2013.07.464 9. modic mt, steinberg pm, ross js, masaryk tj, carter jr. degenerative disk disease: assessment of changes in vertebral body marrow with mr imaging. radiology. 1988 jan 1;166(1):193–9. pmid:3336678 doi: 10.1148/ radiology.166.1.3336678 10. gopalakrishnan n, nadhamuni k, karthikeyan t. categorization of pathology causing low back pain using magnetic resonance imaging (mri). journal of clinical and diagnostic research. 2015 jan;9(1):tc17-20. pmid: 25738056 doi: 10.7860/jcdr/2015/10951.5470 [publisher full text] 11. biluts h, munie t, abebe m. review of lumbar disc diseases at tikuranbessa hospital. ethiopian medical journal. 2012 jan;50(1):57–65. pmid: 22519162 12. dahal s, joshi a, pant s. spectrum of lumbar spine pathologies in patients with low back pain on mr examination: a retrospective hospital based study. post-graduate medical journal of nams. 2015;12(02). 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https://doi.org/10.1148/radiology.166.1.3336678 https://doi.org/10.1148/radiology.166.1.3336678 https://doi.org/10.7860/jcdr/2015/10951.5470 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4347147/pdf/jcdr-9-tc17.pdf http://pmjn.org.np/index.php/pmjn/article/view/189/170 http://jiom.com.np/index.php/jiomjournal/article/view/792/740 https://doi.org/10.1007/s00776-014-0686-0 https://doi.org/10.1007/s00776-014-0686-0 https://doi.org/10.1007/s00402-009-0849-1 https://doi.org/10.4184/asj.2013.7.4.322 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3863659/pdf/asj-7-322.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3863659/pdf/asj-7-322.pdf https://doi.org/10.2214/ajr.10.4367 https://doi.org/10.2214/ajr.10.4367 https://www.ajronline.org/doi/pdf/10.2214/ajr.10.4367 radha acharya manuscript finalised ds to pdf oct 24.docx https://doi.org/10.22502/jlmc.v10i1.473 original research article peripheral neuropathy and foot care practices among patients with diabetes mellitus attending a tertiary care hospital: a cross-sectional study radha acharya,a,e samridhi chauhanb,e jyotsna pandeyc,f, ashmita chaudharyb,e, chandranshu pandeyd,f abstract: introduction: peripheral neuropathy is the most common microvascular complication of diabetes mellitus. foot care is an important part of diabetes management. this study aimed to identify the prevalence of peripheral neuropathy and foot care practices among diabetic patients. methods: a descriptive cross-sectional study was conducted in 178 patients diagnosed with diabetes mellitus and attending out-patient and in-patient departments of internal medicine at kathmandu university hospital, dhulikhel. the participants were conveniently selected. face-to-face interviews and a foot examination were used to collect data. the michigan neuropathy screening instrument and the nottingham assessment of functional foot care were used to determine the prevalence of peripheral neuropathy and to assess foot care practices. results: the prevalence of peripheral neuropathy was 41% among the participants, and it was associated with increasing age. the majority (75.8%) of the participants had good foot care practices. male gender was significantly associated with good foot care practices [aor = 5.973, 95% ci (2.037-17.515)], whereas past smokers [aor = 0.296, 95% ci (0.111-0.791)] and not receiving diabetes education [aor = 0.367, 95% ci (0.151-0.892)] were significantly associated with poor foot care practices. conclusion: the prevalence of peripheral neuropathy was found to be high, and it was linked to an increased age group. the majority of the participants had good foot care practices. however, in comparison, females were found less likely to practice foot care than males. key words: diabetes mellitus, foot care practices, foot ulcers, peripheral neuropathy. submitted: january 25, 2022 accepted: november 17, 2022 published: january 4, 2023 aassociate professor, department of nursing bm.sc. nursing, department of nursing cmedical officer, department of pediatrics dmedical officer, department of anesthesia ekathmandu university school of medical sciences, kavre, nepal. f-kathmandu university school of medical sciences, dhulikhel hospital, kavre, nepal corresponding author: radha acharya e-mail: radhaacharya@kusms.edu.np orcid: https://orcid.org/0000-0002-3622-4554 introduction: in 2019, it was estimated that 463 million people would have diabetes, and this number is projected to reach 578 million by 2030 and 700 million by 2045.[1] diabetic peripheral neuropathy (dpn) is the most common microvascular complication among people with diabetes that involves peripheral nervous system dysfunction.[2] how to cite this article: acharya r, chauhan s, pandey j, chaudhary a, pandey c. peripheral neuropathy and foot care practices among patients with diabetes mellitus attending a tertiary care hospital: a cross-sectional study. journal of lumbini medical college. 2022;10(1):13 pages. doi: https://doi.org/10.22502/jlmc.v10i1.473 epub: january 4, 2023. j. lumbini med. coll. vol 10, no 2, july-dec 2022 https://doi.org/10.22502/jlmc.v10i1 https://orcid.org/0000-0002-3622-4554 acharya a, et al. peripheral neuropathy and foot care practices among diabetic patients diabetic peripheral neuropathy can affect the nerves of both the upper and lower extremities. it most commonly starts in the feet and can arise in both feet.[3] approximately, 50% of dpn may be asymptomatic, putting affected feet at a higher risk of foot injuries and problems.[4] different studies conducted in india showed the prevalence of diabetic neuropathy to be 32.2% and 60.7%, respectively. [5,6] similar studies done in nepal showed 10.7%, 38.1%, and 45.4% prevalence of diabetic peripheral neuropathy, respectively.[7,8,9] foot care is an important part of diabetes patient education to prevent foot ulceration. the american diabetes association recommends an annual comprehensive foot evaluation to identify predisposing factors for ulcers and amputations among diabetic people.[10] daily foot and shoe checks, proper foot hygiene, not walking barefoot, wearing appropriate shoes, and trimming toenails are very important for diabetic patients. similarly, avoiding using anything abrasive on the feet, getting early professional care for wounds and lesions, and having a routine foot examination by a trained health care worker are all part of proper self-foot care practices.[11] in diabetic patients, routine foot examinations and foot care techniques can reduce ulcer incidence by 50% and amputation by up to 85%.[12,13] though significant relationships between diabetic neuropathy and foot care practices were not found in a previous study, complications from diabetic neuropathy can be decreased through practicing proper foot care practices.[14] this study was conducted to determine the prevalence of peripheral neuropathy and associated factors among patients with diabetes mellitus attending dhulikhel hospital. methods: this was a hospital-based cross-sectional study done among patients with diabetes mellitus who visited the out-patient (opd) and inpatient departments of internal medicine at kathmandu university hospital, dhulikhel hospital, kavre, nepal. the study was initiated after an approval was received from the institutional review committee of kathmandu university of medical science (approval number: 203/19) and from the head of the department of internal medicine at dhulikhel hospital. patients who had been diagnosed with diabetes for at least six months were included. patients with other health conditions that can cause peripheral neuropathy, such as congenital neuropathies, hypothyroidism, cerebrovascular disease, chronic renal or liver failure, patients on antiretroviral therapy, or chemotherapy, were excluded from the study. a total of 178 patients were conveniently sampled for the investigation, which was determined from a prior study by kc a et al. that found a prevalence of 10.74 percent, at a level of error of 5%, and a 95% confidence interval with a 20% attrition rate.[7] the sample size was calculated using the formula n = z2 p (1-p)/d2.[15] instruments for data collection part i: the socio-demographic characteristics consisted of age, gender, level of education, income, and clinical characteristics including smoking status, duration of illness, types of medication received, family history of diabetes, prior diabetes education, and body mass index (bmi). part ii: nottingham assessment of functional foot care assessment, which consists of 26 items, was used to assess foot care among patients with diabetes. responses to questions were recorded on a categorical scale (scored 0-3) according to the frequency of occurrence of the behavior. the maximum obtainable score was 78. it was considered good practice if the score was at least 50% and poor practice if the score was less than 50%.[16] j. lumbini med. coll. vol 10, no 2, july-dec 2022 acharya a, et al. peripheral neuropathy and foot care practices among diabetic patients part iii: a michigan neuropathy screening instrument (mnsi) was used to determine peripheral neuropathy. it consists of two parts, history and physical assessment. a physical assessment was done to determine peripheral neuropathy. the assessment consists of: (1) an inspection of the feet for deformities, dry skin, hair or nail abnormalities, calluses or infection, (2) semi-quantitative evaluation of vibration sensation at the dorsum of the great toe, (3) ankle reflex grading and, (4) monofilament testing. the total score was 10 points, out of which 2.5 points were considered presence of peripheral neuropathy in participants.[17] data collection procedure the researcher received training in foot evaluation in diabetic patients from a nurse educator at dhulikhel hospital's diabetic counseling section. the study was initiated once the diabetic counseling section granted the verbal permission. the researcher then approached diabetic patients admitted to medical wards and patients visiting the opd of internal medicine. the study's objectives were conveyed to the participants. informed consent for voluntary participation was taken from the participants who met inclusion criteria. the researcher conducted interviews using semi-structured and structured questionnaires to obtain socio-demographic information, diabetes-related information, and foot-care practices information. the researcher evaluated peripheral neuropathy in terms of foot examination, vibration sensitivity with a 125 hz tuning fork test, muscle stretch responses with a queen square reflex hammer, and monofilament testing with a 10g filament. it took approximately 30 minutes to complete each interview and foot examination. for inpatient participants, interviews were conducted at their bedsides (one corner of the room) by using a curtain, whereas for those visiting the opd, interviews were conducted in room number four of the internal medicine opd. data was only accessible to the researcher. on average, seven patients participated in the study every day. the data was collected from november 18th to december 23rd, 2020. version 23 of the statistical package for the social sciences (spss) was used to tabulate and analyze the gathered data. both descriptive and inferential statistics were used to analyze the acquired data. the socio-demographic data, clinical characteristics, foot care practice, and prevalence of peripheral neuropathy were described using frequencies, percentages, median mean, and standard deviation (sd). binary logistic regression was used to investigate the relationship between selected independent variables and foot care practices, as well as peripheral neuropathy, by computing crude and adjusted odds ratios with 95% confidence intervals (ci). the link between peripheral neuropathy and foot care behaviors was investigated using the chi square test, with a p value of 0.05 considered statistically significant. results: the mean age of the participants was 57.2 ± 11.1 years. among the participants, 51.1% were from the age group of 41-60 years, and 56.2% were male (table 1). table 2 revealed that more than one-third of the study participants (43.3%) had smoked in the past. almost two-thirds of the individuals (69.7%) did not have a family history of diabetes. the average length of disease was 6.8±6.0 years. regarding foot care practice, 69.7% of the participants examined their feet once a week or less. about two-thirds of the participants (65.2%) examined shoes before wearing them, but the majority (73.6%) never did so after taking them off. j. lumbini med. coll. vol 10, no 2, july-dec 2022 acharya a, et al. peripheral neuropathy and foot care practices among diabetic patients table 1: socio-demographic characteristics of the participants (n = 178) characteristics frequency (%) age in completed years 30-40 14 (7.9) 41-60 91 (51.1) >60 73 (41.0) sex male 100 (56.2) female 78 (43.8) level of education illiterate 90 (50.6) primary level 29 (16.3) secondary level 45 (25.3) higher secondary level 10 (5.6) bachelor or above 4 (2.2) income per month in rupees ≤ 20000 114 (64.0) >20000 64 (36.0) more than half (56.8%) of the participants never checked their feet for drying after washing, while 71.3% of the participants rarely/never dried in between the toes. most of the participants (69.1%) never used moisturizing cream on their feet. more than half (59.5%) of the participants trimmed their toenails about once a month. almost half (51.1%) of the participants sometimes table 2: clinical characteristics of the participants (n = 178) characteristics frequency (%) smoking status current smoker 27 (15.1) past smoker 77 (43.3) non smoker 74 (41.6) family history of diabetes yes 54 (30.3) no 124 (69.7) duration of diabetes in years <1year 12 (6.7) 1-5 years 75 (42.1) 6-10 years 55 (31.0) >10 years 36 (20.2) types of medication oral anti -diabetic medication 146 (82.0) injectable insulin 3 (1.7) both 29 (16.3) diabetes education received yes 111 (62.4) no 67 (37.6) bmi underweight 3 (1.7) normal 63 (35.4) overweight 66 (37.1) obesity 46 (25.8) j. lumbini med. coll. vol 10, no 2, july-dec 2022 acharya a, et al. peripheral neuropathy and foot care practices among diabetic patients wore shoes with lace-up, velcro, or strap fastenings. a majority (87.1%) of the participants had never worn pointed shoes, with two-thirds (68%) of the participants sometimes wearing flip flops. most of the participants (83.1%) rarely/never broke in new shoes gradually, whereas two-thirds (68.5%) never used nylon socks. most of the participants, i.e. (93.3% and 92.7%), never used a hot water bottle in bed or put their feet on a radiator, respectively. in the present study, 75.8% of the participants had good foot care practices. (additional file 1) table 3 shows the mnsi physical assessment of the patients. the overall prevalence of diabetic peripheral neuropathy was 41% which was calculated based on the mnsi examination score. table 3 michigan neuropathy screening instrument physical assessment findings of the participants (n=178) items categories number (%) right left appearance of feet normal yes 78 (43.8) 81 (45.5) no 100 (56.2) 97 (54.5) type of abnormal appearance deformities 5 (2.8) 4 (2.2) dry skin/callus 53 (29.8) 52 (29.2) fissure 73 (41.0) 74 (41.6) athletes foot 20 (11.2) 17 (9.6) ulceration absent 176 (98.9) 176 (98.9) present 2 (1.1) 2 (1.1) ankle reflexes present 148 (83.1) 152 (85.4) present/reinforcement 27 (15.2) 23 (12.9) absent 3 (1.7) 3 (1.7) vibration perception at great toe present 102 (57.3) 95 (53.3) decreased 33 (18.5) 30 (16.9) absent 43 (24.2) 53 (29.8) monofilament testing normal 140 (78.7) 146 (82) reduced 27 (15.1) 23 (12.9) absent 11 (6.2%) 9 (5.1) j. lumbini med. coll. vol 10, no 2, july-dec 2022 acharya a, et al. peripheral neuropathy and foot care practices among diabetic patients table 4: factors associated with peripheral neuropathy among the participants (n=178) characteristics peripheral neuropathy number (%) cor (95% ci) aor (95% ci) p value absent present age in years 30-40 13 (92.9) 1 (7.1) 0.05 (0.01-0.41) 0.04 (0.01-0.38) 0.005 41-60 63 (69.2) 28 (30.8) 0.29 (0.15-0.56) 0.22 (0.10-0.49) <0.001 >60 29 (39.7) 44 (60.3) 1.0 1.0 sex male 57 (57.0) 43 (43.0) 1.21 (0.66-2.21) 0.70 (0.30-1.66) 0.419 female 48 (61.5) 30 (38.5) 1.0 1.0 smoking status current smoker 15 (55.6) 12 (44.4) 1.77 (0.72-4.38) 2.00 (0.69-5.82) 0.203 past smoker 39 (50.6) 38 (49.4) 2.16 (1.11-4.20) 1.66 (0.76-3.62) 0.202 nonsmoker 51 (68.9) 23 (31.1) 1.0 1.0 family history of diabetes no 70 (56.5) 54 (43.5) 1.42 (0.73-2.75) 1.18 (0.54-2.57) 0.679 yes 35 (64.8) 19 (35.2) 1.0 1.0 duration of diabetes <1 year 7 (58.3) 5 (41.7) 0.64 (0.17-2.40) 0.82 (0.18-3.73) 0.797 1-5 years 50 (66.7) 25 (33.3) 0.45 (0.20-1.01) 0.70 (0.25-1.96) 0.493 6-10 years 31 (56.4) 24 (43.6) 0.69 (0.30-1.61) 0.73 (0.25-2.07) 0.550 > 10 years 17 (47.2) 19 (52.8) 1.0 1.0 type of medication only one 88 (59.1) 61 (40.9) 0.98 (0.44-2.20) 1.12 (0.39-3.19) 0.835 both 17 (58.6) 12 (41.4) 1.0 1.0 diabetes education received no 41 (61.2) 26 (38.8) 0.86 (0.46-1.60) 0.73 (0.35-1.53) 0.403 yes 64 (57.7) 47 (42.3) 1.0 1.0 bmi underweight/ normal 38 (57.6) 28 (42.4) 0.96 (0.45-2.05) 0.66 (0.27-1.63) 0.370 overweight 41 (62.1) 25 (37.9) 0.79 (0.37-1.07) 0.56 (0.24-1.34) 0.191 obesity 26 (56.5) 20 (43.5) 1.0 1.0 note: aor: adjusted odds ratio, cor crudes odds ratio, ci: confidence interval j. lumbini med. coll. vol 10, no 2, july-dec 2022 acharya a, et al. peripheral neuropathy and foot care practices among diabetic patients table 5 factors associated with foot care practices among the participants (n=178) characteristics practice level number (%) cor (95% ci) aor (95% ci) p value poor good age in years 30-40 6 (42.9) 8 (57.1) 0.61 (0.19-1.97) 0.30 (0.06-1.37) 0.12 >41-60 14 (15.4) 77 (84.6) 2.5 (1.19-5.37) 2.48 (0.99-6.24) 0.054 >60 23 (31.5) 50 (68.5) 1.0 1.0 sex male 14 (14.0) 86 (86) 3.64(1.75 -7.52) 5.97 (2.04-17.52) <0.001 female 29 (37.2) 49 (62.8) 1.0 1.0 education illiterate 30 (33.3) 60 (66.7) 0.54 (0.14-2.10) 1.92 (0.36-10.36) 0.449 primary 4 (13.8) 25 (86.2) 1.70 (0.32-8.93) 2.33 (0.37-14.52) 0.364 secondary 6 (13.3) 39 (86.7) 1.77 (0.38-8.26) 2.82 (0.49-16.22) 0.244 higher 3 (21.4) 11 (78.6) 1.0 1.0 income per month in rupees ≤20000 29 (25.4) 85 (74.6) 0.82 (0.40-1.70) 0.79 (0.33-1.91) 0.599 >20000 14 (21.9) 50 (78.1) 1.0 1.0 smoking status current smoker 5 (18.5) 22 (81.5) 1.12 (0.36-3.44 0.55 (0.14-2.10) 0.378 past smoker 23 (29.9) 54 (70.1) 0.60 (0.28-1.26) 0.30 (0.11-0.79) 0.015 nonsmoker 15 (20.3) 59 (79.7) 1.0 1.0 family history of diabetes no 29 (23.4) 95 (76.6) 1.15 (0.55-2.40) 1.74 (0.69-4.38) 0.239 yes 14 (25.9) 40 (74.1) 1.0 1.0 diabetes education no 21 (31.3) 46 (68.7) 0.54 (0.27-1.09) 0.37 (0.15-0.89) 0.027* yes 22 (19.8) 89 (80.2) 1.0 1.0 note: aor: adjusted odds ratio, cor: crudes odds ratio, ci: confidence interval j. lumbini med. coll. vol 10, no 2, july-dec 2022 acharya a, et al. peripheral neuropathy and foot care practices among diabetic patients table 4 revealed the significant association found between age and peripheral neuropathy [aor 0.041, 95% ci (0.005-0.375)]. the prevalence of peripheral neuropathy was less likely to occur in the age group 30-40 years than other age groups. table 5 showed that, the statistically significant association was found between foot care practices and sex of participants [aor=5.973, 95% ci (2.037-17.515), p < 0.001]. male participants were about six times more likely to practice foot care than females. foot care practice and smoking status [aor = 0.296, 95% ci (0.111-0.791), p = 0.015], and foot care practice and diabetes education [aor=0.367, 95% ci (0.151-0.892), p=0.027] were also found to have significant associations. past smokers were less likely to practice foot care than nonsmokers and current smokers. the participants who had received diabetes education were more likely to practice adequate foot care (p=0.027). there was no statistically significant association found between peripheral neuropathy and foot care practices among the participants [χ2=1.675, p > 0.05]. discussion: the aim of the study was to identify the prevalence of peripheral neuropathy and foot care practices among diabetic patients. in this study, the prevalence of peripheral neuropathy was 41%. similar findings were observed in other studies.[8,9,18,19] a systematic review and meta-analysis conducted in africa also showed a 46% prevalence of peripheral neuropathy, which was consistent with the present study.[20] in contradiction, the studies conducted in tanzania by amour et al. and in india by begum et al. reported the prevalence of peripheral neuropathy 72.2% and 52.9% respectively, which were higher than the present study.[21,22] likewise, the prevalence of peripheral neuropathy found in our study was higher than in the studies conducted by d’souza m, kc a, sun j, and kisozi t et al. which reported prevalence of 32.2%, 10.7%, 30%, and 29.4%, respectively.[5,7,23,24] few other studies showed that the prevalence of peripheral neuropathy was 29.2% among them, 33.7% of which was found in known diabetic mellitus, and 9.2% was found in newly detected diabetes mellitus.[5,25] the results of the studies suggested that the peripheral neuropathy can be prevented if the problem is screened timely and detected early enough. the major determinants associated with diabetic peripheral neuropathy were found to be male gender, smoking, and age > 40 years of age.[5,7] the variation in prevalence may be due to diabetes types, sample size, and instruments used to detect peripheral neuropathy. the mean age of the patients in this study was 57.2 ± 11.1 years. in the present study, one of the contributing factors for diabetic peripheral neuropathy was increasing age. likewise, other studies conducted by shrestha hk, karki d, amour aa, and katulanda p et al. demonstrated that increasing age, gender, longer duration of diabetes, smoking, obesity, and glycemic control were found to be significantly associated with diabetic peripheral neuropathy.[8,9,21,26]. old age is an independent risk factor for the development of diabetic neuropathy in type ii diabetes mellitus. another probable reason may be that type ii dm usually diagnosed in old age because they are asymptomatic. katulanda p et al. observed that females were more likely to develop diabetic peripheral neuropathy than males which were similar to our study although it was not statistically significant.[26] our study j. lumbini med. coll. vol 10, no 2, july-dec 2022 acharya a, et al. peripheral neuropathy and foot care practices among diabetic patients also demonstrated that longer duration of diabetes (>10 years) was more prevalent (52.8%) in peripheral neuropathy, but it was not significant, which was supported by a study done by shrestha et al.[8]. another study revealed that the duration of diabetes mellitus more than one year and elevated fasting blood glucose levels were significant predictors for patients to have diabetic peripheral neuropathy.[27] the lack of association between the duration of diabetes and peripheral neuropathy may be due to other risk factors for peripheral neuropathy like glycemic control, dyslipidemia, and hypertension, which were not included in this study. in the present study, there was no association found between peripheral neuropathy and smoking status, which was in contrast to the study conducted by begum et al.[22] while the study conducted by ugoyo et al. showed that there was no significant association found between body mass index and peripheral neuropathy, which was comparable with our study.[21] whereas, amour et al. demonstrated that obesity was found to be statistically significant with peripheral neuropathy.[28] moreover, the present study also found that about three-fourth of the participants had conducted good foot care practices, while 24.2% had poor foot care practices. this finding was consistent with the studies conducted by george h, shrestha tm and gholap mc et al. which reported that more than two-third of the participants had good foot care practices.[18,29,30] the possible reason for good foot care practice may be that the majority of the patients were literate and had received diabetic education. on the contrary, few other studies have indicated that the majority of participants had poor foot care practice.[31,32,33,34] similarly, chatterjee s et al., pavithra h et al. and seid a et al. also reported that 40%, 41.6% and 53% participants respectively had good foot care practice, but lower than the present study.[35,36,37] chatterjee s et al. revealed that nearly two-thirds of the study participants examined their feet everyday, which is contradictory to the current study (22.5%).[35] the results of this study are comparable to those of pavithra h et al., who reported 30.9% of participants in their study.[36] according to the study conducted by seid s et al. 38.7% and 45.7% of the participants had never checked their shoes before putting them on and after taking them off, respectively which is higher in the present study (56.7%, 71.3%).[37] furthermore, our study also demonstrated the significant association of gender, smoking status, and diabetes education with foot care practices. male participants were about six times more likely to practice foot care than female participants, which is statistically significant and this finding is comparable with the study conducted by d’souza et al.[5] the reason could be the better education of male gender than female in nepal. similarly, abu-elenin et al. also showed the significant association among foot care practices and diabetic educations.[33] muhammad-lotfi et al. revealed that age, level of education, and duration of diabetes had no significant relationship with foot practice.[31] this finding was consistent with that of the current study, but it is not comparable with the studies conducted by pourkazemi et al. and magbanua et al. which showed significant associations between foot care practices and duration of diabetes.[38,39] moreover, in the present study, there was no significant association found between peripheral neuropathy and foot care practices among the participants, which was in line with the study done in iraq by saber et al.[14] although there was no association between peripheral neuropathy and foot care practices, good foot care practice can help in decreasing diabetic foot complications. so it is very important to practice good foot care among all diabetic patients, especially those who have diabetic peripheral j. lumbini med. coll. vol 10, no 2, july-dec 2022 acharya a, et al. peripheral neuropathy and foot care practices among diabetic patients neuropathy, to prevent diabetic foot ulcers. the limitations of the study are that the questionnaires regarding types of shoes were only asked verbally to the participants, but if the shoes were shown in a real setting, it would have decreased the distortion of the questionnaires. apart from that, the study participants did not have equal opportunities to engage in the study due to the convenient sampling technique, which reduced the generalizability of the findings. conclusion: the prevalence of peripheral neuropathy was found to be high, and it was linked to an increased age group. the participants thought foot care was a useful practice. foot care practices were shown to be substantially linked with gender, smoking status, and diabetes education. as a result, it is critical to give all diabetics frequent clinical foot examinations, diabetic education, and encouragement of proper self-foot care practices. conflict of interest: the authors 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wledge-and-practice-diabetes 35. chatterjee s, basu m, bandyopadhyay k, de a, dutta s. knowledge and practice of foot care amongst diabetic patients attending a tertiary care hospital of kolkata, india. journal of preventive medicine and holistic health. 2017;3(1):15-21. available from: https://www.jpmhh.org/article-details/44 19 36. pavithra h, akshaya km, nirgude as, balakrishna ag. factors associated with awareness and practice about foot care among patients admitted with diabetes mellitus: a cross sectional research from a medical college hospital of southern india. nepal j epidemiol. 2020;10(3):897-904. pmid: 33042593 doi: https://doi.org/10.3126/nje.v10i3.29213 37. seid a, tsige y. knowledge, practice, and barriers of foot care among diabetic patients attendingfelegehiwot referral hospital, bahir dar, northwest ethiopia. 2015;2015(0):934623. doi: https://doi.org/10.1155/2015/934623 38. pourkazemi a, ghanbari a, khojamli m, balo h, hemmati h, jafaryparvar z, et al. diabetic foot care: knowledge and practice. bmc endocrdisord. 2020;20(1):40. pmid: 32192488 doi: https://doi.org/10.1186/s12902-020-051 2-y 39. magbanua e, lim-alba r. knowledge and practice of diabetic foot care in patients with diabetes at chinese general hospital and medical center. j asean fed endocr soc. 2017;32(2):123-31. pmid: 33442095 doi: https://doi.org/10.15605/jafes.032.02.05 j. lumbini med. coll. vol 10, no 2, july-dec 2022 https://dx.doi.org/10.21608/ejcm.2018.23001 https://dx.doi.org/10.21608/ejcm.2018.23001 https://dx.doi.org/10.5455/ijmrcr.knowledge-and-practice-diabetes https://dx.doi.org/10.5455/ijmrcr.knowledge-and-practice-diabetes https://www.jpmhh.org/article-details/4419 https://www.jpmhh.org/article-details/4419 https://pubmed.ncbi.nlm.nih.gov/33042593/ https://doi.org/10.3126/nje.v10i3.29213 https://doi.org/10.1155/2015/934623 https://pubmed.ncbi.nlm.nih.gov/32192488/ https://doi.org/10.1186/s12902-020-0512-y https://doi.org/10.1186/s12902-020-0512-y https://pubmed.ncbi.nlm.nih.gov/33442095/ https://doi.org/10.15605/jafes.032.02.05 https://doi.org/10.22502/jlmc.v10i1.478 original research article birth preparedness and complication readiness among husbands whose wives were delivered within the last 12 months: a cross-sectional study rupa prajapati a,c , surendra maharjan b,c abstract: introduction: birth preparedness and complication readiness (bpcr) is an essential element of antenatal care package which promotes pregnant women and their families to effectively plan for normal births and prepares them for any complication that may arise. this study aimed to explore the husbands’ preparedness and their knowledge level on bpcr. methods: a descriptive cross-sectional study was conducted among 117 husbands whose wives delivered within the last 12 months in the out-patient and in-patient wards of obstetrics and pediatrics departments of a medical college. the data was collected from august to december, 2021 using non-probability purposive sampling technique and pre-tested semi-structured interview questionnaire. the statistical analysis was made at 95% confidence level. the data were summarized and described using descriptive statistics such as proportion, percentage, ratios, frequency distribution, mean and standard deviation. results: none of the respondents knew all the three key danger signs of the postpartum period. more than three quarters (78.6%) of the husbands were prepared in bpcr component. conclusion: few husbands knew all the key danger signs during pregnancy, labor, postpartum and newborn periods. slightly more than three-quarter of husbands were prepared well for birth and complication readiness. individual components of bpcr was also poor among the respondents. keywords: birth preparedness and complication readiness, husbands, wives. introduction: birth preparedness and complication readiness (bpcr) is an essential element of antenatal care (anc) package which promotes pregnant women and their families to effectively plan for normal births and prepares them for any complication that may arise.[1,2] birth preparedness is an active process including preparation and decision making for pregnancy, childbirth and the postpartum period by the submitted: 13 february, 2022 accepted: 07 august, 2022 published: 12 september, 2022 alecturer, nursing program blecturer, department of community medicine clumbini medical college, palpa, nepal corresponding author: rupa prajapati, lecturer, nursing program, lumbini medical college, palpa, nepal e-mail: rupa.prajapatikathmandu@gmail.com orcid: https://orcid.org/0000-0002-5679-3201 couple and their families. it generally addresses the three delays in seeking obstetrics emergency care-delay in recognition of problem, delay in seeking care, and delay in receiving care at facility. the importance of bpcr as well as birthing by a skilled birth attendant cannot be stressed enough, as this can be the difference between life and death.[1,3,4,5] male involvement in bpcr is the care and support given to their wives during pregnancy and childbirth, which improves healthcare utilization and thus reduce the three delays. although the husbands usually accompany the pregnant mother during anc, it is still rare and somewhat how to cite this article: prajapati r, maharjan s. birth preparedness and complication readiness among husbands whose wives were delivered within the last 12 months: a cross-sectional study. journal of lumbini medical college. 2022;10(1):8 pages. doi: https://doi.org/10.22502/jlmc.v10i1.478 epub: 2022 september 12 j. lumbini. med. co ll. vol 10, no 1, jan-june 2022 https://doi.org/10.22502/jlmc.v10i1 mailto:rupa.prajapatikathmandu@gmail.com https://orcid.org/0000-0002-5679-3201 prajapati r, et al. birth preparedness and complication readiness among husbands a taboo for them to be present during labor.[2] nepal’s very ambitious aim to reduce the maternal mortality ratio to 70 per lakh live births and neonatal mortality rate to less than one per thousand live births is not easy to achieve due the poor birth preparedness, low institutional deliveries and birthing by non-skilled birth attendants. this leads to complications that contribute to the majority of neonatal and maternal deaths.[1,6] although many studies have been done on various aspects of maternal and child health, there have been very few studies carried out to find involvement of husband in birth preparedness and complication readiness in nepal. so, this study aimed to explore the husbands’ preparedness and their knowledge level on ‘birth preparedness of complication readiness’. methods: a descriptive cross-sectional study was conducted among 117 husbands whose wives delivered within the last 12 months visiting lumbini medical college and teaching hospital (lmcth). the sample size for the study was calculated using the formula: sample size (n)=z 2 pq/(d) 2 where, z=1.96 value for 95% confidence limits p = proportion of husbands on birth preparedness and complications readiness q = (1-p) d = permissible error, i.e. 10% taking p = 57% from the study of bhusal ck et al.[2] n = 94.1 ~ 95. the pretesting of the instrument was done in 10% of the sample size i.e. 10 similar type of respondents in lmcth. the content validity of the instrument was established through the advice of experts from the nursing fields and consultant faculties of department of obstetrics and gynecology. the internal consistency for each component was estimated using cronbach’s coefficient alpha. the computed values of cronbach’s coefficient alpha was 0.937 hence reliable to conduct the study. the data was collected from august to november, 2021 using non probability purposive sampling technique. ethical approval was taken from the institutional review committee of the institute (irc–lmc 03 c/021). husbands whose wives delivered within the last 12 months, irrespective of the outcome and those who were willing to participate in the study were included in the study. husbands who were not staying with their wives during pregnancy and child birth were excluded. a pre-tested semi-structured interview questionnaire was used for data collection. it was taken from the safe motherhood questionnaire developed by maternal and neonatal health program of jhpiego, the affiliate of johns hopkins university [4], and adapted according to the objectives of the study and local context. the questionnaire was translated into nepali to find any misinterpretation and was modified where needed. it consists of three parts, i.e. sociodemographic variables, preparedness of husband in bpcr and knowledge on danger signs regarding bpcr. the tool on sociodemographic variables consists of husbands’ age, caste, religion, education, occupation and income. the level of education was classified as "illiterate", "basic level" (including grade 1 to 8), "secondary level" (including grade 9 to 12), and "higher level" (including both undergraduate and postgraduate levels). the tool on ‘husbands preparedness/practice in bpcr’ consists of eight items focusing on preparedness of husband on eight components of bpcr. the tool on ‘knowledge of ‘danger signs’ regarding bpcr’ consists of four items focusing on danger signs during pregnancy, labor and child birth, during the first two days after birth, during the first seven days after birth. scoring keys on husband involvement in bpcr: good involvement in bpcr: are those who practised at least five components from eight parameters in bpcr. poor involvement in bpcr: are those who practised upto four components from eight parameters of bpcr. j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np prajapati r, et al. birth preparedness and complication readiness among husbands knowledge of key danger signs of pregnancy: a husband was considered knowledgeable if he spontaneously mentioned all the three key danger signs of pregnancy such as vaginal bleeding, blurred vision and swollen hands/ face otherwise not knowledgeable. knowledge of key danger signs of labor: a husband was considered knowledgeable if he spontaneously mentioned all the four key danger signs of labor such as severe vaginal bleeding, convulsions, prolonged labor and retained placenta otherwise not knowledgeable. knowledge of key danger signs of postpartum: a husband was considered knowledgeable if he spontaneously mentioned all the three key signs of postpartum such as severe vaginal bleeding, foul smelling discharge and high fever otherwise not knowledgeable. knowledge of key danger signs of newborn baby : a husband was considered knowledgeable if he spontaneously mentioned all the four key danger signs of newborn baby such as difficult or fast breathing, poor sucking/feeding, lethargy /unconscious, and convulsions. data was collected by interview technique using semi-structured questionnaire regarding birth preparedness and complication readiness among husbands whose wives delivered within the last 12 months. first priority was given to the postnatal ward for data collection as the probability of finding husband of recently delivered wives was high. the researcher visited the ward, established the interpersonal relationship with the ward sister and sought permission to see the details of the patient in case sheet. the interpersonal relationship was established with both wives and husbands of target sample. in case of absence of husband in the ward, husband contact details were taken and requested for his presence for data collection. the data collection procedure was carried out around 11 am after doctor round. those clients who were discharged early were given first priority for data collection. each respondent was given 15 to 20 minutes to complete the questionnaire. in areas where wives’ information regarding antenatal period was required, both husbands’ and wives’ final views were taken into consideration. four to six respondents were assessed per day. similarly, the patient information was screened from out-patient department registers of the department of obstetrics and the department of pediatrics. if both husband and wife were together, data collection procedure were carried out otherwise not. data processing and analysis after checking the data for its completeness, missing values and coding of questionnaires, data were entered into excel version 2016 and analyzed using statistical package for social sciences (spss) version 20. the statistical analysis was made at the 95% confidence level and with a 10% margin of error. the data were summarized and described using descriptive statistics such as proportion, percentage, ratios, frequency distribution, mean, and standard deviation. results: there were 117 husbands who participated in this study. most (98.3%) of them were hindu. majority (46.2%) of the respondents were janajati, followed by dalits (20.5%). less than two-third (63.2%) of the respondents had education up to secondary level while only 10.3% had higher level education. similarly, more than half (58.1%) of the respondents’ wives had education up to secondary level while only 12.8% had higher level education. majority (79.5%) respondents belonged to joint family and 18.8% belonged to nuclear family. agriculture was the major profession among 36.8% of the respondents whereas, more than half (67.5%) of the respondents’ wives were homemakers. the husband was the main earner in 71.8% of the families. more than three-quarters (82.9%) of respondents’ wives had at least four or more anc visits. no complications were reported among 83.8% of respondents’ wives during pregnancy. more than three quarter (76.9%) of the respondents said that the decisions were made by both partners. only the husband was decision maker in 12% families. the remaining profiles are depicted in table 1. husband preparedness in ‘birth preparedness and complication readiness: among all the respondents, more than three quarters (78.6%) were well prepared in bpcr component and 21.4% were less well prepared. j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np prajapati r, et al. birth preparedness and complication readiness among husbands table 1: sociodemographic variables of the respondents (n=117) characteristics frequency (%) religion hindu 115 (98.3) buddhist 2 (1.7) age in years <21 3 (2.6) 21-35 98 (83.8) >35 16 (13.7) caste brahmin 20 (17.1) chettri 19 (16.2) dalit 24 (20.5) janjati 54 (46.2) husband’s education illiterate 4 (3.4) basic level 27 (23.1) secondary level 74 (63.2) higher level 12 (10.3) husband’s occupation business 36 (30.8) farmer 43 (36.8) office worker 36 (30.8) homemaker 2 (1.7) earner husband 84 (71.8) both 33 (28.2) monthly income (rupees) ≤ 10,000 49 (41.9) 10,000 29,999 37 (31.6) 30,000 49,999 16 (13.7) ≥ 50,000 15 (12.8) family type nuclear 22 (18.8) joint 93 (79.5) extended 2 (1.7) j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np prajapati r, et al. birth preparedness and complication readiness among husbands similarly, 20 (17.1%) said they had prepared all eight components of birth preparedness. the number of respondents who identified each of the components of preparedness is shown in table 2. table 2: components of birth preparedness and complication readiness (n=117) variables yes no frequency (%) frequency (%) identified skilled birth attendant 77 (65.8) 40 (34.2) identified a preferable birth place 76 (65.0) 41(35.0) did you arrange a source of household support to provide temporary family care during her absence? 78 (66.7) 39 (33.3) identified means of transportation 96 (82.1) 21(17.9) saved or arranged alternative funds 86 (73.5) 31(26.5) accompanied your wife to health facility 87 (74.4) 30 (25.6) arranged blood donor 73 (62.4) 44 (37.6) prepared clean clothes and other materials for baby and mother 107 (91.5) 10 (8.5) knowledge on danger signs regarding danger signs during pregnancy, only six (5%) of the respondents knew all three important key danger signs during pregnancy. similarly, only 10 (8.5%) said that they knew all the four major danger signs during labor/delivery. none of the respondents knew all the three key danger signs of the postpartum period. only nine (7.7%) of the respondents mentioned all the four danger signs of newborn. the knowledge of respondent on each danger sign during pregnancy, labor, postpartum and newborn are depicted in table 3. discussion: birth preparedness birth preparedness is an essential component of safe motherhood that helps to reduce the delay in reaching care, seeking care and receiving care in case of obstetrics emergency.[1] numerous studies have shown that the preparedness is influenced by various factors such as education, religion, family beliefs, financial status.[5] majority of the respondents were aged between 21 and 35 years which is similar to studies done in nepal.[1] the level of birth preparedness was good among 78.6% of the respondents which is significantly higher than a study done in ethiopia and another study done in nepal where only 46.9% and 57.6% were prepared.[2,7] only about 17% had done all eight steps of birth preparedness in the present study. about two thirds (65.8%) had identified a skilled birth attendant (sba) for delivery and a preferable birth place compared to 91.1% and 83.6% for identifying sba and preferable birth place respectively in a study from myanmar.[8] j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np prajapati r, et al. birth preparedness and complication readiness among husbands table 3: knowledge of danger signs during pregnancy, labor, postpartum and of newborn (n=117) danger signs frequency (%) pregnancy danger signs vaginal bleeding 87 (79.4) blurred vision 18 (15.4) swollen hands/feet 12 (10.3) danger signs during labor vaginal bleeding 75 (64.1) convulsions 24 (20.5) prolonged labor 55 (47.0) retained placenta 52 (44.4) danger signs during postpartum vaginal bleeding 84 (71.8) foul smelling discharge 10 (8.3) high fever 21 (17.9) danger signs of newborn difficult/ fast breathing 91(77.8) poor sucking 59(50.4) lethargy/ unconsciousness 26(22.2) convulsions/spams 20(17.1) a study in ethiopia showed only 29.3% and 54.6% had identified a sba and a preferable birth place respectively.[7] slightly less than three quarter (73%) respondents had enough savings or had alternate source in case of emergency. this is better than other studies from ethiopia where only 39.6% had saving but similar to a study from myanmar where 81.7% had saved for birth preparedness.[7,8] this study showed that 82.1% had already identified a means of transport for delivery of their wives. the present finding is in contrast with findings from ethiopia where only 11.1% in one study and 44.6% in another study had identified transport facility. this difference could be due to differences in geography, in the study sites and the availability and ease of access of transportation.[7,9] similarly, a study from myanmar showed slightly more than half (52.1%) had planned for transportation.[8] regarding arranging a potential blood donor in case of an emergency, 62.4% said they had arranged a potential blood donor which is better than the study conducted in myanmar and ethiopia with 15.5% and 47.6% j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np prajapati r, et al. birth preparedness and complication readiness among husbands respectively.[7,8] another study from ethiopia found only 17.3% had arranged for blood donor.[10] more than ninety percent had prepared clean clothes for mother and baby which is similar to other studies.[7,9,11] the differences seen in relation to birth preparedness activities may be due to differences in culture, belief systems, family type, and the fact that some societies including nepal still believe that birthing and taking care of the mother and newborn is a woman’s business and that the female members of the family should look into it.[12,13] knowledge about danger signs when it comes to knowledge about the various danger signs during pregnancy, labor and postpartum period, this study showed that the husbands had little to no knowledge. most respondents spontaneously mentioned few of danger signs but very few could tell all of them or even the key danger signs. none of the husbands could tell all the three major danger signs during the postpartum period which is a crucial phase of the mother. the key danger signs during pregnancy, i.e. vaginal bleeding, blurred vision and swollen hands or feet were only correctly mentioned by 74.4%, 15.4% and 10.3% respectively which indicates that the husbands have very little about the topic. this is similar to findings from other studies done in ethiopia and cameroon.[7,9,14] similarly, a study from india showed almost half the respondents knew the danger signs during pregnancy.[11] the present study depicted none of the respondents could mention all three key danger signs during the postpartum period though some of them knew some of the danger signs. a similar study from ethiopia found only 7.5% of the husbands knew all three danger signs during postpartum period.[7] the study is not without limitations. as it was conducted in a single setting the findings of the study cannot be generalized. in addition, the study was based on self reporting and hence needed to recall events of last 12 months, so along with the subjective interpretation, recall bias might be present. conclusion: very few husbands knew all the key danger signs during pregnancy, labor, postpartum and of the newborn. slightly more than three quarter of husbands were prepared well for birth and complication readiness. individual components of bpcr was also poor among the respondents. the findings of the study highlighted that the husbands did not have enough knowledge regarding bpcr which could directly affect the health of both mother and child. conflict of interest: the authors declare that no conflicts of interest exist. source of funding: none. references: 1. silwal k, poudyal jk, shah r, parajuli s, basaula y, munikar s, et al. factors influencing birth preparedness in rapti municipality of chitwan, nepal. international journal of pediatrics. 2020;2020:pmid7402163 doi: https://doi.org/10.1155/2020/7402163 2. bhusal ck, bhattarai s. social factors associated with involvement of husband in birth preparedness plan and complication readiness in dang district, nepal. journal of community medicine & health education. 2018;08(636 issn: 2161-0711 doi: 10.4172/2161-0711.1000 636 3. solnes miltenburg a, roggeveen y, van roosmalen j, smith h. factors influencing implementation of interventions to promote birth preparedness and complication readiness. bmc pregnancy and childbirth. 2017;17(1):270. doi: doi 10.1186/s12884-017-1448-8 4. jhpiego (2004) monitoring birth preparedness and complication readiness: tools and indicators for maternal and newborn health. baltimoremd: jhpiego. pp 1–19. doi: https://www.healthynewbornnetwork.org/ resource/monitoring-birth-preparedness-a j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np https://doi.org/10.4172/2161-0711.1000636 https://doi.org/10.4172/2161-0711.1000636 prajapati r, et al. birth preparedness and complication readiness among husbands nd-complication-readiness-tools-and-indi cators-for-maternal-and-newborn-health/ 5. affipunguh pk, laar as. assessment of knowledge and practice towards birth preparedness and complication readiness among women in northern ghana: a cross-sectional study. 2016. 2016;2(6):9. doi: http://dx.doi.org/10.18203/issn.2454-215 6.intjscirep 6. markos d, bogale d. birth preparedness and complication readiness among women of child bearing age group in goba woreda, oromia region, ethiopia. bmc pregnancy and childbirth. 2014;14(1):282. doi: https;//doi.org/10.1186/1471-2393-14-28 2 7. baraki z, wendem f, gerensea h, teklay h. husbands involvement in birth preparedness and complication readiness in axum town, tigray region, ethiopia, 2017. bmc pregnancy and childbirth. 2019;19(1):180.pmid:31117972 doi: 10.1186/s12884-019-2338-z 8. wai km, shibanuma a, oo nn, fillman tj, saw ym, jimba m. are husbands involving in their spouses' utilization of maternal care services?: a cross-sectional study in yangon, myanmar. plos one. 2015;10(12):e0144135.doi:10.1371/jour nal.pone.0144135 9. mersha ag. male involvement in the maternal health care system: implication towards decreasing the high burden of maternal mortality. bmc pregnancy and childbirth. 2018;18(1):493. pmid: 30547771 doi: 10 .1186/s12884-018-2139-9 10. kahsay woldegebriel, gidey gebreamlak, haftom g. assessment of husbands’ participation on birth preparedness and complication readiness in enderta woreda, tigray region, ethiopia, 2012. journal of women's health care. 2013;03. issn:: 2167-0420 doi:http://dx.doi.org/10.4172/2167-0420 .1000140 11. mahendra g, afrafarheen mv, vijayalakshmi s. husband’s participation in birth preparedness and complication readiness. obs gyne review: journal of obstetric and gynecology. 2018;4(4). doi: https://doi.org/10.17511/joog.2018.i04.05 12. thapa dk, niehof a. women's autonomy and husbands' involvement in maternal health care in nepal. social science and medicine (1982). 2013;93:1-10. pmid: 23906115 doi:https://doi.org/10.1016/j.socscimed. 2013.06.003 13. mullany bc. barriers to and attitudes towards promoting husbands' involvement in maternal health in katmandu, nepal. social science & medicine (1982). 2006;62(11):2798-809. 14. ijang yp, cumber snn, nkfusai cn, venyuy ma, bede f, tebeu pm. awareness and practice of birth preparedness and complication readiness among pregnant women in the bamenda health district, cameroon. bmc pregnancy and childbirth. 2019;19(1):371.doi: https://doi.org/10.11 86/s12884-019-2511-4 j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np https://doi.org/10.1186/s12884-018-2139-9 https://doi.org/10.1186/s12884-018-2139-9 aerodigestive and ear foreign bodies at lumbini medical college anup acharya,a,d madan mohan singh,b,d sushil shahc,d —–————————————————————————————————————————————— abstract: introduction: aerodigestive and ear foreign bodies are common ear nose throat (ent) emergencies. they are commonly encountered by otolaryngologists, paediatricians, and primary care physicians. objective: the aim of this study is to analyze different types of foreign bodies and sociodemographic correlates of self-inflicted foreign body insertion in ear, nose and throat. method: seventy-four patients with aerodigestive foreign body coming to our hospital over a period of one year, starting from january 1, 2012, were enrolled in the study. hospital based cross sectional descriptive study was done. socio-demographic data was collected by history and clinical examination of all those patients. the data collected from 74 patients were entered and analyzed using descriptive and analytical statistical methods using spss version 17.0. result: there were total of 74 cases of ent foreign body. male predominance was noted (61%). foreign body of ear was found to be most frequent (43%) followed by throat (37%) and nose (20%). foreign body of nose was almost limited in paediatrics population (14 out of 15) whereas in the elderly group foreign body of throat was only found. seeds, meat bolus or bone or both, insects and cotton bud were the most common foreign bodies. there was significant relation between the type of foreign body and age (p <0.05) and the living foreign body and ear. conclusion: foreign bodies of nose, ear and throat are common in ent department. they should be timely managed to prevent potential complications. keywords: ear • foreign body • nose • throat ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer b associate professor c medical officer d department of ent head and neck surgery lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. anup acharya e-mail: anupent@gmail.com how to cite this article: acharya a, singh mm, shah s. aerodigestive and ear foreign bodies at lumbini medical college. journal of lumbini medical college. 2013;1(1):1-3. doi:10.22502/jlmc.v1i1.1. ___________________________________________________________________________________ j. lumbini. med. coll. vol 1, no 1, jan-june 2013 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v1i1.1 introduction: ear, nose and throat (ent) foreign bodies are one of the most common emergencies faced by otorhinolaryngologists. the different types of foreign bodies (fb) are classified as living and non-living. the non-living ones are categorized into organic and inorganic.1,2 children are naturally curious about their surroundings and about our body orifices. they are inclined to place toys, foodstuff and household articles in the ear, nose or the oral cavity. it is even difficult for them to control the foreign body because of lack of posterior dentition.3,4 foreign bodies lodged within the ear, nose, larynx, trachea, pharynx or esophagus may present as a minor irritation or a life-threatening problem.3,5,6 foreign body in adults is usually accidental. coins are the commonest fb in throat in children while bone are more common in adult population.4 this study was carried out to compare the incidence and varieties of aerodigestive foreign bodies presented in our hospital and analyze the socio-demographic correlates. methods: this hospital based cross sectional study was performed from january 2012 to december 2012 in the department of ent, lumbini medical college teaching hospital, palpa. data were collected while taking history, during clinical examination 1 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np acharya a. et al. aerodigestive and ear foreign bodies at lumbini medical college. and during removal procedure. patients or the caregivers of children were interviewed about age, sex, address, site of lodgment, type of fb. patients with any types of aerodigestive foreign bodies and patients of all ages were included in the study. aural foreign bodies were removed with forceps, hook or by syringing under local or general anesthesia according to age and type of foreign bodies and cooperation of patients. all nasal foreign bodies were removed with foreign body hook or forceps in the outpatient department. the foreign body of the throat was subjected to x-ray soft tissue neck lateral and ap and removed by rigid pharyngoscopy or oesophagoscopy. the data collected from 75 patients were entered and analyzed using spss 17 software. results: seventy-four cases were included in the study. thirty-four (46%) patients including an infant were less than 16 years of age. next 34 (46%) were adults of age 17 to 60 years. six (8%) were elderly, above 60 years of age. the age of the patients ranged from eight months to 79 years. there were 45 (61%) males and 29 (39%) females with male to female ratio of 1.55:1. foreign body of the ear was the most common. it was found in 32 cases (43%). it was followed by the foreign body of throat which accounted for 27 (37%) cases. there were 15 (20%) cases of foreign body nose. site of the foreign body was analyzed with the age-group. in the pediatric group, nasal foreign bodies was common, which constituted 14 out of 15 (93%) foreign body nose. in the elderly group (>60 years of age), all cases (100%) were of foreign body throat. seeds were the most common foreign body overall. types of foreign bodies are shown in table 1. discussion: foreign body is a common ent emergency accounting for about 11% of the cases in ent emergency.1,5,7 our study showed male predominance with m:f ratio of 1.55:1 which is also supported by other studies.1,2,8,9,10,11,12 however a study by koirala et al. showed female predominace.4 foreign body ear was the most common (43%) followed by throat (37%) and nose (20%). this was comparable to similar studies.2,13 aural foreign was found in pediatrics and adults but not in elderly. children have the tendency to explore the objects they get and are curious about the body orifices including ear. adults have a habit of picking ear with ear bud. this is why ear bud were the second most common type of aural foreign body. nasal foreign body was almost exclusively limited to pediatric age group. there were 15 nasal foreign bodies out of which 14 were present in pediatric group. the one in the adult was a leech which is not a common foreign body. this fact is supported by other studies.1,14,15 the relation of the nasal foreign body with pediatric age group was statistically significant. insects were the most common living foreign body. they get access to ear during night or when the subject is sleeping. in our study 12 out of 13 living foreign body were insect, mostly cockroach, all in the ear. one was a leech that was found in nose. there was a statistical significant relation between living foreign body and ear as the site of foreign body. the patient with the leech in the nose gave history of drinking water from stream in the jungle. this behavior is common in the hilly region of the country. among the foreign body of throat, coin were common in pediatric group. meat bolus or bone or bone were common in adults and elderly. this is similar to the findings in a study by koirala et al. done in manipal teaching hospital.4 in the elderly group, all the cases were of fb throat. this may be due to poor dentition, poor coordination during swallowing, and reduced sensation due to absent teeth. of all the foreign body, seeds were the most common (n=17, 23%). this is easily understood by the fact that lmc gets most of the patient directly depending on agricultural. of the seeds, corn was the most common. boiled, roasted, barbecued and raw corn seeds were found. in the season of corn harvest, one can see a large population enjoying different corn recipes as side or main meals. foreign body ear was removed by syringing, with forceps or ring curette. most of table 1: type of foreign body and their frequency (n=74) type of foreign body n % seeds 17 23 meat bolus 16 22 insects 12 16 cotton bud 9 12 bead, coin, fish-bone (each) 4 5.5 bamboo splinter 1 1.35 wood splinter 1 1.35 leech, button cell (each) 1 1.35 thumb pin, erasure (each) 1 1.35 orange bolus 1 1.35 2 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 acharya a. et al. aerodigestive and ear foreign bodies at lumbini medical college. jlmc.edu.np them were removed in opd. small uncooperative children or children in whom manipulation was done outside with laceration of canal skin was taken to ot for ga. all the foreign body of nose were removed in opd with topical anesthesia and nasal decongestion 20 minutes prior to removal to reduce pain and bleeding during removal. fb of pharynx and upper esophagus was removed by rigid esophagoscopy. those of mid or lower esophagus was first tried with flexible esophagogastroscopy. this is due to the fact that pharynx and upper esophagus are collapsed structures so that flexible endoscopy of these area would result in difficult visualization, instrumentation and manipulation for removal of foreign body. we had a case of eight month male child who developed acute stridor and was treated in peripheral hospital in line of lrti. in our emergency, he was initially thought of having rti but on x-ray chest was found to have a foreign body in throat. it was a thumb-pin in the hypopharynx with the pointed end anteriorly and repeatedly puncturing the tissue resulting in edema and airway compromise. he was successfully managed. conclusion: foreign bodies are common in ear, nose and throat. type and site of foreign body may differ in different ages and between different places. they generally present with minor irritation but can potentially be associated with significant complications if not taken care of properly. acute respiratory symptoms in a child should always arouse the suspicion of aerodigestive foreign body. references: 1. mukherjee a, haldar d, du a s et al. ear, nose and throat foreign bodies in children: a search for socio-demographic correlates. int j pediatr otorhinolaryngol 2011;75(4): 510-2. 2. shrestha i, shrestha bl, amatya rcm. analysis of ear, nose and throat foreign bodies in dhulikhel hospital. kathmandu univ med j. 2012;11(2):4-8. 3. carney as, patel n, clarke r. foreign bodies in the ear and the aerodigestive tract in children. in, gleeson m, editor. scott brown’s otorhinolaryngology, head and neck surgery (7thed, vol 1: hodder arnold) 2007:1184-93. 4. koirala k, rai s, chhetri s, shah r. foreign body in the esophagus-comparison between adult and pediatric popula on. nepal j med sci. 2012;1(1):42-4. 5. kitcher ed, jangul a, baidool k. emergency ear, nose and throat admissions at the korle-bu teaching hospital. ghana med j. 2007;41(1):9-11. 6. kalan a, tariq m. foreign bodies in the nasal cavities: a comprehensive review of the aetiology, diagnosticpointers, and therapeu c measures. postgrad med j. 2000;76:484-7. 7. ribeiro da silva bs, souza lo, camera mg, tamiso agb, castanheira vr. foreign bodies in otorhinolaryngology: a study of 128 cases. int arch otorhinolaryngol. 2009;13(4):394-9. 8. singh gb, sidhu ts, sharma a, dhawan r, jha sk, singh n. management of aural foreign body: an evaluative study in 738 consecutive cases. am j otolaryngol–head neck med surg. 2007;28:87-90. 9. choroomi s, curotta j. foreign body aspiration and language spoken at home: 10-year review. j laryngol otol. 2011;125:719-23. 10. shlizerman l, mazzawi s, rakover y, ashkenazi d. foreign body aspiration in children: the effects of delayed diagnosis. am j otolaryngol–head neck med surg. 2010;31:320-4. 11. rybojad b, niedzielski a, niedzielska g, rybojad p. risk factors for otolaryngological foreign bodies in eastern poland. otolaryngol head neck surg. 2012;147(5):889-93. 12. gautam v, phillips j, bowmer h, reichl m. foreign body in the throat. j accident emerg med. 1994;11:113-6. 13. endican s, garap jp, dubey sp. ear, nose and throat foreign bodies in melanesian children: an analysis of 1037 cases. int j pediatr otorhinolaryngol. 2006;70:1539-45. 14. sarkar s, roychoudhury a, roychaudhuri bk. foreign bodies in ent in a teaching hospital in eastern india. ind j otolaryngol head neck surg. 2010;62(2):118-20. 15. chai ck, tang ip, tan ty, jong de. a review of ear, nose and throat foreign bodies in sarawak general hospital. a five year experience. med j malaysia. 2012;67(1):17-20. 3 jlmc.edu.np original research article —–————————————————————————————————————————————— abstract: background: psoriasis is a worldwide disease and varies in its clinical profile and epidemiology in different regions of the world. the disease is common and few epidemiological data are available in our country. objective: the purpose of this study was to evaluate the epidemiologic and clinical features of psoriasis in lumbini medical college. methods: a retrospective investigation of a total of 240 patients visiting out patient department (opd) of dermatology and venereology of lumbini medical college with psoriasis was done. the parameters included were age at onset of disease, age at first treatment, current age, sex, type of disease and distribution of lesions. data and statistical analysis was done with spss 17.0. results: the mean age of patients at onset of disease was 26.4 (sd = 14.3) years. m:f ratio was 1.16. psoriasis vulgaris (pv) was the most common variety of the disease. extensor surface of the body was most commonly involved. conclusion: psoriasis is a common dermatological disease accounting 2.9% of all dermatology patients in our center. pv is the most common clinical subtype. the disease is more frequent in the third decade of life and has a male predominance in our region. treatment compliance has been found to be poor. keywords: clinical • dermatologic • epidemiology • psoriasis —–————————————————————————————————————————————— j. lumbini. med. coll. vol 2, no 1, jan june 2014 ___________________________________________________________________________________ a lecturer, department of dermatology and venereology b medical officer c lumbini medical college, palpa corresponding author: dr. jameel akhtar mikrani e-mail: drjameelmikrani@gmail.com how to cite this article: mikrani ja, shrestha a. clinical and epidemiological features of psoriasis in patients visiting lumbini medical college. journal of lumbini medical college. 2014;2(1):1-3. doi: 10.22502/jlmc. v2i1.45. ___________________________________________________________________________________ jameel akhtar mikrania,c, arati shresthab,c. clinical and epidemiological features of psoriasis in patients visiting lumbini medical college there is considerable difference in the incidence of disease due to environmental, genetic and geographical factors. prevalence in u.k. is 2.2%,2 8.5% in norway,3 5.2% in france,4 6.6% in australia,5 2.2% in us,6 2.3% in india,7 0.4% in sri lanka,8 0.3% in china.9 psoriasis is a chronic disease that has a fluctuating course and the course is altered by the treatment. psoriasis rarely causes mortality, but significantly affects the quality of life of the patient. in addition, it adds to the cost of treatment of the disease itself and its systemic involvement or introduction: psoriasis is a common, chronic, disfiguring, inflammatory and proliferative condition of the skin, in which both genetic and environmental influences have a critical role. it is an autoimmune epidermal proliferative disease of the skin and connective tissue. etiologic factors include environmental, genetic and immunologic factors. the most characteristic lesions consist of red, scaly, sharply demarcated, indurated plaques, present particularly over extensor surfaces and scalp (fig 1). morphological variants are common. the disease is enormously variable in duration, periodicity of flares and extent.1 fig 1: generalized plaque psoriasis https://doi.org/10.22502/jlmc.v2i1.45 1 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 mikrani ja. et al. clinical and epidemiological features of psoriasis in patients visiting lumbini medical college. comorbidity. these patients have skin symptoms, may develop arthritis, depression and cardiovascular diseases. they may have obesity, hypertension and diabetes as comorbid conditions. as many as 15.5% of psoriasis patient develop psoriatic arthritis.2,4,5 there are many treatment options for this disease namely topical, systemic, phototherapy and biological agents. the outcome of the treatment may differ in different individuals. one should understand that the treatment is a control rather than cure.3-6 the current study presents the clinical and epidemiological features of psoriatic patients attending the dermatology outpatient department of lumbini medical college teaching hospital, which is a 700 bedded multi-specialty hospital in the semiurban area of lumbini, nepal. methods: all patients diagnosed with psoriasis from the out-patient department of dermatology and venereology of lumbini medical college were selected for the study. their records were reviewed retrospectively. patients visiting from 1st of june 2010 to 31st of may 2013 were included in the study. sociodemographic data and subtype of disease was studied. all the data was entered into microsoft excel and statistical analyses were performed with spss 17. the descriptive statistics like percentage, proportion, mean and standard deviation was calculated. statistical significance was analyzed at p < 0.05. results: a total of 240 patients were enrolled in the study. out of those, 129(53.75%) were male and 111(46.25%) were female. the patients' age ranged from 6 years to 86 years (m = 36.1, sd = 22.3). the prevalence rate of this disease among dermatology patients of lmc was 2.9% (male 2.5% and female 3.6%). mean age at onset was 26.4±14.3 years (29.7±13.8 in male and 21.4±13.1 in female). mean age at first presentation to the hospital was 28.9±14.8 years. the difference in the mean age at onset of disease and that at first hospital visit was statistically significant (p<0.05). most of the patients were getting treatment from various small clinics on irregular basis. patients of nine districts (75 districts in the country) visited our hospital, namely palpa, syangja, gulmi, arghakhanchi, baglung, rupandehi, kapilbastu, nawalparasi and parbat. most patients (40.2%) visited from palpa where the medical college is located. disease was classified as shown in table 1. psoriasis vulgaris was the most common type of disease which accounted for 80% of the cases. the most common site was extensor surfaces (85.3%), scalp (46.6%), hands and feet (28.1%), lumbosacral region (13.8%) and genitals (3.2%). discussion: there are few clinical and epidemiological studies on psoriasis in our country. in our study 2.9% of the patients coming to dermatology department were suffering from psoriasis. we do not have a national data on this condition but we assume this study to reflect the scenario of the country since most of the patients were from their permanent address. a similar study in the capital city showed the prevalence rate of 3.6%.10 psoriasis was found to be more common in male (53.75%) in our study with m:f = 1.16. this finding is supported by various other studies.10-12 some studies show that this disease is equal or more common in female.13 this may be a likely scenario even in our place due to limited access to health care facilities in case of female. psoriasis vulgaris was the most common variety in our study compromising 80% of the total cases. this result was supported by other studies.10,13 extensors of the body, scalp, hands and feet were among the mostly affected body parts by the disease. these were some of the hallmark features of this disease. conclusion: psoriasis is a relatively common dermatological disease. it has affected 2.9% of the people visiting opd of dermatology and venereology department. it affects male more disease n % psoriasis vulgaris 192 80 psoriasis guttate 38 15.83 pustular psoriasis 5 2.08 psoriasis palmo plantar 4 1.67 psoriasis erythroderma 1 0.42 others 0 0 table 1: types of psoriasis (n=240) 2 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 mikrani ja. et al. clinical and epidemiological features of psoriasis in patients visiting lumbini medical college. than female. people are affected most in their third decade; however people coming to our center were mostly of fourth decade. psoriasis vulgaris is the most common clinical type, accounting for 80% of the patients. extensor surface of the body was the most affected region. most of the patient had a poor compliance to treatment. 1. o’daly ja. psoriasis, a systemic disease beyond the skin, as evidenced by psoriatic arthritis and many comorbidities – clinical remission with a leishmania amastigotes vaccine, a serendipity finding. in: o'daly ja (ed.) psoriasisa systemic disease. usa: intech; 2012:1-56. doi:10.5772/25789. 2. seminara nm, abuabara k, shin db, langan sm, kimmel se, margolis d. et al. validity of the health improvement network (thin) for the study of psoriasis. br j dermatol. 2011 mar;164(3):602–9. 3. bo k, thoresen m, dalgard f. smokers report more psoriasis, but not atopic dermatitis or hand eczema: results from a norwegian population survey among adults. dermatology. 2008;216(1):40–5. 4. wolkenstein p, revuz j, roujeau jc, bonnelye g, grob jj, bastuji-garin s et al. psoriasis in france and associated risk factors: results of a case-control study based on a large community survey. dermatology. 2009;218(2):103–9. 5. kilkenny m, stalhakis v, jolley d, marks r. maryborough skin health survey: prevalence and sources of advice for skin conditions. australas j dermatol. 1998 nov; 39(4):233–7. 6. stern rs, nijsten t, feldman sr, margolis dj, rolstad t. psoriasis is common, carries a substantial burden even when not extensive, and is associated with widespread treatment dissatisfaction. j investig dermatol symp proc. 2004 mar;9(2):136–9. 7. gunawardena da, gunawardena ka, vasanthanathan ns, gunawardena ja. psoriasis in sri-lanka – a computer analysis of 1366 cases. br j dermatol. 1978 jan;98(1):85-96. 8. yip sy. the prevalence of psoriasis in the mongoloid race. j am acad dermatol. 1984 jun;10(6):965-8. 9. shrestha dp, gurung d. psoriasis: clinical and epidemiological features in a hospital based study. nepal journal of dermatology, venerology & leprology. 2012;10(1):41-45. 10. icen m, crowson cs, mcevoy mt, dann fj, gabriel se, maradit kremers h. trends in incidence of adult onset psoriasis over three decades: a population-based study. j am acad dermatol. 2009 mar;60(3):394–401. 11. vena ga, altomare g, ayala f, berardesca e, calzavarapinton p, chimenti s et al. incidence of psoriasis and association with comorbidities in italy: a 5-year observational study from a national primary care database. eur j dermatol. 2010 sepoct;20(5):593–8. 12. menter a, gottlieb a, feldman sr, van as, leonardi cl, gordon kb et al. guidelines of care for the management of psoriasis and psoriatic arthritis. j am acad dermatol. 2008 may;58(5):826-50. 13. cakmur h, dervis e. the relationship between quality of life and the severity of psoriasis in turkey. eur j dermatol. 2015;25(2):169-76. references: 3 lmc journal vol. 2.indd 59 original article l m coll j 2013; 1(2): 59-61 evalua on of biochemical marker for bone turnover in post menopausal women joshi kr, devi sp and lanjikar pp department of biochemistry, lumbini medical college and teaching hospital (lmc&th), pravas, palpa, nepal corresponding author: mr. keshab raj joshi, lecturer, dept. of biochemistry, lmc&th, pravas, palpa, nepal; e-mail: keshab_ish@yahoo.com / keshabrajoshi@gmail.com abstract introduc on: menopause is the permanent cessa on of menses resul ng from reduced ovarian hormone secre on that occurs naturally or is induced by surgery, chemotherapy, or radia on. aims and objec ves: to evaluate the risk of accelerated bone loss by assessing bone markers like alkaline phosphatase (alp) and calcium in postmenopausal women. material and methods: the present study was carried out on 100 total subjects out of which experimental group consists of 50 subjects i.e post menopausal women. control group consists of 50 subjects pre menopausal women. results: the result of the present study suggest that the serum calcium level were signifi cantly reduced but the serum alkaline phosphatase (alp) levels had a slightly raise in post menopause group when compared to the pre menopause groups. conclusion: in normal post menopausal women, an increase in bone turnover accelerates the reduc on in bone mass, whereas decrease in bone turnover is associated with preserva on of bone mass. key words: postmenopausal women, calcium and alkaline phosphatase introduction the word ‘menopause’ is defi ned from the greek words “meno” (month) and “paus’’ (to stop). menopause is said to have occurred when menstrua on has ceased for twelve months.1 menopause is defined as the permanent cessa on of menses resul ng from reduced ovarian hormone secre on that occurs naturally or is induced by surgery, chemotherapy, or radia on.2 post-menopause is an estrogens deficient state. it applies to the whole of a woman’s life a er menopause.1 menopause and ageing is associated with accelerated loss of cor cal bone. bone loss occurs when the balance between forma on and resorp on is upset and resorp on is excessive resul ng in a nega ve remodelling balance.3 osteoporosis is an important public health problem in older adults. it is more common in postmenopausal women and not only gives rise to morbidity but also markedly diminishes the quality of life in this popula on. there is lack of informa on about the risk factor of osteoporosis in developing countries.4 serum alkaline phosphatase is the most commonly used marker of bone forma on. alp is a ubiquitous enzyme that plays an important role in osteoid forma on and mineraliza on. the total alp serum pool consists of several dimeric isoforms which originate from various ssues such as liver, bone, intes ne, spleen, kidney and placenta.5 menopause is the permanent cessa on of menstrua on due to loss of ovarian follicular function, which results in decreased production of estradial and other hormones. decreased levels of estrogen leads to increased osteoclast formationl and enchanced bone resorp on, which inturn leads to loss of bone density and destruc on of local architecture resul ng in microfractures.6 aim of the study: to evaluate the risk of accelerated bone loss by assessing bone markers like alkaline phosphatase (alp) and calcium in postmenopausal women. materials and methods the present study was carried out on 100 total subjects out of which experimental group consists of 50 subjects i.e post menopausal women. control group consists of 50 subjects pre menopausal women. a total 50 post menopausal subjects were recruited for the study with the age group of >45 years for experimental group. exclusion criteria were smokers, alcoholics and calcium supplement. a total 50 pre menopausal subjects were recruited for the study with the age group of 12-40 years for control group. exclusion criteria were pregnancy, smokers, alcoholics and oral contracep ves. results the present study analyse the serum calcium level and alp level in post menopausal women and compared with the pre menopausal women. the study was carried out on two groups of popula on, experimental 60 journal of lumbini medical college group i.e. post menopausal women consisting of 50 females and control group i.e. pre menopausal women consis ng of 50 females. exclusion criteria include smoking, consump on of alcohol, pregnancy, oral contraceptive administration and calcium supplementa on. table 1: comparison of mean values of ca (mg/dl) and alp (u/l) between post and pre menopausal women variable post menopausal pre menopausal mean sd mini max mean sd mini max ca mg/dl 8.73 0.60 5.50 9.40 9.65 0.68 9.00 13.50 alp u/l 111.86 66.56 41.00 414.00 82.40 78.50 21.00 550.00 table 2: test of signifi cance of mean values of ca and alp between post and pre menopausal women. variable post menopausal pre menopausal p t ca mg/dl 8.73 9.65 0.000 7.09* alp u/l 111.86 82.4 0.046 2.03* *indicates 5 % level of signifi cance table 1 and 2: shows that serum calcium were signifi cantly reduced in post menopause group mean (8.73±0.60) when compared to the pre menopause group mean (9.65±0.68) which shows a strong signifi cant of p=0.000, but both group values were within the normal reference range. where as serum alkaline phosphatase (alp) levels had a slight raise in post menopause group mean (111.86±66.5) when compared to the pre menopause group (82.40±78.50) showing only 5% signifi cant with p= 0.046, in these group also the values fall in the normal reference range. table 3: shows a signifi cant nega ve co rela on between calcium and alkaline phosphatase (r= -0.1496), where in serum alkaline phosphatase levels are elevated whereas serum calcium levels are reduced in postmenopausal women. table 3: pearson correla on coeffi cient of serum calcium and serum alp levels in post menopausal women. correla on coeffi cient case (n=50) r value between calcium and alp in post menopausal women -0.1496 correlation coeffi cient between post ca and post alp = 0.1496 discussion menopause is associated with numerous physiological and biochemical changes affecting bone mineral metabolism. results from various case control study on es ma on of serum calcium, inorganic phosphate, total proteins, albumin, alkaline phosphatase and acid phosphatise activities in pre and post menopausal women have shown that serum calcium levels of post menopausal women is not sta s cally signifi cant. this is in accordance with the fi ndings of ashuma , suresh and naidu and masse et.al who also reported higher levels of these parameters in post menopausal women.7-9 in the present study we had signifi cance in case and control means but s ll the values tend to remain in normal reference range. the serum calcium were signifi cantly reduced in post menopause group mean (8.73±0.60) when compared to the pre menopause group mean (9.65±0.68) which shows a strong signifi cant of p=0.000. where as serum alkaline phosphatase (alp) levels had a sight raise in post menopause group mean (111.86±66.5) when compared to the pre menopause group (82.40±78.50) showing only 5% signifi cant with p= 0.046. ashuma et.al, said that ageing and menopause, leads to decline in estrogen and progesterone produc on which has been implicated in the increased levels of calcium in post menopausal women.7 it is well known that estrogen defi ciency induces synthesis of cytokines by osteoblast, monocytes and t cells and thereby s mulates bone resorp on by increasing osteoclas c ac vity. this results in modifi ca on of the reabsorp on, excre on and resorp on of calcium leading to increased circula ng levels of this ion.10-12 no signifi cant varia on was observed in serum levels of calcium and alp in the various years since menopause group (ysm). however contrary to this fi nding higher calcium and alp have been demonstrated in early post menopausal women (≤10 ysm) compared to late menopausal women (≤10 ysm).13 bone is a connec ve ssue that provides mechanical support to the body vital organs and act as reservoir of calcium and phosphate as 99% of calcium and 85% of phosphate are present in skeleton. peak bone mass is achieved during the third decade of life which gradually declines leading to osteopenia which predisposes to osteoporosis14. conclusion in normal post menopausal women, an increase in bone turnover accelerates the reduc on in bone mass, whereas decrease in bone turnover is associated with preserva on of bone mass. in our present study serum calcium level and alp levels were es mated in post 61 kr joshi a et al menopausal women were es mated and compared with pre menopausal women. the comparison study reveals that the serum calcium were signifi cantly reduced in post menopause group mean when compared to the pre menopause group mean which shows a strong signifi cant of p=0.000. whereas serum alkaline phosphatase (alp) levels had a slightly raised in post menopause group mean when compared to the pre menopause group showing only 5% signifi cant with p= 0.046. a signifi cant nega ve correla on was observed between serum calcium and alp levels in postmenopausal experimental women references 1. harrison’s principle of internal medicine. 14th edi on. mc graw hill publica on vol. 1-chapter 6 women’s health – anthoy l. komaroff , celeste robb – nicholson, beverly woo – page no. 22. vol. 2 – chapter 337 – disorders of ovary and female reproduc ve tract – bruce r. carr, karan d. bradshow – page no. 2102. 2. nelson hd, haney e, humphrey l et al. “management of menopause-related symptoms” agency for healthcare research and quality. 3. chinyere adanna, cynthia uzoma and augusta chinyere. “biochemical bone turnover markers in postmenoposal women in calabar municipality” asian j biochem, 2007; 2 (2): 130-5. 4. afsaneh keramat, bhushan patwardhan, bagher larijani et al. “the assessment of osteoporosis risk factors in iranian women compared with indian women” bmc musculoskeletal disorders j 2008; 28(9): 1471-4. 5. delmas p d, eastell r, garnero p et al. “the use of biochemical markers of bone turnover in osteoporosis” osteoporosis int 2000; 6: 2-17. 6. deepthi sk, amar g, narayan r, naidu jn. “study of biochemical bone turnover markers in postmenopausal women leading to osteoporosis” int j applied biol pharmacu cal technol 2012; 3(3): 301. 7. ashuma s, shashi s, sachdeva s. “biochemical markers of bone turnover; diagnos c and therapeu c principles” osteoporosis 2005; 3(2): 305-11. 8. suresh m, naidu dm. “influence of years since menopause on bone mineral metabolism in south indian women” ind j med sci 2006; 60: 190-8. 9. masse p, jougleux jl, caissie m et al. “bone mineral density and metabolism at an early stage of menopause when oestrogen and calcium supplement are not in used and without interference of major confounding variables” j am college nutr 2005; 24: 354-60. 10. esbrit, p. “hyper calcemia of malignancy: new insights into an old syndrome” clin lab 2001; 47: 67-71. 11. riggs bl, khosla s, melton lj. a unitary model of involu onal osteoporosis: oestrogen defi ciency causes both type 1 and type 2 osteoporosis in postmenopausal women and contributes to bone loss in ageing men. j bone miner res 1998; 13: 763-73. 12. kurland es, cosman f, mcmahon dj. parathyroid hormone as a therapy for idiopathic osteoporosis in men. eff ect on bone mineral density and bone markers. j clin endocinol metab 2000; 85: 3069-76. 13. suresh m, naidu dm. “influence of years since menopause on bone mineral metabolism in south indian women” indian j med sci 2006; 60: 190-8. 14. k.satya narayana, sravanthi koora, g.t sivaraja sundari et al. “the use of serum & urinary biochemical markers of bone turnover in post menopausal women” int j healthcare biomed res. 2012; 1(1): 6-12. https://doi.org/10.22502/jlmc.v11i1.499 original research article evaluation of intra-operative and post-operative complications of non descent vaginal hysterectomy: a single-center hospital-based prospective study buddhi kumar shrestha a,c , satindar ray b,c abstract: introduction: globally, hysterectomy is the most common major gynecological procedure. patients opting hysterectomy for benign non prolapse cases may be offered non-descent vaginal hysterectomy with quicker recovery, shorter hospital stay, less intra and post-operative morbidity compared to abdominal route. vaginal approach for hysterectomy is desirable in nepal due to limited health resources. this study aimed to evaluate the intra and post-operative complications of non-descent vaginal hysterectomy (ndvh). methods: a prospective study was conducted at college of medical sciences over one-year period. a total of 50 cases were selected for ndvh on the basis of inclusion and exclusion criteria. data regarding age, parity, uterine size, estimated blood loss, length of operation, complication and hospital stay were recorded. results: majority of women were in the age group of 41-45 years (mean age: 44.7±5.6 years) and multiparous (38%). the common indications for ndvh were fibroid uterus (66%) and adenomyosis (14%). the mean volume of blood loss was 121.5ml±110.94 and 3% required blood transfusion. the mean drop in hemoglobin level was statistically significant post surgery [1.05gm/dl]. the mean surgical time was 69.54±19.32 minutes. in the post-operative period, 10% women had uti and 2% had fever. the mean duration of hospital stay was 4.06±0.24 days. conclusion: non-descent vaginal hysterectomy is a major surgery suitable in low-and middle income countries like nepal with good outcome and low complication rates. keywords: complications, intra-operative, non-descent vaginal hysterectomy, pre-operative. submitted: february 14, 2023. accepted: april 13, 2023. published: june 1, 2023. a associate professor, department of obstetrics and gynecology. b resident, department of obstetrics and gynecology c college of medical sciences, bharatpur, chitwan, nepal. corresponding author: buddhi kumar shrestha. college of medical sciences, bharatpur, chitwan, nepal. email: drbuddhi205@gmail.com orcid: http://orcid.org/0000-0002-6196-4642 introduction: hysterectomy is the most common major gyneco-surgical procedure performed globally with a broad spectrum of indications ranging from malignant gynecological diseases to obstetrical conditions.[1,2] regardless of the how to cite this article: shrestha bk, ray s. evaluation of intra-operative and post-operative complications of non descent vaginal hysterectomy: a single-center hospital-based prospective study. j lumbini med coll. 2023;11(1):7 pages doi: https://doi.org/10.22502/jlmc.v11i1.499 . epub: june 1, 2023. j. lumbini med. coll . vol 11, no 1, jan-june 2023 https://doi.org/10.22502/jlmc.v10i1 mailto:drbuddhi205@gmail.com http://orcid.org/0000-0002-6196-4642 https://doi.org/10.22502/jlmc.v10i2 shrestha bk, ray s. intraand post-operative complications of non descent vaginal hysterectomy mode [abdominal /vaginal /laparoscopic/ robotic/combined], it is most often performed for benign conditions to improve the patient’s quality of life when medical or other less invasive methods have failed.[3,4] various factors to be considered in choosing the route for hysterectomy should include safety, cost-effectiveness and the medical needs of the patient .[5] non-descent vaginal hysterectomy (ndvh), a vaginal approach without uterine prolapse, is associated with less morbidity, lower health care costs, less hospital stay, minimal complications and better patient satisfaction compared to laparoscopic techniques.[6 ] it is also associated with less complications rate, less operative time and a faster convalescence. [ 7,8] vaginal approach for hysterectomy is desirable in low and middle income countries like nepal due to limited health resources. this study was therefore conducted to note the various intra and post-operative complications of ndvh. methods: this study was a single-centered hospital-based prospective study conducted at the department of gynecology and obstetrics, college of medical sciences and teaching hospital, bharatpur, over a one-year period from 15 th march 2019 to 14 th march 2020 after approval from the institutional ethical committee [comsth-irc/2019-150]. the sample size was derived from cochran´s formula: n = zpq/ e 2 , where, n = minimal sample size , z = 1.96 , p = prevalence , q = 1-p , e = 0.05 taking prevalence (p) as 2.9% [9], the sample size for this study was calculated to be 46. a total of 50 cases were enrolled in the study. all the cases were selected on the basis of inclusion and exclusion criteria. the inclusion criteria were age above 35 years, uterine size not exceeding 16 weeks of gravid uterus , adequate vaginal access with good uterine mobility and non-prolapsed uterus, no previous pelvic surgery, d ysfunctional uterine bleeding (dub), adenomyosis, leiomyoma, and endometrial hyperplasia. cases with nulliparity and those with suspicion of malignancy and complex adnexal masses were excluded. detailed history including significant past history, surgical history, family history, menstrual history and personal history were taken to determine the risk factors for outcomes of ndvh. proper general physical and systemic examination and routine investigations were done. special consent for conversion to abdominal hysterectomy if needed was taken. all the cases were reassessed in operating theatre after the patient was anaesthetized, to confirm the size, mobility of uterus, vaginal accessibility, and laxity of pelvic muscles. vaginal hysterectomy was considered successful if it was not converted to abdominal route. in bigger size uterus, debulking techniques were performed as and when required. the intra-operative events i.e. the length of operation (incision of cervico-vaginal junction to the closure of vault) and estimated blood loss during surgery measured with gauze visual analogue [ 10] as well as intra-operative complications i.e. visceral injury (bladder/ ureteric/ bowel), conversion to total abdominal hysterectomy (tah), hemorrhage requiring blood transfusion, if any, were recorded. the post-operative complications like fever, hemorrhage, urinary tract infection, vaginal vault infection, paralytic ileus, chest infection, vault granuloma, and post-operative psychosis were recorded if encountered post operatively. j. lumbini med. coll . vol 11, no 1, jan-june 2023 jlmc.edu.np http://jlmc.edu.np/ shrestha bk, ray s. intraand post-operative complications of non descent vaginal hysterectomy data regarding age, parity, uterine size, indications, intra-operative and post operative events and complications, adjuvant procedures, clinical outcome and hospital stay were recorded. patients were prescribed an identical regime of analgesia and prophylactic antibiotics post-operatively for five days. the post-operative haemoglobin was estimated on the first post-operative day to compare the drop in haemoglobin following surgery. all the cases were advised for follow up in two weeks after discharge with histopathology report and thereafter in four weeks for observation of late complications. the collected data were recorded in a preformed performa and entered in statistical package for social sciences (spss tm ) software version 20. descriptive analysis is presented in mean ±sd. frequency tables were generated for the categorical data and are presented in frequency and percentage. a p-value less than 0.05 was considered to be statistically significant. results: the most common age group of the women enrolled in the study was 41-45 years with the mean age 44.70±5.60 years. majority (38%) of women had parity 2. out of 50 cases, the most common indication for ndvh was uterine fibroid in 33 patients (66%) followed by adenomyosis in seven cases (14%), endometrial hyperplasia in four cases (8%), dysfunctional uterine bleeding in three cases (6%), endometrial polyp in two cases (4%) and chronic cervicitis in one case (2%). thirty one (62%) of women had uterine size six to ten weeks, nine (18%) had 10-12 weeks size uterus, eight (16%) had normal to six weeks size uterus and two (4%) women had 12-16 weeks size uterus. out of 50 cases, 43 cases had no co-morbidities and one case had type ii diabetes mellitus, one case had type ii dm and hypothyroidism, one with hepatitis b, and four cases with systemic hypertension. all 50 patients were monitored during intra-operative period for blood loss and duration of surgery. the mean duration of surgery was 69.54 minutes (sd 19.32; ci 95%). the mean volume of blood loss was 121.5ml (sd±110.94; ci 95%). among 50 patients, six cases needed debulking technique (12 %), of which the most common technique was bisection in five cases (10%) and the second most common was myomectomy in one case (2%). during ndvh, only three cases needed blood transfusion due to hemorrhage and there were no other complications like visceral injury or conversion to abdominal hysterectomy. women who underwent ndvh had undergone hemoglobin (hb) level estimation both in pre and post-operative periods. the estimated hb had been compared in both periods in terms of minimum and maximum level, mean and standard deviation. preoperatively, it was found that the mean hb level was 11.54gm/dl (sd±1.23). post-operatively, the mean level was 10.49gm/dl (sd±1.18). table 1: comparison of pre-operative and post-operative hemoglobin level. hemoglobin level mean ± sd standard error of mean p value* pre-operative hb (gm/dl) 11.54±1.23 0.12 <0.001 post-operative hb (gm/dl) 10.49±1.18 *paired t test j. lumbini med. coll . vol 11, no 1, jan-june 2023 jlmc.edu.np http://jlmc.edu.np/ shrestha bk, ray s. intraand post-operative complications of non descent vaginal hysterectomy in comparison between pre-operative and post-operative hb level (table 1), there was a mean drop in hb level of 1.05gm/dl (p-value <0.001) which was statistically significant (p<0.05). the most common postoperative complication was urinary tract infection (10%) and fever in 1 case (2%) (fig.1). the other complications like hemorrhage, vault hematoma or infection, paralytic ileus, chest infection, vault granuloma or post-operative psychosis were absent. eighty two percent of women had ambulated within 24 hours of ndvh. the mean duration of hospital stay was 4.06 days (sd±0.237). forty-seven patients (94%) had four days of hospital stay and remaining three patients (6%) had five days. fig.1 post-operative complications of the study population discussion: hysterectomy is the second most common surgery performed on women after caesarean section around the world.[11] it is a well-known fact that 70-80% of hysterectomies are performed by abdominal route despite higher complication rate and vaginal approach is usually reserved for utero-vaginal prolapse.[12,13] the factors that may influence the route of hysterectomy for any surgical indication include uterine size, mobility, accessibility and pathology confined to the uterus (no adnexal pathology or known or suspected adhesions).[14] majority of the patients were in the age group of 41-45 years in our study. similar age prevalence was noted in other case series reviews.[15,16,17] most of the patients were multiparous comparable to other studies.[13,14,15,18,19] the commonest indication for ndvh was fibroid uterus, which remained commonest indication in the studies by dewan et al.,[15] bharatnur et al.,[16] singh et al.[17] and goel et al.[18] the mean blood loss (121.5 ml) was less than the amount reported in other studies like dewan et al. (290ml),[15] bharatnur et al. (164ml) [16] and goel et al. (168ml).[18] but it was high compared to some other studies by bhadra et al. (100ml)[13] and 35.56 ml by singh and colleagues.[17] three (6%) of the patients required blood transfusion, which was similar to the result of crest study[19] but less compared to the study by rachana and colleagues (15%) of nepal.[20] the mean j. lumbini med. coll . vol 11, no 1, jan-june 2023 jlmc.edu.np http://jlmc.edu.np/ shrestha bk, ray s. intraand post-operative complications of non descent vaginal hysterectomy duration of surgery was 69.54 minutes as compared to bhadra et al.(55 minutes)[13], dewan et al. (54.5 minutes),[15] bharatnur et al. (65minutes)[16] and goel et al. (64 minutes).[18] whereas it was shorter compared to the study conducted by rachana et al. ( 120 minutes)[20] and durga et al. (90minutes).[21] the operative time was definitely more in the earlier phase of the learning. the size of uterus was bigger in our cases as compared to sheth in his personal series of 5655 cases.[22,23] due to the larger size of myoma preventing descent, six cases required debulking technique and the reasons were similar as cited by goel et al.[18] in their analysis of 75 cases. eighty two percent of our ndvh ladies had ambulated within 24 hours of surgery which was better compared to mehta et al (66%).[ 24] the post-operative uti and fever were the only complications in our study population similar to the study conducted by mehta et al.[24] the duration of hospital stay was four days which was similar to the studies by rachana et al.[20] and shorter compared to average stay of 7-8 days for abdominal hysterectomy in our hospital. the hospital stay of 2-5 days during ndvh was reported in other studies.[25,26]. the intra-operative and post-operative complications were less in our study population. while comparing complications of vaginal hysterectomy with other route, it has best outcomes with minimal complications.[27] the limitation of the study was small size of population. so, the numbers of complication were documented less. more studies comparing this approach with other alternatives such as abdominal route and laparoscopic approaches should be done in future and the outcome, complications as well as cost effectiveness of ndvh in comparison to other methods should be done in the local setting. conclusion: non-descent vaginal hysterectomy is a feasible vaginal surgery in low and middle income countries like nepal with low intra-operative and post operative complications with no mortality in our study. source of funds : no funds were available for the study. conflict of interest: the authors declare that no competing interests exist. references: 1. odeh amarin z. hysterectomy: past, present and future [internet]. london: intecopen; 2022. doi: http://dx.doi.org/10.5772/intechopen.1030 86 2. american college of obstetricians and gynecologists. committee opinion no 701: choosing the route of hysterectomy for benign disease. obstet gynecol. 2017;129(6):e155-9. pmid: 28538495 doi: https://doi.org/10.1097/aog.000000000000 2112 3. thurston j, murji a, scattolon s, wolfman w, kives s, sanders a, et al. no. 377-hysterectomy for benign gynaecologic indications. j obstet gynaecol can. 2019;41(4):543-57. pmid: 30879487 . doi: https://doi.org/10.1016/j.jogc.2018.12.006 4. manandhar t, sitaula s, thapa bd, agrawal a, thakur a. prevalence of hysterectomy among gynecological surgeries in a tertiary care hospital. jnma j nepal med assoc. 2020;58(232):965-970. pmid: 34506386 doi: https://doi.org/10.31729/jnma.5315 5. landeen lb, bell mc, hubert hb. bennis ly, knutsen-larson ss, j. lumbini med. coll . vol 11, no 1, jan-june 2023 jlmc.edu.np http://dx.doi.org/10.5772/intechopen.103086 http://dx.doi.org/10.5772/intechopen.103086 https://pubmed.ncbi.nlm.nih.gov/28538495/ https://doi.org/10.1097/aog.0000000000002112 https://doi.org/10.1097/aog.0000000000002112 https://pubmed.ncbi.nlm.nih.gov/30879487/ https://pubmed.ncbi.nlm.nih.gov/30879487/ https://doi.org/10.1016/j.jogc.2018.12.006 https://pubmed.ncbi.nlm.nih.gov/34506386/ https://doi.org/10.31729/jnma.5315 http://jlmc.edu.np/ shrestha bk, ray s. intraand post-operative complications of non descent vaginal hysterectomy seshadri-kreaden u. clinical and cost comparisons for hysterectomy via abdominal, standard laparoscopic, vaginal and robot-assisted approaches. s d med. 2011;64(6):197-9. pmid: 21710804 6. ransom sb, mcneeley sg, white c, diamond mp. a cost analysis of endometrial ablation, abdominal hysterectomy, vaginal hysterectomy and laparoscopy – assisted vaginal hysterectomy in the treatment of primary menorrhagia. j am assoc gynaecol laparosc. 1996;4(1):29-32. pmid: 9050708 doi: https://doi.org/10.1016/s1074-3804(96)80 105-8 7. aarts jwm, nieboer te, johnson n, tavender e, garry r, mol bmj, et al. surgical approach to hysterectomy for benign gynaecological disease. cochrane database syst rev. 2015;2015(8):cd003677. pmid: 26264829 doi: https://doi.org/10.1002/14651858.cd00367 7.pub5 8. maresh mj, metcalfe ma, mcpherson k, overton c, hall v, hargreaves j, et al. the value national hysterectomy study: description of the patients and their surgery. bjog. 2002;109(3):302-12. pmid: 11950186 doi: https://doi.org/10.1111/j.1471-0528.2002. 01282.x 9. bansal n, hiremath pb, meenal c, prasad v. an audit of indications and complications associated with elective hysterectomy at svmch and rc, ariyur, pondicherry. international journal of medical research & health sciences. 2013;2(2):147-55. available from: https://www.ijmrhs.com/abstract/an-audit of-indications-and-complications-associat ed-with-elective-hysterectomy-at-svmch-a nd-rc-ariyur-pondicherry-116.html 10. ali algadiem e, aleisa aa, alsubaie hi, buhlaiqah nr, algadeeb jb, alsneini hal. blood loss estimation using gauze visual analogue. trauma mon. 2016;21(2):e34131. pmid: 27626017 doi: https://doi.org/10.5812/traumamon.34131 11. chattopadhyay s, patra kk, halder m, mandal a, pal p, mandal a, et al. a comparative study of total laparoscopic hysterectomy and non-descent vaginal hysterectomy for treatment of benign diseases of uterus. international journal of reproduction, contraception, obstetrics and gynecology. 2017;6(3):1109-1112. doi: https://doi.org/10.18203/2320-1770.ijrcog 20170594 12. berek js. berek & novak's gynecology. 16th ed. wolters kluwer; 2019 available from: https://solution.lww.com/berekandnovakg ynecology15e 13. bhadra b, choudary ap, tolassaria a, nupur n. non-descent vaginal hysterectomy (ndvh): personal experiences in 158 cases. al ameen journal of medical science. 2011;4(1):23-7. available from: http://ajms.alameenmedical.org/articlepdfs /ajms%204.1.%2023-27.pdf 14. kovac sr, barhan s, lister m, tucker l, bishop m, das a. guidelines for the selection of the route of hysterectomy: application in a resident clinic population. am j obstet gynecol. 2002;187(6):1521–7. pmid: 12501056 doi: https://doi.org/10.1067/mob.2002.129165 15. dewan r, agarwal s, minocha b, sen sk. non-descent vaginal hysterectomy -an experience. the journal of obstetrics and gynecology of india. 2004;54(4):376-8. available from: https://www.nepjol.info/index.php/njog/ article/download/11134/8993 16. bharatnur s. comparative study of abdominal versus vaginal hysterectomy in j. lumbini med. coll . vol 11, no 1, jan-june 2023 jlmc.edu.np https://pubmed.ncbi.nlm.nih.gov/21710804/ https://pubmed.ncbi.nlm.nih.gov/9050708/ https://pubmed.ncbi.nlm.nih.gov/9050708/ https://doi.org/10.1016/s1074-3804(96)80105-8 https://doi.org/10.1016/s1074-3804(96)80105-8 https://pubmed.ncbi.nlm.nih.gov/26264829/ https://pubmed.ncbi.nlm.nih.gov/26264829/ https://doi.org/10.1002/14651858.cd003677.pub5 https://doi.org/10.1002/14651858.cd003677.pub5 https://pubmed.ncbi.nlm.nih.gov/11950186/ https://doi.org/10.1111/j.1471-0528.2002.01282.x https://doi.org/10.1111/j.1471-0528.2002.01282.x https://www.ijmrhs.com/abstract/an-audit-of-indications-and-complications-associated-with-elective-hysterectomy-at-svmch-and-rc-ariyur-pondicherry-116.html https://www.ijmrhs.com/abstract/an-audit-of-indications-and-complications-associated-with-elective-hysterectomy-at-svmch-and-rc-ariyur-pondicherry-116.html https://www.ijmrhs.com/abstract/an-audit-of-indications-and-complications-associated-with-elective-hysterectomy-at-svmch-and-rc-ariyur-pondicherry-116.html https://www.ijmrhs.com/abstract/an-audit-of-indications-and-complications-associated-with-elective-hysterectomy-at-svmch-and-rc-ariyur-pondicherry-116.html https://pubmed.ncbi.nlm.nih.gov/27626017/ https://pubmed.ncbi.nlm.nih.gov/27626017/ https://doi.org/10.5812/traumamon.34131 https://doi.org/10.18203/2320-1770.ijrcog20170594 https://doi.org/10.18203/2320-1770.ijrcog20170594 https://solution.lww.com/berekandnovakgynecology15e https://solution.lww.com/berekandnovakgynecology15e http://ajms.alameenmedical.org/articlepdfs/ajms%204.1.%2023-27.pdf http://ajms.alameenmedical.org/articlepdfs/ajms%204.1.%2023-27.pdf https://pubmed.ncbi.nlm.nih.gov/12501056/ https://doi.org/10.1067/mob.2002.129165 https://www.nepjol.info/index.php/njog/article/download/11134/8993 https://www.nepjol.info/index.php/njog/article/download/11134/8993 http://jlmc.edu.np/ shrestha bk, ray s. intraand post-operative complications of non descent vaginal hysterectomy non-descent cases. international journal of gynecology and obstetrics. 2011;15(2):34. available from: https://www.ijrcog.org/index.php/ijrcog/ar ticle/view/1896 17. singh a, bansal s. comparative study of morbidity and mortality associated with nondescent vaginal hysterectomy and abdominal hysterectomy based on ultrasonographic determination of uterine volume. int surg. 2008;93(2):88-94. pmid: 18998287 18. goel n, rajaram s, agarwal r, mehta s. step by step non-descent vaginal hysterectomy. 3 rd ed. new delhi: jp medical ltd, 2017. 19. dicker rc, greenspan jr, strauss lt, cowart mr, scally mj, peterson hb, et al. complications of abdominal and vaginal hysterectomy among women of reproductive age in the united states. the collaborative review of sterilization. am j obstet gynecol. 1982;144(7):841-8. pmid: 7148906 doi: https://doi.org/10.1016/0002-9378(82)903 62-3 20. saha r, shrestha ns, thapa m, shrestha j, bajracharya j, padhye sm. non-descent vaginal hysterectomy: safety and feasibility. nepal journal of obstetrics and gynaecology. 2012;7(2):14-6. doi: http://www.dx.doi.org/10.3126/njog.v7i2. 11134 21. bc d, sharma a, mahaseth b, sharma n. a comparative evaluation of non-descent vaginal hysterectomy versus total abdominal hysterectomy: a hospital based case control study. journal of nepalgunj medical college. 2019;17(1):20-2. doi: https://doi.org/10.3126/jngmc.v17i1.2531 0 22. malhotra n , puri r, malhotra j . operative obstetrics and gynaecology. 2 nd rev.ed. new delhi: jp medical ltd; 2014. 23. sheth ss. paghdiwalla kp. in: saraiya ub, rao a k, chateerjee a, bharatnur et al. editors. principles and practice of obstetrics and gynaecology. new delhi, 2003. p.374-80. 24. mehta k, prakash o, fatehpuriya ds, verma l. comparative study of abdominal hysterectomy and vaginal hysterectomy in non-descent cases-a prospective study. international journal of reproduction, contraception, obstetrics and gynecology. 2017;6(4):1265-70. doi: http://dx.doi.org/10.18203/2320-1770.ijrc og20170952 25. doucette rc, sharp ht, alder sc. challenging generally accepted contraindications to vaginal hysterectomy. am j obstet gynecol. 2001;184(7):1386-9. pmid: 11408857 doi: https://doi.org/10.1067/mob.2001.115047 26. magos a, bournas n, sinha r, richardson re, o'connor . vaginal hysterectomy for large uterus. br j obstet gynaecol. 1996;103:246-51. pmid: 8630309 doi: https://doi.org/10.1111/j.1471-0528.1996.t b09713.x 27. aarts jwm, nieboer te, johnson n, tavender e, garry r, mol bwj. surgical approach to hysterectomy for benign gynaecological disease. cochrane database of systematic reviews. 2015;2015(8):cd003677. pmid: 26264829 doi: https://doi.org/10.1002/14651858.cd00367 7.pub 5 j. lumbini med. coll . vol 11, no 1, jan-june 2023 jlmc.edu.np https://www.ijrcog.org/index.php/ijrcog/article/view/1896 https://www.ijrcog.org/index.php/ijrcog/article/view/1896 https://pubmed.ncbi.nlm.nih.gov/18998287/ https://pubmed.ncbi.nlm.nih.gov/7148906/ https://doi.org/10.1016/0002-9378(82)90362-3 https://doi.org/10.1016/0002-9378(82)90362-3 http://www.dx.doi.org/10.3126/njog.v7i2.11134 http://www.dx.doi.org/10.3126/njog.v7i2.11134 https://doi.org/10.3126/jngmc.v17i1.25310 https://doi.org/10.3126/jngmc.v17i1.25310 http://dx.doi.org/10.18203/2320-1770.ijrcog20170952 http://dx.doi.org/10.18203/2320-1770.ijrcog20170952 https://pubmed.ncbi.nlm.nih.gov/11408857/ https://doi.org/10.1067/mob.2001.115047 https://pubmed.ncbi.nlm.nih.gov/8630309/ https://pubmed.ncbi.nlm.nih.gov/8630309/ https://doi.org/10.1111/j.1471-0528.1996.tb09713.x https://doi.org/10.1111/j.1471-0528.1996.tb09713.x https://doi.org/10.1002/14651858.cd003677.pub5 https://doi.org/10.1002/14651858.cd003677.pub5 https://doi.org/10.1002/14651858.cd003677.pub5 https://doi.org/10.1002/14651858.cd003677.pub5 http://jlmc.edu.np/ j. lumbini. med. coll. vol 8, no 2, july-dec 2020 dwivedi r, et al. comparison of external fixation and supplementary kirschner-wires fixation with volar locking plate for the treatment of intra-articular distal end radius fractures. 212 jlmc.edu.np ___________________________________________________________________________________ submitted: 19 august, 2020 accepted: 05 october, 2020 published: 21october, 2020 aassociate professor, department of orthopedics, blecturer, department of orthopedics, cresident, department of orthopedics, dlumbini medical college and teaching hospital, palpa, nepal. corresponding author: dr. rajeev dwivedi e-mail: rd172002@gmail.com orcid: https://orcid.org/0000-0001-7734-3931_______________________________________________________ abstract: introduction: there are controversies regarding the benefit of open reduction and internal fixation with volar locking plates over closed reduction and external fixation along with supplementary kirschner wires fixation for intra-articular distal end radius fracture.therefore, this study aimed to compare the outcomes between external fixation along with supplementary kirschner wires with volar locking plate in the treatment of intra-articular distal end radius fractures. methods: this prospective, observational and analytical study was conducted over one and a half years. forty-seven adults with displaced intra-articular distal end radius fracture were included in the study. twenty-one cases were treated with closed reduction and external fixation along with supplementary kirschner wires, whereas 26 patients were treated with open reduction and volar locking plate fixation. results: at the end of three months, as per the green and o’brien scoring, the mean functional outcome score in the volar plate group was significantly better 80.77(±11.46) than the external fixation group 70.24(±10.66) (p=0.002). however, at the end of six months, the mean score in the volar plate group 86.15(±7.39) was not significantly different from the external fixation group 81.43(±9.63) (p= 0.63). fracture reduction was achieved and maintained better in the volar locking plate group. conclusion: functional outcome of closed reduction and external fixation along with supplementary kirschner wires is comparable with open reduction and internal fixation by volar locking plate in treatment of displaced intraarticular distal radius fractures. radiological correction is achieved and maintained better with volar locking plates. keywords: external fixation; functional outcomes; green and o’brien score; intra-articular distal radius fracture; volar locking plate original research articlehttps://doi.org/10.22502/jlmc.v8i2.397 rajeev dwivedi,a,d mandir khatri,b,d arjun kc c,d comparison of external fixation and supplementary kirschner-wires fixation with volar locking plate for the treatment of intraarticular distal end radius fractures how to cite this article:how to cite this article: dwivedi r, khatri m, kc a. comparison of external fixation and supplementary kirschner-wire fixation with volar locking plate for the treatment of intra-articular distal end radius fractures. journal of lumbini medical college. 2020;8(2):212-217. doi: https://doi. org/10.22502/jlmc.v8i2.397 epub: 2020 october 21. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: there are controversies regarding the management of distal end radius fracture.[1]there are various treatment options available for the distal radius fractures, which range from closed reduction and cast application, percutaneous kirschner (k) wire fixation, open reduction and internal fixation with volar or dorsal plates (locking or nonlocking), bridge plating, use of an external fixator along with supplementary k-wires or a combination of these techniques. the best choice depends on the age and demand of patients.[2,3] for intra-articular distal end radius fractures, commonly performed procedures are open reduction and internal fixation with volar locking plates and j. lumbini. med. coll. vol 8, no 2, july-dec 2020 dwivedi r, et al. comparison of external fixation and supplementary kirschner-wires fixation with volar locking plate for the treatment of intra-articular distal end radius fractures. 213 jlmc.edu.np closed reduction and external fixation along with supplementary k-wires fixation. according to literature, there is no consistent benefit of one method over another.[1,2,3,4] therefore, this study aimed to compare outcomes between external fixation along with additional k-wires with a volar locking plate for intra-articular distal radius fractures. methods: this prospective, observational, and analytical study was conducted at the department of orthopedics, lumbini medical college, and teaching hospital (lmcth), nepal from march 2019 to august 2020. a convenient sampling technique was used; sample size calculation was done. reference values for sample size calculations were taken from the study by pradhan r l et al.[5] radial inclination was taken for reference values and calculation was done at a confidence level of 90% and power of 80%. n = (z1-α/2+z1-β) 2 x (σ1 2 +σ2 2/r)/ (μ1μ2) 2 n=sample size 14.2 at 10% drop out =15.53, 16 patients in each group. this study was approved by the institutional review committee (irc -lmc 015-a/019) of lmcth. informed consent was taken from each participant. patients of 18 years and above with displaced intraarticular distal end radius fracture of ao type c1, c2, or c3 were included in the study. patients with pathological fractures, compound fractures, fractures with distal neurological deficits, and delayed presentation of more than two weeks were excluded from the study. x-rays in anteroposterior (ap) and lateral views of the injured wrist was taken. an ap view of the uninjured side was taken for comparison. ct scan of the wrist was done in every case. selection of procedure, open reduction, and internal fixation with volar locking plates or closed reduction, external fixation and k-wire fixation was the surgeon’s decision. procedure external fixation and k-wire insertion: standard techniques and principles of external fixation were followed. two schanz pins of 2.5mm were inserted in the second metacarpal and two 3.5 mm pins in the radius proximal to the abductor pollicis longus muscle belly. the pins were interconnected with connecting rod and universal clamps. the reduction of fracture was done with traction and counter traction technique and direct manipulation of fragments if necessary. the reduction was checked in the c-arm in ap and lateral views and an external fixator was tightened. two additional k-wires 1.5 to 1.8 mm were inserted, one from the radial styloid and another from the dorso-ulnar side in all cases. final reduction was checked under c-arm. volar locking plate technique: a 2.7 mm twocolumn volar distal radius plate or 2.7 mm volar rim distal radius plate was used to fix the fracture. the fracture was approached through modified henry’s approach. fracture fragments were reduced by direct manipulation, verified under c-arm and temporary fixation was done with k-wires. the plate was placed on the volar surface of the radius. the position of the plate was verified under c-arm and locking screws were inserted. after the closure of the wound, the fracture was immobilized in the below-elbow dorsal slab. acceptable criteria for fracture reduction: the reduction of fracture was considered satisfactory when the following radiological parameters were met.[3,6] 1. the radial inclination of >150. 2. radial shortening of <5 mm compared to the contralateral side. 3. the sagittal tilt between 150 dorsal and 200 volar tilt. 4. intra-articular step-off of <2 mm. postoperative protocol: follow up was done at two weeks, six weeks, three months, and six months. in the volar plating group, suture and slab removal was done at two weeks. physiotherapy of the wrist was started following the removal of the slab. in the external fixator group, pin site inspection and the dressings were done at two weeks. external fixator and k –wires were removed at six weeks following which physiotherapy was started. functional evaluation was done at three months and six months and comparison was done between groups. functional evaluation was done according to the green and o’brien scoring system. [7] this includes pain, activity status, grip strength, and wrist range of motion (rom): flexion and extension (both grip strength and rom measured as a percentage of the normal wrist). points in each range from 0-25 with a maximum score of 100. scores j. lumbini. med. coll. vol 8, no 2, july-dec 2020 dwivedi r, et al. comparison of external fixation and supplementary kirschner-wires fixation with volar locking plate for the treatment of intra-articular distal end radius fractures. 214 jlmc.edu.np <65 were considered poor, and scores between 65 and 79, between 80 and 89, and between 90 and 100 were considered fair, good and excellent, respectively. at six weeks and six months follow-up, ap and lateral views x-rays of the affected wrist was done for radiological evaluation. radiological measurements (dorsal tilt, radial inclination, and radial length) were done for comparison between two groups. data were recorded in the proforma. the data were then coded and entry was done in the statistical package for social sciences (spsstm) version 16.0. the data were processed and analyzed. the mean values of continuous outcome characteristics between the two techniques were compared by the student t-test. ordinal outcomes were compared using fisher exact test or chi-square test as appropriate. all tests were two-sided and p-values <0.05 were considered significant. results: a total of 47 patients were included in the study. twenty-one patients were treated by closed reduction and external fixation along with supplementary k-wires. twenty-six patients were treated by open reduction and internal fixation with a volar locking plate. fractures united within six months in all patients. the demographic characteristics of patients are shown in table 1. at the end of three months, as per the green and o’brien score, the mean functional outcome score in the volar plate group was significantly better 80.77(±11.46) compared to the external fixation group 70.24(±10.66)(p=0.002). however, at the end of six months, the mean score in the volar plate group 86.15(±7.39) was not significantly different from that in the external fixation group 81.43(±9.63) (p= 0.63). functional outcomes at three months and six months are shown in table 2. at the end of three months, 18 (69.23%) cases were good to excellent in the volar plate group compared to the external fixator group where 8 (38.09%) cases had good to excellent outcomes (p=0.033). at the end of six months, 21 (80.76%) cases had good to excellent in the volar plate group compared to 16 (76.19%) cases in the external fixation group (p=0.703) table 1. demographic characteristics of patients (n=47). patients characteristics external fixation group (n=21) volar plate group (n=26) age in years mean ± sd (range ) 37.48 ± 11.65 (18-60) 34 ± 10.45 (18-55) male to female ratio 2:1 1.6:1 c1 6 12 c2 6 10 c3 9 4 dominant side involved 61.90% 57.7% the results of the radiological evaluation are shown in table 3. an analysis of radiographs at six weeks showed that correction of the anatomical parameters; radial length, radial inclination, and dorsal tilt were achieved better with a volar locking plate than external fixation, mainly volar tilt correction which was statistically significant (p=0.040). at six months evaluation radial length, radial inclination, and dorsal tilt were maintained better in the volar locking plate group in comparison to external fixation (p=0.005, 0.001 and 0.007 respectively). all fractures united within the acceptable radiological limit except in four cases, where articular step-off of more than two (2-3) millimeters was seen, stepoff was seen in three (14.28%) cases in the external fixation group, and one (3.84%) case in the volar plate group (p=0.311). there were four (19.04%) cases of complications in the external fixator group in the form of pin tract infection which improved with regular dressing and oral antibiotics as per the culture and sensitivity report. in the volar plate group, there was one (3.84%) complication as postoperative hematoma which improved after wound care. table 2. functional outcomes as per the green and o’brien scoring at 3 months and 6 months. treatment groups outcomes at 3 months n (%) outcomes at 6 months n (%) excellent good fair poor excellent good fair poor external fixator 2 (9.5%) 6 (28.6%) 9 (42.9%) 4 (19%) 7 (33.3%) 9 (42.9%) 4 (19%) 1 (4.8%) volar plate 9 (34.6%) 9 (34.6%) 5 (19.2%) 3 (11.5%) 14 (53.8%) 7 (26.9%) 5 (19.2%) 0 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 dwivedi r, et al. comparison of external fixation and supplementary kirschner-wires fixation with volar locking plate for the treatment of intra-articular distal end radius fractures. 215 jlmc.edu.np discussion: restoration of anatomy following distal end radius fracture is important to reduce the disability and for better functional outcome.[8,9] both external fixation and volar plating are accepted procedures with their advantages and disadvantages. external fixation is based on the principles of ligamentotaxis. easy, quick application, and minimal invasion are the advantages of an external fixator. pin site infection, difficult care of hardware, and cumbersomeness are the disadvantages.[10,11] with the introduction of volar locking plates, open reduction and internal fixation with volar locking plates have become the preferred method of a surgery over the last decade. [12] low profile volar locking plates and multi-angle locking head screws allow stable and anatomical reconstruction of multi fragmentary intra-articular fracture of distal end radius and it has been gaining popularity among surgeons.[13,14] but consensus regarding the superiority of volar locking plate over external fixation in the management of distal end radius fracture is uncertain. in the present study, according to the green and o’brien scoring system outcomes were better in the volar locking plate group at three months postoperative period but at six months follow up there was no significant difference in outcomes between the two groups. the radiological correction was achieved better in the volar locking plate group and it was maintained better than the external fixation group till six months follow-up. results similar to our study have been shown by various other studies. in a recent randomized controlled trial conducted by sharma et al., results in the volar locking plate and external fixation group were comparable in terms of retaining anatomy and function, however, volar locking plates were superior in providing early recovery similar to present study.[15] germaine gq et al., found no significant difference between the results of the external fixator and the volar locking plate with regards to radiological and functional outcomes and complications.[16] a similar study was conducted by pradhan rl et al., where a similar evaluation tool was used for functional evaluation. the mean functional score was better in the volar locking plate group at three months follow up. but the results were not different at six months and one year which was similar to our study.[5] in a randomized controlled trial conducted by jeudy et al. the open reduction and internal fixation (orif) group did better than the external fixator group. however, open reduction and volar plating did not yield better subjective results than the external fixator group.[17] they suggested orif with a volar locked plate as a better option for young and active individuals. two recent meta-analyses conducted by wang et al., and fu et al., have advocated the use of volar locking plates over external fixators. [18,19] the latest meta-analysis conducted by gouk et al., concluded there is no difference in functional outcomes, grip strength, and radiographic outcomes between both methods of treatment even though rom was found better in the orif group.[20] in a study by shukla et al., they found at a year follow– up overall outcome of the external fixator group was better over volar plating.[6] in this study, we have seen better outcomes during early postoperative periods in the volar locking plate group that could be due to stable fixation provided by locking plate which allows early rehabilitation programs. perugia et al., in a review article found a stable internal fixation obtained with a plate enables an early movement of wrist that prevents the stiffness of the wrist and improves the capacity of the wrist to perform normal function.[9] table 3. radiological results at 6 weeks and 6 months. radiological parameters external fixator mean (±sd) volar plate mean (±sd) statistics 6 weeks radial length 10(±0.54) 10.23(±0.765) t=0.019, df=44.43, p=0.235 radial inclination 19.24(±1.44) 19.96(±1.39) t=0.132, df=45, p=0.089 dorsal tilt 2.76(±4.99) -0.62(±5.79) t=0.437, df=45, p=0.040 6 months radial length 9.14(±0.57) 9.77(±0.86) t=0.044, df=43.53, p=0.005 radial inclination 17.81(±1.07) 18.92(±1.16) t=0.047, df=44.10, p=0.001 dorsal tilt 4.86(±4.45) 0.85(±5.19) t=0.46, df=44.43, p=0.007 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 dwivedi r, et al. comparison of external fixation and supplementary kirschner-wires fixation with volar locking plate for the treatment of intra-articular distal end radius fractures. 216 jlmc.edu.np in the present study, irrespective of radiological differences, functional outcomes in both groups are comparable in the later phase of the study. this finding is in agreement with a study conducted by kasapinova et al.[21] in their study, they found no correlation between the x-ray parameters and quality of life and functional outcomes. small sample size, non-randomization, and selection of procedure as per the surgeon’s decision, use of two different types of volar locking plates, and shorter duration of follow-up are the limitations of this study. conclusion: radiological correction is achieved and maintained better by volar locking plates. though functional outcomes are better in volar locking plates at three months, it becomes comparable with the external fixator and supplementary k-wire fixation group at six months follow-up. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available for the study. references: 1. koval k, haidukewych gj, service b, zirgibel bj. controversies in the management of distal radius fractures. j am acad orthop surg. 2014;22(9):566-75. pmid: 25157038. doi: https://doi.org/10.5435/jaaos-22-09-566 2. schneppendahl j, windolf j, kaufmann ra. distal radius fractures: current concepts. j hand surg. 2012;37(8):1718-25. pmid: 22763062. doi: https://doi.org/10.1016/j. jhsa.2012.06.001 3. shin ek, jupiter jb. current concepts in the management of distal radius fractures. 2007;74(4):233-46. pmid: 17877939 4. handoll hhg, madhok r. surgical interventions for treating distal radial fractures in adults. cochrane database syst rev. 2003;(3):cd003209. pmid: 12917953. doi: https://doi.org/10.1002/14651858.cd003209 5. pradhan rl, sharma s, pandey bk, manandhar rr, prasai t, lakhey s, et al. comparison of volar locking plate and external fixation with k wire augmentation in unstable distal radius fractures. nepal medical college journal. 2015;17(1– 2):67-72. available from: https://www.nmcth. edu/images/gallery/vol.%2017%20no.%20 1-2%20march/june%202015/pradhan_rl.pdf 6. shukla r, jain rk, sharma nk, kumar r. external fixation versus volar locking plate for displaced intra-articular distal radius fractures: a prospective randomized comparative study of the functional outcomes. j orthop traumatol. 2014;15(4):265-70. pmid: 25193416. doi: https://doi.org/10.1007/s10195-014-0317-8 7. kwok ihy, leung f, yuen g. assessing results after distal radius fracture treatment: a comparison of objective and subjective tools. geriatr orthop surg rehabil. 2011;2(4):15560. pmid: 23569685. doi: https://doi. org/10.1177/2151458511422701 8. batra s, gupta a. the effect of fracture-related factors on the functional outcome at 1 year in distal radius fractures. injury. 2002;33(6):499502. pmid: 12098546. doi: https://doi. org/10.1016/s0020-1383(01)00174-7 9. dario p, matteo g, carolina c, marco g, j. lumbini. med. coll. vol 8, no 2, july-dec 2020 dwivedi r, et al. comparison of external fixation and supplementary kirschner-wires fixation with volar locking plate for the treatment of intra-articular distal end radius fractures. 217 jlmc.edu.np cristina d, daniele f, et al. is it really necessary to restore radial anatomic parameters after distal radius fractures? injury. 2014;45(suppl 6):s21-6. pmid: 25457314. doi: https://doi. org/10.1016/j.injury.2014.10.018 10. slutsky dj. external fixation of distal radius fractures. j hand surg. 2007;32(10):162437. pmid: 18070654. doi: https://doi. org/10.1016/j.jhsa.2007.09.009 11. paksima n, panchal a, posner ma, green sm, mehiman ct, hiebert r. a meta-analysis of the literature on distal radius fractures: review of 615 articles. bull hosp jt dis. 2004;62(1-2):406. pmid: 15517856. 12. wilcke mkt, hammarberg h, adolphson py. epidemiology and changed surgical treatment methods for fractures of the distal radius: a registry analysis of 42,583 patients in stockholm county, sweden, 2004–2010. acta orthop. 2013;84(3):292-6. pmid: 23594225. doi: https://doi.org/10.3109/17453674.2013.792035 13. downing nd, karantana a. a revolution in the management of fractures of the distal radius? j bone joint surg br. 2008;90-b(10):12715. pmid: 18827233. doi: https://doi. org/10.1302/0301-620x.90b10.21293 14. jagdev ss, kedia r, pathak sk, salunke a. comparison of outcome of extra articular lower end radius fracture with percutaneous pinning and volar locking plate. international journal of research in orthopaedics. 2017;3(4):651-5. doi: https://dx.doi.org/10.18203/issn.24554510.intjresorthop20172503 15. sharma a, pathak s, sandhu h, bagtharia p, kumar n, bajwa rs, et al. prospective randomized study comparing the external fixator and volar locking plate in intraarticular distal radius fractures: which is better? cureus. 2020;12(2):e6849. pmid: 32181084. doi: https://doi.org/10.7759/cureus.6849 16. xu gg, chan sp, puhaindran me, chew wy. prospective randomised study of intra-articular fractures of the distal radius: comparison between external fixation and plate fixation. 2009;38(7):600-6. pmid: 19652851 17. jeudy j, steiger v, boyer p, cronier p, bizot p, massin p. treatment of complex fractures of the distal radius: a prospective randomised comparison of external fixation ‘versus’ locked volar plating. injury. 2012;43(2):174-9. pmid: 21704995. doi: https://doi.org/10.1016/j. injury.2011.05.021 18. wang j, lu y, cui y, wei x, sun j. is volar locking plate superior to external fixation for distal radius fractures? a comprehensive meta-analysis. acta orthop traumatol turc. 2018;52(5):334-42. pmid: 30497657. doi: https://doi.org/10.1016/j.aott.2018.06.001 19. fu q, zhu l, yang p, chen a. volar locking plate versus external fixation for distal radius fractures: a meta-analysis of randomized controlled trials. indian j orthop. 2018;52(6):602-10. pmid: 30532300. doi: https://doi.org/10.4081/or.2019.7809 20. gouk c, ng sk, knight m, bindra r, thomas m. long term outcomes of open reduction internal fixation versus external fixation of distal radius fractures: a meta-analysis. orthop rev (pavia). 2019;11(3):7809. pmid: 31579208. doi: https://doi.org/10.4081/or.2019.7809 21. kasapinova k, kamiloski v. outcome evaluation in patients with distal radius fracture. prilozi. 2011;32(2):231-46. pmid: 22286627 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 7, no 1, jan-june 2019 ___________________________________________________________________________________ submitted: 13 september, 2018 accepted: 14 january, 2019 published: 24 april, 2019 a lecturer, department of paediatrics b kathmandu medical college teaching hospital, kathmandu corresponding author: anwesh bhatta e-mail: anwesh.bhatta@gmail.com orcid: https://orcid.org/0000-0002-6100-545x_______________________________________________________ —–————————————————————————————————————————————— abstract: introduction: who advocates for exclusive breastfeeding in infants till 6 months of age. exclusive breastfeeding has been estimated to reduce 70% of infection related mortality in children. this study aims to elaborate the current trend of breastfeeding and its impact on common infectious morbidities in children. method: this study was a prospective longitudinal study done at kathmandu medical college teaching hospital with a sample size of 103 infants. detailed proforma including sociodemographic data, breastfeeding related data and morbidities were collected at one and half months of life. the patients were followed up at 6 months of age again and the same proforma was again filled up. statistical analysis was done with spss 20.0 and various associations were elucidated. results: a total of 103 infants were analyzed. males were 58 in numbers with mean birth weight of the infants being 3048±537 grams. breast feeding was initiated within an hour in around 37%. at one and half months of age, 63% reported of exclusive breastfeeding which decreased to 23% at 6 months of age. breastfeeding for at least 45 days decreased the incidence of acute respiratory infections(ari), acute otitis media (aom) and diarrheal diseases although statistically significant difference was found with only aris. conclusion: prevalence of exclusive breastfeeding is low in the study. the study has also shown that breastfeeding significantly reduces incidence of common infectious morbidities in infants. keywords: breastfeeding, acute respiratory infections, acute otitis media, acute diarrheal episodes —————————————————————————————————————————————— original research articlehttps://doi.org/10.22502/jlmc.v7i1.262 anwesh bhattaa,b rydam basneta,b trend of breastfeeding and its impact on morbidity in children in a tertiary care hospital in kathmandu introduction: breast milk is the first nutrition as well as immunization of a child. breast feeding has been regarded globally as an effective and inexpensive intervention to reduce childhood morbidity and mortality.[1] world health organization (who) and united nations international children’s emergency fund (unicef) recommend initiation of breast feeding within an hour of birth and that breast feeding be continued for at least six months of life with no other foods and liquids. after six months of life, the child should be continued on breastfeeding along with age appropriate complementary feeding.[2] the different biological components of breast milk, such as secretory iga and igg, play a supporting role in developing immune system to fight infections. [3] furthermore, breast milk is the perfect nutrient providing all the nutrition the newly born requires for optimal growth and development. who states that five leading causes of death in children below five years include preterm birth complications, pneumonia, birth asphyxia, diarrhea and malaria.[4] approximately 47% of these deaths have been attributable to malnutrition.[4] a simple and effective intervention like optimal breast feeding till 2 years of age, can prevent potentially over 13% deaths which amounts to around 900,000 deaths per year.[5] nearly half of all diarrheal episodes and one-third of respiratory ailments in children under five years of age can be prevented with proper breastfeeding practices in low and middle income countries.[6] how to cite this article: bhatta a, basnet r. trend of breastfeeding and its impact on morbidity in children in a tertiary care hospital in kathmandu. journal of lumbini medical college. 2019;7(1):5 pages. doi: 10.22502/jlmc. v7i1.262. epub: 2019 apr 26. https://orcid.org/0000-0002-6100-545x https://doi.org/10.22502/jlmc.v7i1.262 bhatta a. et al. trend of breastfeeding and its impact on morbidity in children jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 given the high number of deaths that can be prevented by mere optimal breastfeeding, this research intends to elucidate the current trend of breastfeeding and its impact on some common morbidity in children. methods: this study was a prospective longitudinal study done over a period of six months at kathmandu medical college and teaching hospital, sinamangal, kathmandu. the study was carried out between august 2017 and january 2018. inclusion criteria included all children presenting to the immunization clinic of kathmandu medical college at one-and half months of life. these children were followed up at six months of age and the same questionnaire was filled up again. ethical clearance was obtained from institutional review committee (irc) of kathmandu medical college prior to data collection. written informed consent was taken from the parents/ caregivers allowing the child to be enrolled in the study. taking prevalence of breastfeeding as 55%[7] and precision of 5% and error of 10%, sample size was calculated to be 97. with a 20% margin for loss to follow up, a total of 120 samples were enrolled in the study. purposive sampling method was used to collect data and there was an attrition of 17 subjects. hence, the final sample size was 103 infants. the parents/caregivers sat for a face to face interview and a detailed proforma was filled up. the proforma was prepared by the researcher himself after extensive study on the subject matter and inputs from esteemed professionals on the subject matter. it took 8-10 minutes to fill up the proforma and included sociodemographic details of the child and mother, birth weight of the baby, type of delivery etc. the proforma also included details about the breastfeeding like initiation of breast feeding and duration of breast feeding and it was grouped as one of the following: exclusive, predominant, mixed feeding or no breast feeding. exclusive breastfeeding and predominant breastfeeding were defined as per who.[8] • exclusive breastfeeding: the infant has received only breast milk from his/her mother or a wet nurse, or expressed breastmilk and not other liquids or solids with exception of drops or syrup consisting of vitamins, mineral supplements or medicines. • predominant breastfeeding: the infant’s predominant source of nourishment has been breastmilk. however, the infant may also have received water and water based drinks. • mixed feeding: the infant has received breast milk but it is not the predominant source of nourishment. • no breastfeeding: the infant has not received breast milk. who groups exclusive and predominant breastfeeding as full breastfeeding.[8] early initiation of breastfeeding implied when the baby was started on breast milk within an hour of birth. the proforma also included details about any prelacteal feeds and other feedings that were given if exclusive breastfeeding was not done. the parents/ caregivers were then asked about acute respiratory infections (ari), acute otitis media (aom) and diarrheal episodes in their children. acute respiratory infections and acute otitis media needed to be physician diagnosed to be considered. diarrheal episodes were reported on the basis of history given by the parents. the patient was followed up again at six months of age and the same set of questions were asked and recorded. weight of the infant was taken with the same weighing machine in both the visits with minimal clothing on the child’s body. all the variables were checked and entered into statistical package for social sciences (spss) version 20.0 and analysis was done. the collected data was analyzed using descriptive statistics like frequency, percentage, mean, median and standard deviation. data was also analyzed using inferential statistics like chi square and mann whitney u test. result: a total of 103 infants were analyzed. the infants had visited the immunization clinic for their vaccination at one and half months and were again followed up at six months. the mean age of the infants was 47.52±2.52 days. males were 58 in number(56.3%) while bhatta a. et al. trend of breastfeeding and its impact on morbidity in children jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 females were 45(43.7%). the mean birth weight of the infants was 3048±537 grams. the mode of deliveries of these babies included lower segment caesarean section in 53 (51.46%) cases while normal vaginal delivery was done in 48 cases (46.6%). two babies (1.94%) were born via operative vaginal delivery (forceps/vacuum). the mean maternal age was found to be 27.37±3.78 years. the education level of the mothers varied. most of the mothers (52.4%, n=54, n=103) had completed at least bachelor level of education while few of them had completed primary schooling. ten years of formal education resulted in significantly longer duration of breastfeeding as compared to mothers who had not had at least ten years of formal education (mann whitney u test= 534.5, p=0.023). the study also revealed that most of the mothers were housewives (62.1%, n=64, n=103) while rest used to work at government or private institutions. most of the parents/caregivers reported that their family was a nuclear one (61.2%, n=63, n=103) while rest reported to hail from joint family. after the delivery of the babies, breast feeding was initiated within an hour in around 37% (n=38, n=103) of subjects while in 45 subjects; the initiation was only after 24 hours of birth. in 58 babies who were initiated breast feeding after 4 hours of life, the major reason for delay was the fact that their baby was kept for observation following cesarean delivery away from the mother. it was astounding that out of 53 caesarean deliveries, 50 of the babies were taken away from the mother just for observation while three of them needed supportive treatment for other morbidities. on analysis of impact of education in early initiation of breastfeeding, completion of at least secondary level of education in mother resulted in early initiation of breastfeeding in their babies. this association was found to be statistically significant (chi square=4.414, df=1, p=0.036). other reasons for delay in initiation of breastfeeding included mother being too ill to feed or the mother was lacking milk secretion. prelacteal feed was given in six cases. regarding current feeding at one and a half months of life, 63% (n=65, n=103) reported of exclusive breast feeding while 14.6% (n=15, n=103) reported of predominant breast feeding. mixed feeding and no breastfeeding were reported in 17.5% (n=18, n=103) and 5% (n=5, n=103) respectively. formula feed was the major food being given to subjects not on exclusive breastfeeding while subjects were also given cattle milk and cereals in some cases. the median weight at one and a half months was found to be 4500gm with iqr of 1000gm. during the follow up at six months of age, it was found that only 24 subjects were exclusively breastfed till six months of age which amounts to 23.3% (n=24, n=103) of all enrolled subjects. in the remaining 79 subjects, formula feeding was the most prevalent feed given in 80% (n=63, n=79). similarly, 31.6% (n=25, n=79) of the babies received cattle milk as well while 42% (n=33, n=79) received cereals too. the median weight at six months of age was found to be 7000 gm with iqr of 1500 gm. the mean weight gain between birth and one and half month of life was 1479.41±451.67gm while the mean weight gain between birth and six months of life was 4081.35±818.06gm. the weight gain in subjects receiving exclusive breast feeding vs non-exclusive breast feeding were not found to be significant at both one and half months and six months of age (mann whitney u test=1095.5, p=0.339). in the study, the incidence of ari, aom and diarrheal episodes were found to be 48.5% (n=50, table 1. incidence of acute respiratory infection in differently breastfed infants variables acute respiratory infectionpresent absent statistics exclusive breastfeeding for 45 days yes 24 26 41 12 x2=9.525,p=0.002,df=1 no exclusive breastfeeding for 6 months yes 6 44 18 35 x2=6.944,p=0.008,df=1 no full breastfeeding for 6 months yes 31 19 49 4 x2=13.757,p=0.001,df=1 no bhatta a. et al. trend of breastfeeding and its impact on morbidity in children jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 n=103), 2.9% (n=3, n=103) and 8.7% (n=9, n=103) respectively. regarding the incidence of acute respiratory infections in exclusive vs non-exclusive breastfeeding, there was found to be statistically significant protection of exclusive breastfeeding against aris. in fact, children who were exclusively breastfed for just the first one and half months of life were also conferred significant protection against aris even till six months of age.(table 1) the protection against ari continued to be significant in children breastfed exclusively till six months of age (x2=6.944, p=0.008, df=1). moreover, not just exclusively breastfed but, fully breastfed children were also offered the protection against ari which was statistically significant(x2=13.757,p=0.001,df=1). thus, breastfeeding babies, even for as short duration as one and a half months offered significant protection against aris in children. in the study, breastfeeding and its impact on incidence of acute otitis media and diarrheal episodes was also analyzed. it was found that babies who were exclusively breastfed had lower incidence of acute otitis media but the difference was not statistically significant. (table 2) breastfeeding till 45 days of life also reduced the incidence of acute diarrheal episodes in children, but the reduction was not statistically significant (table 3). exclusive breastfeeding for six months also did not show any significant association on the incidence of both these conditions. analysis was also carried out regarding the benefit of early initiation of breastfeeding against other morbidities. however, it was found that there was no significant difference in incidence of ari, aom or diarrheal episodes due to early initiation of breastfeeding. discussion: this study was done to elucidate the current trend of breastfeeding in one of the tertiary medical variables acute otitis media present absent statistics exclusive breastfeeding for 45 days yes 1 2 64 36 x2=1.177,p=0.278,df=1 no exclusive breastfeeding for 6 months yes 0 3 24 76 x2=0.076,p=0.783,df=1 no full breastfeeding for 6 months yes 2 1 78 22 x2=0.216,p=0.642,df=1 no table 2: incidence of acute otitis media in children differently breastfed variables acute diarrheal disease present absent statistics exclusive breastfeeding for 45 days yes 3 6 62 32 x2=2.484,p=0.115,df=1 no exclusive breastfeeding for 6 months yes 0 9 24 70 x2=1.738,p=0.187,df=1 no full breastfeeding for 6 months yes 5 4 75 19 x2=1.559,p=0.212,df=1 no table 3: incidence of acute diarrheal episodes in differently breastfed infants bhatta a. et al. trend of breastfeeding and its impact on morbidity in children j. lumbini. med. coll. vol 6, no 2, july-dec 2018 jlmc.edu.np college and teaching hospital situated in the capital of the country. of the 103 babies who were enrolled in the study, 53 babies (51.4%) were born via lscs as compared to 50 via vaginal deliveries (spontaneous and instrumental). this rate of caesarean section was very high when compare to global rate (18.6%).[9] moreover, the cs rates in nepal is much higher than the global rate and has been reported to be anywhere from 15% to an astounding 81%.[10,11] since most of the enrolled patients in this study were born at kathmandu medical college and teaching hospital, the 51% lscs rate is similar to the reported 46% as of 2017.[10] the mean age of mothers in the study was found to be 27.37±3.78 years. since the research did not include parity of the mother, this result could not be generalized. however, this data is in line with the ndhs data which mentions that the age specific fertility rate of urban women is highest for age 20-29 years.[12] in the study, we found that around 52% of mothers had completed at least their bachelor’s degree of education. this figure is much higher than the ndhs data which showed that women who have passed secondary education stands at mere 24%.[12] in the study, we also found that at least 10 years of formal education, i.e. completed secondary education, made mothers breastfeed their children for longer duration than mothers who did not complete the 10 year formal education. this variability in the data may be due to the fact that the current research was carried out in the heart of urban nepalkathmandu. the research reported 62% of mothers to be housewives which was very similar to the 61% reported by the world bank.[13] in the current study, it was found that 37% of babies were breastfed within an hour of birth. this is lower than 55% babies being breastfed within an hour of birth as reported in ndhs 2016.[12] the lower figure reported in the current study may have been due to high number of lscs deliveries which caused delayed initiation of breastfeeding. the study revealed that at one and half months of life, 63% of babies were being exclusively breastfed. this data is lower than the national data of 79.6% babies being exclusively breastfed at that age. [12] in the study, it was found that 5% of babies had not received breast milk at all during the first one and half months of life which at national level stands at 0%.[12] similarly, only 23.3% of the enrolled babies were exclusively breastfed for 6 months. this figure too, is much below the national figure of 66%. this discrepancy in figure may reflect the urban population of our study which curtails employed mothers to exclusively breastfeed their children for optimum period. of the subjects enrolled in the study, 48.5% have had at least one episode of ari in the first six months of life. this figure is lower than the reported incidence of ari in children under five years at national level which was 765 per 1000 children. [14] similarly, diarrhea was found to be in 8.7% of enrolled subjects which is also lower than the national figure of 502 per 1000 under five children. these findings of lower morbidities in our study may be explained by the better health service and hygiene in the urban part of the country as compared to rural parts. breastfeeding for even first one and half months of life conferred protection against aris at least till six months of age. studies have shown that breastfeeding conferred the highest protection for children against respiratory infections.[3] admission in hospitals in low and middle income countries (lmic) following respiratory tract infection was 57% lower in children who were breastfed.[6] in developed countries, the protection was much higher, and as high as 72% reduction in admissions during the first year of life occurred in babies who were breastfed for at least 4 months. [15] similarly, the risk of severe bronchiolitis was reduced by 74% in babies who were breastfed for at least 4 months.[16] breastfeeding has been shown to reduce the chance of mortality from respiratory tract infections.[17] the result of this study also concur with the conclusions from various meta-analysis and systematic reviews done around the world in both low income as well as developed countries.[6,18] although most of the studies have shown the benefit of breastfeeding if done exclusively for at least four months, this study infact establishes the protective role of full breastfeeding if only done for as short as 45 days. in the current study, breastfeeding was not found to alter the incidence of acute otitis media in children. however multiple studies done around the world have shown significant protection offered by breast milk against otitis media in infants and children. in a large systematic review and metaanalysis, breastfeeding has been shown to confer protection against acute otitis media till two years of age. the protection is even greater in children who are exclusively breastfed and for a longer duration of time.[19] similarly in another study, incidence of acute otitis media was found to be significantly low in infants exclusively breastfed as compared to ones who were given formula feed.[20] the current study was not able to establish this relation perhaps because of shorter duration of the study wherein subjects were followed up for just six months of life during which otitis media is not a common morbidity. this study also tried to assess the protective efficacy of breastfeeding against diarrheal episodes in infants. breastfeeding was not found to affect the incidence of diarrheal episodes in children. however, to the contrary, multiple studies have shown breastfeeding to confer significant protection against diarrheal episodes during infancy. about half of all cases of diarrhea could be reduced with breastfeeding.[6] about 72% of hospital admissions for diarrheal diseases could be avoided with breastfeeding.[6] horta et al has also shown the beneficial effect of breastfeeding in children under five years of age with larger protection at smaller age. [3] longer duration of breast feeding was associated with greater protection against diarrheal episode. [20] in the 2003 lancet child survival series, breastfeeding promotion was identified as one of the most cost-effective interventions against under-five deaths in general, and against diarrhea in particular. [5] lamberti et al has concluded that the risk of dying from diarrhea in children less than 6 years of age was 10.5 times higher in infants who were not breastfed as compared to ones who were breastfed.[21] this study however did not show significant reduction in diarrheal episodes with breastfeeding perhaps due to low incidence of diarrhea in this study due to small sample size. also, urban population with better hygienic care may have contributed to low incidence of diarrhea in this study. this study was able to establish the benefit of breastfeeding on some common morbidities in children. however, the study was done for a relatively short period of six months and benefit of breastfeeding for a prolonged time could not be elucidated. this study has not taken the number of episodes of ari and diarrheal illness into account which would have given a better insight on the significance of breastfeeding on these morbidities. also, the study needs to be carried out for longer than 6 months duration to better elucidate the effect of breastmilk on these morbidities. conclusion: the study has shown that exclusive breastfeeding for a duration of six months was much less as compared to the national average. similarly, the breastfeeding has positive impact on reduction of incidence of common morbidities in children like acute respiratory infections, acute otitis media and acute diarrheal diseases. conflict of interest: the authors declare that no competing interests exist. source of funds: no funds were available. references: 1. american academy of pediatrics. breastfeeding and the use of human milk. vol. 129, pediatrics. 2012 mar. doi: 10.1542/peds.2011-3552 2. unicef. infant and young child feeding global database. 2016. https://data.unicef.org/topic/nutrition/infant-andyoung-child-feeding/ 3. horta b., victora c. short-term effects of breastfeeding: a systematic review on the benefits of breastfeeding on diarrhoea and pneumonia mortality. world health organization. 2013. http://www.who.int/iris/ handle/10665/95585 4. who. who fact sheet, children: reducing mortality. 2016. http://www.who.int/mediacentre/factsheets/fs178/ en/ 5. jones g, steketee rw, black re, bhutta za, morris ss, bellagio child survival study group. how many child deaths can we prevent this year? lancet. 2003 jul 5;362(9377):65–71.doi: 10.1016/s0140-6736(03)13811-1 6. victora cg, bahl r, barros ajd, frança gva, horton s, krasevec j, et al. breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. lancet. 2016 jan;387(10017):475–90. doi:10.1016/s01406736(15)01024-7 7. patil cl, turab a, ambikapathi r, nesamvuni c, chandyo rk, bose a, et al. early interruption of exclusive breastfeeding: results from the eight-country mal-ed study. j heal popul nutr. 2015 dec 1;34(1):10. pmid: 26825923 8. who. indicators for assessing breastfeeding practices who/cdd/ser/91.14. world health organization. 1991. p. 1–14. http://apps.who.int/iris/bitstream/10665/62134/1/ who_cdd_ser_91.14.pdf 9. betrán ap, ye j, moller a-b, zhang j, gülmezoglu am, torloni mr. the increasing trend in caesarean section rates: global, regional and national estimates: 19902014. plos one. 2016;11(2):e0148343. pmid: 26849801 10. dns g, prasuti tatha prajanan swasthya kendra a. rising cesarean section rates in nepal: question of safety and integrity on obstetric emergency practice. 2017;7. doi: 10.19080/jgwh.2017.07.555716 11. chhetri s, singh u. caesarean section: its rates and indications at a tertiary referral center in eastern nepal. heal renaiss. 2011;9(3):179–83. doi: 10.3126/hren. v9i3.5587 12. icf m of h and pne. nepal demographic and health survey 2016 key indicators report ministry of health ramshah path, kathmandu nepal new era ministry of health. 2017 . available from: www.dhsprogram.com. 13. world bank gender data portal | country nepal. available from: http://datatopics.worldbank.org/gender/ country/nepal 14. department of health services. annual report 2014/15. kathmandu; 15. ip s, chung m, raman g, chew p, magula n, devine d, et al. breastfeeding and maternal and infant health outcomes in developed countries. evid rep technol assess. 2007 apr;(153):1–186. pmid: 17764214 16. nishimura t, suzue j, kaji h. breastfeeding reduces the severity of respiratory syncytial virus infection among young infants: a multi-center prospective study. pediatr int.2009;51(6):812–6. pmid: 19419530 17. abdullah a, hort k, butu y, simpson l. risk factors associated with neonatal deaths: a matched case–control study in indonesia. glob health action. 2016 dec 16;9(1):30445. pmid: 28157054 18. 18. sankar mj, sinha b, chowdhury r, bhandari n, taneja s, martines j, et al. optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. acta paediatr. 2015 dec;104(s467):3–13. doi: 10.1111/apa.13147 19. 19. bowatte g, tham r, allen k, tan d, lau m, dai x, et al. breastfeeding and childhood acute otitis media: a systematic review and meta-analysis. acta paediatr. 2015 dec;104:85–95.doi: 10.1111/apa.13151 20. 20. boone km, geraghty sr, keim sa. feeding at the breast and expressed milk feeding: associations with otitis media and diarrhea in infants. j pediatr. 2016 jul;174:118–25. pmid: 27174145 21. 21. lamberti lm, fischer walker cl, noiman a, victora c, black re. breastfeeding and the risk for diarrhea morbidity and mortality. bmc public health. 2011 apr 13;11(suppl 3):s15. pmid: 21501432 j. lumbini. med. coll. vol 6, no 2, july-dec 2018 jlmc.edu.np bhatta a. et al. trend of breastfeeding and its impact on morbidity in children j. lumbini. med. coll. vol 9, no 1, jan-june 2021 chhetri ud, et al. assessment of mental health problems of school children using self report strengths and difficulties questionnaire. jlmc.edu.np ___________________________________________________________________________________ submitted: 17 july, 2020 accepted: 09 may, 2021 published: 24 may, 2021 aassociate professor, department of pediatrics blecturer, department of pediatrics cassistant professor, department of psychiatry dlumbini medical college teaching hospital, palpa, nepal. corresponding author: uma d chhetri e-mail: udchhetree@gmail.com orcid: https://orcid.org/0000-0002-7896-5393_______________________________________________________ abstract introduction: psychological disorders among children and adolescents are the least discussed health problems in pediatrics. there is limited data on the prevalence of mental health problems among adolescents in low-income countries like nepal. this study intended to find the prevalence of mental health problems among school children in a secondary school in western nepal. methods: in this descriptive cross-sectional study, students of grades six to eleven of two private schools of a district in nepal were randomly selected. the self-rated version of goodman’s strength and difficulty questionnaire were used to assess mental health problem in these adolescents. outcomes were measured in a scale of zero to 10 for each of emotional, conduct, hyperactivity, peer problem and pro-social behavior. difficulty scale and its impact on life were also measured. results: out of 902 students, 5% (n=49) had significant and 14% (n=127) had probable mental health problem. peer problems was the commonest (25%) followed by emotional (15%) and conduct problem (15%) and hyperactivity and pro-social problems were seen in 7% each. boys had more mental health problem than girls except emotional problem. mental health problem was more common in lower grade or younger age students. its impact on life were 0-7.4%. abnormal internalizing and externalizing problems were reported in 20% and 11% respectively. conclusion: mental health problem was prevalent (5 to 25%) in secondary school children. screening school children for the same would be beneficial for early diagnosis. keywords: emotion; mental health; peer problem; school children; strength difficulty questionnaire original research articlehttps://doi.org/10.22502/jlmc.v9i1.392 uma d chhetri,a,d anita lamichane,a,d shami pokhrel,b,d bhaskar sharmac,d assessment of mental health problems of school children using self report strengths and difficulties questionnaire how to cite this article:how to cite this article: chhetri ud, lamichane a, pokhrel s, sharma b. assessment of mental health problems of school children using self report strengths and difficulties questionnaire. journal of lumbini medical college. 2021;9(1):6 pages. doi: https://doi.org/10.22502/jlmc. v9i1.392. epub: may 24, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: around 10-20% of children and adolescents experience mental health disorders worldwide. by 14 years of age, half of the mental health issues start and these remain undiagnosed and undertreated.[1] childhood and adolescent period is a transitional phase, that faces various mental challenges in one’s life. the desire for greater independence, pressure to match up to peers standard, exploration of sexual identity, technology use, bullying, relationship with family take up major roles for affecting mental health in children and adolescents.[2] their psychosocial adjustment and academic performances may be hampered in the lack of adequate care and attention. [3] nepal lags behind in the matter of mental health, as it lacks the national mental health policy especially for children and adolescents. recent concerns are made to know the public health importance of identifying and treating mental health problems (mhp) in nepal,[4] which are likely to decrease the childhood morbidities related to mental health.[5] this study aimed to assess the mhp in school going children in palpa district of western nepal. methods: this was a descriptive cross-sectional study done among school going students of grades six to j. lumbini. med. coll. vol 9, no 1, jan-june 2021 chhetri ud, et al. assessment of mental health problems of school children using self report strengths and difficulties questionnaire. jlmc.edu.np 11. two private schools were selected purposefully from tansen municipality of palpa district. at the time when general school health program was conducted in those two schools, mental health assessment was done. the time of study was fixed at six months after the start of their school session. ethical clearance was taken from the institutional review committee (irc) of lumbini medical college teaching hospital prior to the study. approval to conduct the study was also taken from the school management. all adolescents were informed about the aims and procedures of the study. those participants who were 16 years and older signed consent forms whereas younger participants got their consent form signed by their parents and returned to the data collector. sample size was calculated using formula for estimation of proportion, n= z2pq/e2. z=1.96, p=0.19 [6], q=1-p=0.81, e= 0.05. so, n= 237. taking 20% of non-respondents, the minimum sample size was 285. the strengths and difficulties questionnaire (sdq) is an instrument that has been widely used to assess mhps, emotional and behavioural problems and strength among children and adolescents.[7] the final conclusion on the presence or absence of mhps as measured by sdq is ideally computed from the combined reports from parents, teachers, and selfreport by the participant.[7] however, self-reports may be sufficient screening tool for adolescents aged 11 years or older.[8] the clinical usefulness of sdq in identifying mhps in adolescents has been established, with a reliability and validity that is as good as that of child behaviour checklist.[9] the self-rated sdq possesses 25 items in the following 5-item scales: emotional and conduct problems, hyperactivity/inattention, peer relationship problems, and pro-social behaviour. each item is scored on a 3-point scale (0 not true; 1 somewhat true; 2 certainly true) and the sum of all answered items in a scale creates its total score (possible range, 0–10), whereas the sum of all answered items in the first four scales creates the total overall score (possible range, 0–40). the higher the total score, the larger the difficulties. the sdq total scores could be considered as “normal” (range, 0–15), “borderline” (range, 16–19), and “abnormal” (range, 17–40), indicating the presence of general psychopathology. for the subscales, abnormal scores were taken as follows: emotional scale and hyperactivity/ inattention range, 7 to 10; conduct problems range, 5 to 10; peer relationship problems range, 6 to 10; and pro-social behaviour range, 0 to 4. the abnormal sdq score in any area indicate substantial risk of clinically significant problem in that area.[10] the questionnaire was explained to the students in both english and nepali languages. fifteen to twenty minutes were given to fill up the questionnaire. after the completion, the forms were returned to the data collector. the data thus obtained were entered and analyzed using statistical package for social sciences (spsstm) software version 16.0. results: a total of 904 students participated in the study. two questionnaires were incompletely filled and hence were excluded. so, 902 students (58% male and 42% female) were included in the study. the mean age of the students was 14.09+1.71 years (range:10-19 years). among 902 students, the prevalence of mhps as per total sdq score were 49 (5%) significant, 127 (14%) probable and 726 (81%) normal. male and female students were equal in significant and probable total sdq score. peer problems were the commonest (25%) followed by emotional (15%) and conduct problem (15%). hyperactivity was present in 7% and prosocial problems too in 7% of the students. males predominated in all the four types of mhps. on the other hand, females predominated in emotional problem (table 1). abnormal internalizing problem (emotional and peer) was reported in 356 (20% i.e. 6% significant and 14% probable) children with m:f=1:1. internalizing problem is the combination of emotional and peer problem so the sample will be double of 902 that is 1804. on the other hand, 197 (10.75%) had abnormal externalizing problem (conduct and hyperactivity) (5% significant and 6% probable) with m:f=7:5 and 6.5% abnormal prosocial problem with m:f=7:3 (table 2). table 3 shows the grade wise distribution of probable and significant mhp. most of the children had probable mhp (9.4-22%) while 3.6-11% had significant mhp. distribution of probable and significant mhp according to the students grades in decreasing frequency were grade vi (30%), followed by vii (26%), viii and x (16% each), ix (14%) and xi (7%). the lower class or younger age students suffered more from mhps while the upper class or older age students suffered less. eleven to fourteen years students (grade vi) had significant (11%) mhp j. lumbini. med. coll. vol 9, no 1, jan-june 2021 chhetri ud, et al. assessment of mental health problems of school children using self report strengths and difficulties questionnaire. jlmc.edu.np table 1. mental health status of the participants. variables normal (%) probable (p %) (borderline) significant (s%) (abnormal) total (p+s%) emotional problems 769 (85) 71 (8) 62 (7) 133(15) m:f 3:2 1:1 1:2 2:3 conduct problems 770 (85.5) 63 (7) 69 (7.5) 132 (14.5) m:f 3:2 3:2 3:2 3:2 hyperactivity 837 (93) 45 (5) 20 (2) 65 (7) m:f 3:2 3:2 1:1 4:3 peer problem 679 (75) 177 (20) 46 (5) 223 (25) m:f 3:2 3:2 3:2 3:2 prosocial behavior 844 (93) 32 (4) 26 (3) 58 (7) m:f 3:2 4:1 3:2 7:3 total difficulties 726 (81) 127 (14) 49 (5) 902 m:f 3:2 1:1 1:1 3:2 table 2. normal, borderline and abnormal internalizing and externalizing problems of the participants. variables normal (%) probable (p%) (borderline) significant (s%) (abnormal) total (p+s)% internalizing (emotional + peer) problem 1448 (80%) 248 (14%) 108 (6%) 356 (20%) m:f 3:2 4:3 1:1 1:1 externalizing (conduct + hyperactivity) problem 1607 (89%) 108 (6%) 89 (5%) 197 (10.75%) m:f 3:2 3:2 4:3 7:5 pro-social behavior 844 (93.5) 32 (3.5) 26 (3) 58 (6.5%) m:f 3:2 4:1 3:2 7:3 table 3. distribution of normal, borderline and abnormal mental health problems according to grades. grades vi vii viii ix x xi total age range (years) 10-14 11-15 13-16 13-18 14-18 16-19 10-19 mean age (years) 11.7 12.8 13.78 14.65 15.81 17.19 14.09 standard deviation 0.63 0.75 0.68 0.79 0.77 0.90 1.71 normal (%) 86 (70) 133 (74) 161 (84) 136 (85) 161 (84) 49 (82) 726 (80) probable (%) 23 (19) 39 (22) 18 (9.5) 15 (9.4) 24(12.5) 8 (13) 127 (14.1) significant (%) 13 (11) 7 (4) 11 (6) 8 (5) 7 (3.6) 5 (4) 9 (5.4) total p+s %) 36 (30) 46 (26) 29 (15.5) 23 (14.4) 31(16.1) 13 (7) 136 (5.6) total (%) 122 (13.5) 179 (19.8) 190 (21) 159(17.6) 192 (21) 60 (6.6) 902(100) table 4. impact grading of mhp on various aspects. impact grading, n (%) grade vi grade vii grade viii grade ix grade x grade xi total none or little 64 (52.5) 112 (63) 115 (60) 113 (41) 134 (69.8) 32 (53.3) 570 (63) medium amount 49 (40) 59 (33) 70 (37) 41 (26) 57 (29.7) 28 (47) 304 (34) great deal 9 (7.4) 8 (4.5) 5 (3) 5 (3) 1 (0.5) 0 28 (3) total medium and great deal 58 (47.4) 67 (37.5) 75 (40) 46 (29) 58 (30.2) 28 (47) 332 (37) total students 122 (13.5) 179 (20) 190 (21) 159 (17.6) 192 (21.3) 60 (6.7) 902 (100) j. lumbini. med. coll. vol 9, no 1, jan-june 2021 chhetri ud, et al. assessment of mental health problems of school children using self report strengths and difficulties questionnaire. jlmc.edu.np than others (4-6%). table 4 shows the impact of mhp on child’s home life, friendship, class room learning and leisure activities. impacts were graded as not at all, a little, medium and great amount. great degree of impact on life were reported by 0-7.4% of students while medium degree of impact was reported by 26-47% of students. the lower the class or younger the students, the more severe impacts were reported than the elder students or higher-class students. class xi had reported zero severe impact. there was no relation between standard of class and impact on their lives. table 5 shows the grade wise distribution of first two common mental health problems with their percentage. peer problem topped the list in all the grades i.e., age 13 to 16 except grade xi or age 17 years where emotional problem replaced the peer. table 5. distribution of first two common mental health problems as per the students grades and mean age. grade commonest mhp (%) 2nd most common mhp (%) vi peer 30% pro-social 18% vii peer 30% conduct 20% viii peer 26% conduct 19% ix peer 19% emotional 16% x peer 19% conduct 13% xi emotional 20% peer 20% discussion: nineteen percent prevalence of mhp in our study was similar to the study by bastola r in pokhara, nepal.[11] the decreasing frequency of mhp were internalizing, followed by externalizing and prosocial problem in both the studies. internalizing problems were little higher (23% vs 20%) than in our study. [11] higher values may be because the sample was from four public schools in pokhara. the samples represented the poor socioeconomic group in which psychosocial problems are common. adolescents who were facing abuse at home, followed by ‘do not feel good’ about their home environment, had high academic school stress, not staying with their parents, hardly sufficient income, whose mothers were illiterate and disturbed marital status of parents were more likely to develop psychosocial problems. [11] the study by sharma b et al. had higher sdq than ours; externalizing problem 30% and internalizing problem 35.8% as compared to 10.75% and 20% respectively in our study.[6] the reasons of high mhp were explained as rapid industrialization and urbanization, and majority of young parents were employed and lived in unitary setup, unavailability of time for their children leading to psychosocial problem. the study found that the risk of mhp increased twice in nuclear family than in joint families, four times more externalization problem in private schools than government schools and twice more common in males than females.[6] khattri jb et al. found the overall prevalence of psychiatric cases to be 37.5% (n=261) in rural kusma village of baglung, nepal which is almost twice than that in our study (19 %).[12] in another study by bhola p et al. 10% (vs 5.4% in our study) of adolescents had total difficulty level in abnormal (significant) range with 9% (vs.7%) risk for emotional symptoms, 13% (vs.7.5%) conduct problems, 12.6% (vs.2 %) hyperactivity or inattention and 9.4% (vs.5%) peer problems. males (57.5%) had more mhps than females (42.5%) [13]. the higher level of mhp might be because the sample was of higher age group than ours. we too found that the higher age group had higher mhp. the study by keyho k et al. reported 17.2% (vs.5.4%) abnormal and 28.8% (vs.14.1%) borderline (total 46%) (vs.19.5%) prevalence.[14]. the subclass of mhp emotional, conduct, hyperactivity, peer and pro-social problems were higher than our study which might be because they included government school which had comparatively higher mhp. similarly, the study by george m et al. reported 47% (33% abnormal and 14% borderline) mhp. younger age (3-5 years) had more problem (35%) than older age (28%) in (11-14 years) similar to our study but the age group was younger in this study. the m:f ration was also comparable.[15] banerjee m et al. reported increased total sdq 42% with abnormal problems being conduct 40%, emotional 30.5% and peer 18%. this study is an example that persistent violence of any type may cause mhp in children and adolescents.[16] in a review by chaulagain a et al. two school surveys found the prevalence of emotional and behavioral problems in school children ranged between 12.9% and 17.03%, where as a study on emotional and behavioral disorders in homeless children reported a prevalence of 28.6%. while the emotional problem in our study (20%) was higher j. lumbini. med. coll. vol 9, no 1, jan-june 2021 chhetri ud, et al. assessment of mental health problems of school children using self report strengths and difficulties questionnaire. jlmc.edu.np than that of chaulagain et al. (12.9%), homeless children definitely have high behavioral problem.[17 ] rimal h s et al. found abnormal total sdq in 18.6% and peer related problem in 22% of students in their study. however, they had included only significant as abnormal and probable as normal. with that respect total significant sdq was 5.4% and significant peer problem was 5% in our study. female students had significant emotional problem than male students (p<0.05) similar to our study. boys had significantly higher hyperactivity while it was equal in both sexes in our study (p<0.05).[18 ] thapa b et al. reported 6.5% of adolescent students endorse dissatisfaction with themselves and 11.8% had suicidal ideation or attempt from 1160 surveyed population from dhulikhel.[19] lower prevalence of mhp were reported by wolf rs et al. (10%) and olyainka a et al. (10.5%) too.[20,21] male students had more emotional, hyperactivity and conduct problems and female had more peer problems in the study by banerjee et al. while in our study, except in emotional problems, boys had more mhp than the girls.[16] the study could not include parents and teachers view of sdq. the did not follow up the cases after intervention. it would have been better if all 3 versions: student, parent and teacher view or answer of sdq questioners were followed and follow up studies were also done. conclusion: mental health problems are highly prevalent in nepalese school children. the prevalence rate was 20% in our study. peer, emotional and conduct problems occupied 55% of mental health problems. sdq is a good tool for screening mental health problems in school children. all the school children should be screened, as a part of school health program, for mental health problems by school authority for early diagnosis and necessary intervention. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. acknowledgment: the principals, class teachers, and the students of the schools. references: 1. kieling c, baker-henningham h, belfer m, conti g, ertem i, omigbodun o, et al. child and adolescent mental health worldwide: evidence for action. lancet. 2011;378(9801):1515-25. pmid: 22008427 doi: https://doi.org/10.1016/ s0140-6736(11)60827-1 2. world health organization. adolescent mental health. geneva: who; 2020. available from: https://www.who.int/news-room/fact-sheets/ detail/adolescent-mental-health 3. chhabra gs, sodhi mk. impact of family conflict on the psychosocial behavior in male adolescents. journal of nepal paediatric society. 2012;32(2):124-131. doi: https://doi. org/10.3126/jnps.v32i2.6147 4. hamoda h, ferrin m. international association for child and adolescent psychiatry and allied professions. iacapap bulletin: issue 57. geneva; 2020. available from: https://iacapap. 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cases in a rural community of nepal. nepal journal of medical sciences 2013;2(1):52-6. doi: https://doi.org/10.3126/ njms.v2i1.7654 13. k bhola , sathyanarayanan v, rekha dp, daniel s, thomas t. assessment of selfreported emotional and behavioral difficulties among pre-university college students in bangalore, india. indian j community med. 2016;41(2):146-50. pmid: 27051090 doi: https://doi.org/10.4103/0970-0218.177536 14. keyho k, gujar nm, ali a. prevalence of mental health status in adolescent school children of kohima district, nagaland. annals of indian psychiatry. 2019;3(1):39-42. available from: https://www.anip.co.in/text. asp?2019/3/1/39/259094 15. george m, chandak s, wasnik m, khekade s, gahlod n, shukla h. assessment of child’s mental health problems using strengths and difficulties questionnaire. journal of oral research and review. 2019;11(1):7-11. available from: https://www.jorr.org/text. asp?2019/11/1/7/253427 16. banerjee m, bhat aa, chatterjee a. a comparative study of mental health problems among 11-17 year old indian school children living in areas with persistent political violence and children of the same age group living under standard conditions using self rated strength and difficulty questionnaire. sri lanka journal of child health. 2015;44(2):88-91. available from: https://sljch.sljol.info/articles/7990/galley/5923/ download/ 17. chaulagain a, kunwar a, watts s, guerrero aps, skokauskas n. child and adolescent mental health problems in nepal: a scoping review. international journal of mental health system. 2019;13(0):53. doi: https://doi.org/10.1186/ s13033-019-0310-y 18. rimal hs, pokharel a. assessment of mental health problems of school children aged 11-17 years using self report strength and difficulty questionnaire (sdq). journal of nepal paediatric society. 2013;33(3):172-76. doi: https://doi.org/10.3126/jnps.v33i3.8752 19. thapa b, powell j, yi j, mcgee j, landis j, rein l, et al. adolescent health risk and behavior survey: a school based survey in central nepal. kathmandu univ med j (kumj). 2017;15(60):301-7. pmid: 30580346 20. wolf rt, jeppesen p, gyrd-hansen d, the ccc2000 study group, oxholm as. evaluation of a screening algorithm using the strengths and difficulties questionnaire to identify children with mental health problems: a five-year register-based follow-up on school performance and healthcare use. plos one. 2019;14(10):0223314. doi: https://doi.org/10.1371/journal.pone.0223314 21. atilola o, balhara yps, stevenovic d, avicenna m, kandemir h. self-reported mental health problems among adolescents in developing countries: results from an international pilot sample. j dev behav pediatr. 2013;34(2):129137. pmid: 23369959 doi: https://doi. org/10.1097/dbp.0b013e31828123a6 knowledge regarding self care measures and quality of life among patients with chronic renal failure undergoing hemodialysis sarita shah,a,c nabin pokharelb,d —–————————————————————————————————————————————— abstract: introduction: chronic kidney disease (ckd) affects 500 million people worldwide. in the us there are 1400 per million of estimated prevalence or established renal failure while in the uk it is recorded more than 600 per million in 2007. this study aims to assess the knowledge on self care measured by structured knowledge questionnaire, assess the quality of life measured by who qol-bref scale and try to find out the relationship between knowledge of self care measures and quality of life among chronic renal failure patients undergoing haemodialysis. methods: a non experimental descriptive correlational design with a descriptive approach was used for the study. non probability, purposive sampling was used to select 95 crf patients undergoing haemodialysis. the conceptual framework was based on orem’s self care model. the instruments used for data collection were a structured knowledge questionnaire and who qol-bref scale. the structured knowledge questionnaire was divided into two sections, sociodemographic variables and knowledge regarding self care measures. the tool was divided into six areas of knowledge such as introduction, clinical features, diagnosis, evaluation, treatment, self care measures and complications of crf. the main study was conducted among 95 crf patients undergoing haemodialysis in the month of february to march and analysis was done by using descriptive and inferential statistics. karl pearson’s coefficient of correlation was used to compute the co-relation between knowledge & quality of life. results: among the selected 95 patients, karl pearson’s coefficient of correlation was found to be rxy = 0.86 since 0< rxy<1, there is positive correlation between the knowledge of self-care measures and quality of life. conclusion: the study finding revealed that there is positive correlation between the knowledge and quality of life. as the level of knowledge increases, quality of life improves simultaneously. keywords: chronic kidney diseases • chronic renal failure • crf • quality of life ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer b assistant professor c college of nursing, lumbini medical college, palpa, nepal d department of surgery lumbini medical college teaching hospital, palpa, nepal corresponding author: ms. sarita shah e-mail: sarita.sanjeev@ymail.com how to cite this article: shah s, pokharel n. knowledge regarding self care measures and quality of life among patients with chronic renal failure undergoing hemodialysis. journal of lumbini medical college. 2013;1(1):39-42. doi:10.22502/jlmc.v1i1.12. ___________________________________________________________________________________ j. lumbini. med. coll. vol 1, no 1, jan-june 2013 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v1i1.12 introduction: chronic diseases present a significant challenge to 21st century global health policy.1 the rapid rise of common risk factors such as diabetes, hypertension and obesity especially among the poor, will result in even greater and more profound burdens that developing nations are not equipped to handle. attention to chronic diseases, chronic kidney disease in particular, has been lacking, largely due to the global health community’s focus on infectious diseases and lack of awareness. ckd is a worldwide health problem. according to world health organization (who) global burden of disease project, diseases of the kidney and urinary tract contribute to global burden with approximately 850,000 deaths every year and 115,010,107 disability adjusted life years. ckd is 12th leading cause of death and 17th cause of disability.2 this global prevalence, however, may be grossly underestimated for a number of reasons. patients with ckd are at high risk for cardiovascular disease (cvd) and cerebrovascular disease (cbvd), and 39 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np shah s. et al. knowledge regarding self care measures and quality of life among patients with chronic renal failure undergoing hemodialysis they are more likely to die of cvd than to develop end-stage renal failure.3 moreover, patients with cvd often develop ckd during the course of their disease, which may go unrecognized. therefore, an unknown proportion of people whose death and disability attributed to cvd have kidney disease as well.4 renal failure is the inability of the kidneys to adequately filter metabolic waste products from the blood. kidney failure has many possible causes. some lead to a rapid decline in kidney function (acute kidney failure); others lead to a gradual decline in kidney function (chronic kidney failure, also called chronic kidney disease). in addition to the kidneys being unable to filter metabolic waste products (such as creatinine and urea nitrogen) from the blood, the kidneys are less able to control the amount and distribution of water in the body (fluid balance) and the levels of electrolytes (sodium, potassium, calcium, phosphate) in the blood.5 ckd affects 500 million people worldwide. the number of dialysis patients increase by 7% annually.6 the burden and magnitude of chronic kidney disease (ckd) is enormous especially in developing countries.7 lifestyle related diseases are important causes of increased morbidity and mortality in the world today. the calculations by the usrds (united states renal data system, 1999), indicate that 110 of every 100,000 people have esrd.6,7 about 29 of every 100,000 are diagnosed with esrd each year. the availability and quality of dialysis programmes largely depend on the prevailing economic conditions and social support.8 the management of esrd in india is largely guided by economic considerations.5,8 treatment of esrd in india is a low priority for cost strapped public hospitals and in the absence of health insurance plans, less than 10% of all patients receive any kind of renal replacement therapy.9 to determine which residents at risk for ckd may be in the early stages of the disease, a simple, cost-effective diagnostic tool is needed. the urine albumin test, which detects micro albuminuria, is the most sensitive test for detecting early-stage ckd.10 haemodialysis significantly and adversely affects the lives of patients, both physically and psychologically.11 the global influence on family roles, work competence, fear of death, and dependency on treatment may negatively affect quality of life and exacerbate feelings associated with a loss of control.12 the treatment involves circulating the patient's blood outside of the body through an extracorporeal circuit (ecc), or dialysis circuit.13 end-stage renal disease and its treatment profoundly affect health related quality of life not only for the patient but the family also.14 although renal replacement therapy ameliorates some of the symptoms of end-stage renal disease they may not be completely alleviated.15 moreover, with treatment often comes significant life style changes, all of which impact on quality of life.16 quality of life of patients with end renal disease is influenced by the disease itself and by the type of replacement therapy.17 dialysis must be repeated frequently and continued life-long until death or transplant.18 the burden of pain and other physical and mental symptoms, as previously mentioned, can account for more than one-third of the impairment observed in mental hr qol in dialysis patients.19 depression in ckd is likely multifactorial, though is typically attributed to feelings of loss and dependence.20 although depression can occur at any time during the course of ckd, there are times of increased likelihood of a depressive episode, such as the time leading up to and the first year following initiation of dialysis, particularly if kidney transplantation is not an option due to advanced age and/or co morbidity.21 during this period, patients are required to make decisions regarding treatment modality and to make multiple and radical lifestyle changes, all of which impact their occupation, familial role, relationships, and leisure activities.22 they are expected to assimilate information that is foreign and frightening.23 methods: the research design used for the present study is descriptive correlational design. settings are the more specific places where data collection occurs based on the nature of the research question and the type of information needed to address it. the setting planned for this particular study is selected in dialysis unit of kles dr. prabhakar kore hospital and mrc, belgaumkarnataka. in the present study the sample population consists of crf patient undergoing haemodialysis in the hospital with a sample size of 95 crf patients. based on the criteria mentioned, purposive sampling was used to select the sample according to the purpose of the study. purposive sampling is non-probability sampling, in which it entails the use of the most conveniently available people or objects as subjects in a study. the tool used for gathering relevant data was a structured questionnaire on knowledge of self care measures and who qol-bref scale among crf patient undergoing haemodialysis. the research investigator obtained ethical clearance and formal permission from the medical director, k.l.e.s dr. prabhakar kore hospital and mrc, belgaum, karnataka to collect data for the main study. the main study was conducted at k.l.e.s dr. prabhakar kore hospital and mrc, belgaum, from 24th february 2011 to 5th march 2011.the steps used for data collection was as follows: step-1 the investigator obtains permission from respective authority to conduct the study. 40 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 shah s. et al. knowledge regarding self care measures and quality of life among patients with chronic renal failure undergoing hemodialysis jlmc.edu.np step-2 selection of subjects. step-3 self introduction of the investigator. step-4 administration of structured knowledge questionnaire. step-5 administration of whoqol-bref scale. step-6 data were tabulated and analyzed. the data obtained were analyzed in terms of the objectives of the study using descriptive and inferential statistics. the plan of the data analysis was as follows. • organize the data on master sheet. • compute frequency, percentage, mean, standard deviation and range to describe the data. • classify the knowledge scores as follows *good (x̄ + sd), *average (x̄ sd to x̄ + sd), *poor (< x̄ sd); where x̄ is mean and sd is standard deviation. conclusion were drawn from inferential statistics. karl pearson’s coefficient of correlation is used to find out the relationship between knowledge of selfcare measures and quality of life. results: majority of the patients 41 (43.15%) belonged to age group of 52-72 years, and a minimum of 6 (6.31%) patients belonged to age group of 73-93 years. 76 (80%) were male, and a minimum of 19 (20%) patients were female. 25 (26.31%) had business, and minimum 8 (8.42%) patients were unemployed. 27 (28.42%) had primary education, and a minimum of 1(1.05%) patient had no formal education. majority of the patient’s family income/month, 50 (52.63%) had rs >8000, and minimum 8 (8.42%) patient had rs. < 2000. 57 (60%) belonged to the urban area, and a minimum of 38 (40%) patients belonged to rural area. 66 (69.47%) belonged to nuclear family, and a minimum of, 5 (5.26%) patients belonged to extended family. majority of patients 83 (87.36%) were married, and a minimum of 2 (2.10%) patients were widows. the relationship between knowledge of self care measures and quality of life were analyzed by karl pearson’s coefficient of correlation method, and it was found that there was positive correlation between knowledge of self care measures and quality of life. it indicated that the quality of life of crf patients undergoing haemodialysis was influenced by their level of knowledge. karl pearson’s coefficient of co-relation was used to compute the corelation between knowledge & quality of life and was found to be rxy = 0.86. since 0< rxy<1, there is positive correlation between the knowledge of selfcare measures& quality of life. discussion: findings related to the socio-demographic variables among crf patients undergoing hemodialysis: majority of the patients 41 (43.15%) belonged to age group of 52-72 years, and a minimum of 6 (6.31%) patients belonged to the age group of 73-93 years. these findings are similar to a cohort study done at winthrop university hospital, mineola, new york usa7. 76 (80%) were male, and a minimum of 19 (20%) patients were female. majority of patient’s occupation 25 (26.31%) was business, and a minimum of 8 (8.42%) patients were unemployed. these findings were similar to the findings of the study conducted by atlantic health sciences corporation, saint john, new brunswick, canada in 2004.2 27 (28.42%) had primary education, and a minimum of 1(1.05%) patient had no formal education. these findings were similar to the findings of the study conducted at meran school of medicine, seljuk university, konya turkey.4 majority of the patients family income/month 50 (52.63%) was rs.>8000, and a minimum of 8 (8.42%) patients was < 2000. these findings were similar to the findings of the study done at sao paulo university brazil.12 57 (60%) belonged to urban area, and a minimum of 38 (40%) patients belonged to rural area. these findings were similar to the findings of the study conducted at department of nursing, kyungbok college, pocheon, korea.21 66 (69.47%) belonged to nuclear family, and a minimum of 5 (5.26%) patients belonged to extended family. these findings were similar to the findings of the study done at kasha, isfahan, iran.20 majority of the patients 83 (87.36%) were married, and a minimum of 2 (2.10%) patients were widows. these findings were similar to the findings of the study done at the university of granada, spain.17 findings related to knowledge scores among crf patients undergoing haemodialysis: the assessment of knowledge of crf patients regarding self care measures revealed that majority of 62 (65.26%) had an average level of knowledge, 22 (23.15%) had a poor level of knowledge. whereas 11 (11.57%) had a good level of knowledge. area wise mean percentage knowledge levels indicate that in the area of self care measures was 53.15% , introduction of crf was 46.87%, diagnostic evaluation was 40%, complication was 38.42%, treatment was 26.31%, clinical features was 22.63%. findings related to quality of life among crf patients undergoing haemodialysis: 41 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np shah s. et al. knowledge regarding self care measures and quality of life among patients with chronic renal failure undergoing hemodialysis reveals that raw scores were the highest among domain 4 (environmental) for all 95 patients with crf i.e. 1118, which means they showed high quality of life in this domain. they fared better in domain 1 (physical) where raw scores were 1116 and domain 2 (psychological) where raw scores were 1100. they fared the least in domain 3 (social relationship) where they scored 1065 and qol was the least in this domain. the raw and transformed scores as per scoring manual for physical psychological, social relationship and environmental domain were (648-1608), (540-2257), (1416-6472) and (589-1261) respectively. these findings were similar to the findings of the study done at taiwan.18 findings related to relationship between knowledge of self care measures and quality of life among crf patient undergoing haemodialysis: the relationship between knowledge of self care measures and quality of life were analyzed by karl pearson’s coefficient of correlation method, and it was found that there was positive correlation between knowledge of self care measures and quality of life (rxy = 0.86). it indicated that the quality of life of crf patients undergoing haemodialysis was influenced by their level of knowledge. these findings were similar to the findings of the study done at sivas, turkey.24 conclusion: the study emphasizes on the need for improving knowledge in patients and their care givers in which the health personnel can update their knowledge and skills to provide quality nursing care. the study finding revealed that there is positive correlation between the knowledge and quality of life. as the level of knowledge increases, quality of life improves simultaneously. nurse administrator can encourage nursing personnel, patients and care givers to make active contribution towards the proper gain of knowledge. nurse administrator can help prepare skilled nurses, health workers and employees in handling dialysis machines to provide quality of care. the findings of the study have implications for nursing practice, nursing education, nursing administration and research. since present study showed that most of the patients had average knowledge which can be improved by nurses by providing teaching strategy, it helps in uplifting patients’ knowledge and hence improvement in their quality of life. 1. gillanders s, wild m, deighan c, gillanders d. emotion regulation, affect, psychosocial functioning, and wellbeing in hemodialysis patients. am j kidney dis. 2008;51(4):651-62. 2. varughese s, john gt, alexander s, deborah mn, nithya n, ahamed i et al. pre-tertiary hospital care of patients with chronic kidney disease in india. ind j med res. 2007;126:28-33. 3. bataclan rp, dial ma. cultural adaptation and validation of the filipino version of kidney disease quality of life – short form (kdqol-sf version 1.3). nephrology (carlton).2009;14: 663-8. 4. rebollo p, ortega f. new trends on health related quality of life assessment in end-stage renal disease patients. int urol nephrol. 2002;33(1):195-202. 5. ballal hs. the burden of chronic kidney disease in a developing country, india. quest. 2007;9:12-9. 6. manns bj, walsh mw, culleton bf, hemmelgarn b, tonelli m, schorr m et al. nocturnal hemodialysis does not improve overall measures of quality of life compared to conventional hemodialysis. kidney int. 2009;75:542-9. 7. narula as. chronic kidney disease : the looming threat. mjafi. 2008;64:2-3. 8. eskridge ms. hypertension and chronic kidney disease: the role of lifestyle modification and medication management. nephrol nurs j. 2010;37(1): 55-60, 99. 9. kosmadakis gc, bevington a, smith ac, clapp el, viana jl, bishop nc, feehally j. physical exercise in patients with severe kidney disease. nephron clin pract. 2010;115(1):c7-c16. 10. segura-orti e. exercise in haemodialysis patients: a literature systematic review. nefrologia. 2010;30(2):236-46. 11. gotch f, levin nw, kotanko p. calcium balance in dialysis is best managed by adjusting dialysate calcium guided by kinetic modeling of the interrelationship between calcium intake , dose of vitamin d analogues and the dialysate calcium concentration. blood purif. 2010;29(2):163-76. 12. finkelstein fo, wuerth d, finkelstein sh. an approach to addressing depression in patients with chronic kidney disease. blood purif. 2010;29(2):121-4. 13. wyszomierska a, puka j, myszkowska-ryciak j, narojek l. the period of dialysis and nutritional habits of patients with the end stage renal disease. rocz panstw zakl hig. 2009;60(3):289-92. 14. musso cg, michelangelo h, reynaldi j, martinez b, vidal f, quevedo m. combination of oral activated charcoal plus low protein diet as a new alternative for handling in the old end-stage renal disease patients. saudi j kidney dis transpl. 2010;21(1):102-4. 15. hamissi j, porsamimi j, naseh mr, mosalaei s. status of hemodialyzed patients with chronic renal failure. east afr j public health. 2009;6:108-11. 16. koh kp, fassett rg, sharman je, coombes js, williams ad. effect of intradialytic versus home-based aerobic exercise training on physical function and vascular parameters in hemodialysis patients: a randomized pilot study. am j kidney dis. 2010;55(1):88-99. 17. maclaughlin hl, cook sa, kariyawasam d, roseke m, van niekerk m, macdougall ic. nonrandomized trial of weight loss with orlistat, nutrition education, diet, and exercise in obese patients with ckd: 2-year follow-up. am j kidney dis. 2010;55(1):69–76. 18. alavi nm, aliakbarzadeh z, sharifi k. depression, anxiety, activities of daily living and quality of life scores in patients undergoing renal replacement therapies. transplant proc. 2009;41:3693-6. 19. mafra d, jolivot a, chauveau p, drai j, azar r, michel c et al. are gherlin and leptin involved in food intake and body mass index in maintenance hemodialysis? j ren nutr. 2010; 20(3):151-7. 20. milovanov ius, lysenko lv, milovanova liu, dobrosmyslov ia. the role of balanced low-protein diet in inhibition of predialysis chronic kidney disease progression in patients with systemic diseases. ter arkh. 2009;81(8):52-7. 21. sanchez c, aranda p, perez de la cruz a, llopis j. magnesium and zinc status in patients with chronic renal failure: influence of a nutritional intervention. magnes res. 2009;22(2):72-80. 22. ranganathan n, friedman ea, tam p, rao v, ranganathan p, dheer r. probiotic dietary supplementation in patients with stage 3 and 4 chronic kidney disease: a 6-month pilot scale trial in canada. curr med res opin. 2009;25(8):1919-30. 23. reddy v, symes f, sethi n, scally aj, scott j, mumtaz r et al. dietitian-led education program to improve phosphate control in a single-center hemodialysis population. j ren nutr. 2009;19(4):314-20. 24. tsutsui h, koike t, yamazaki c, ito a, kato f, sato h et al. identification of hemodialysis patients' common problem using the international classification of functioning, disability, and health. ther apher dial. 2009;13(3):186-92. references: 42 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 6, no 2, july-dec 2018 ___________________________________________________________________________________ submitted: 05 may, 2018 accepted: 12 december, 2018 published: 21 december, 2018 a assistant professor, department of radiodiagnosis b associate professor and head, department of radiodiagnosis c lecturer, department of radiodiagnosis d lumbini medical college and teaching hospital, pravas, palpa corresponding author: sumnima archarya e-mail: doctorsumnima@gmail.com orcid: https://orcid.org/0000-0001-8612-671x_______________________________________________________ —–————————————————————————————————————————————— abstract: introduction: placenta grows in size with the advancement of gestational age (ga) and plays an important role for delivery of nutrients from mother to fetus. ultrasonography (usg) is implicated for the estimation of ga by using fetal growth parameters like femur length (fl), bi-parietal diameter (bpd), head circumference (hc), and abdominal circumference (ac). this study intends to observe the correlation between placental thickness (pt) and ga. methods: it was an observational, cross-sectional, and analytical study conducted over a period of six months from november 2017 to april 2018. all trans-abdominal usg were done in supine position using 3.5 mhz curvilinear probe by the principal investigator. fetal growth parameters i.e. fl, bpd, hc, and ac were measured to estimate ga. pt was also measured at the same time. results: there was a positive correlation between pt and ga (r = 0.89, n=249, p < 0.001). pearson correlation coefficient between the two variables at second and third trimesters were 0.81 and 0.49 respectively. fisher r-to-z transformation was used to analyze the difference between those two coefficients and was found to be statistically significant (z = 4.6, p < 0.001). this indicates that there was a significant overall relationship between pt and ga. as ga increases, pt also increases. conclusion: our study observed a positive correlation between the pt and ga in second and third trimesters. thickness of placenta can thus be used as a reliable parameter for the estimation of ga during the second and third trimesters, and can be used as a supplementary usg parameter along with fl, bpd, hc and ac. keywords: gestational age, placental thickness, ultrasonography original research articlehttps://doi.org/10.22502/jlmc.v6i2.214 sumnima acharyaa,d awadesh tiwarib,d rupesh sharmac,d placental thickness and its correlation with gestational age: a cross-sectional ultrasonographic study introduction: placenta develops from chorionic villi at about fifth week of intra-uterine life and is visible by transabdominal ultrasonography (tas) at around tenth week of gestation.[1] it grows in size with the advancement of gestational age (ga) and plays an important role for delivery of nutrients from mother to fetus.[2] last menstrual period (lmp) and clinical methods such as first fetal movements and uterine fundal height measurement were initially used for the evaluation of gestational age. but these methods do have drawbacks. lmp may be difficult to ascertain when there are irregular menstrual cycles or conception occurs in lactational amenorrhea. clinical methods are flawed with observer’s bias. [3] these days ultrasonography (usg) is used for the estimation or confirmation of gestational age. usg determines gestational age from various fetal dimensions like femoral length (fl), biparietal diameter (bpd), head circumference (hc), and abdominal circumference (ac). but these conventional methods of measuring fetal dimensions too are associated with some short comings as in the case of hydrocephalus.[4] hence, there should be alternative method which can reliably estimate the gestational age. how to cite this article: acharya s., tiwari a., sharma r. placental thickness and its correlation with gestational age and fetal growth parameters: a cross-sectional ultrasonographic study. journal of lumbini medical college. 2018;6(2):5 pages. doi: 10.22502/jlmc.v6i2.214. epub: 2018 dec 21. https://orcid.org/0000-0001-8612-671x acharya s. et al. placental thickness and its correlation with gestational age and fetal growth parameters jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 placental thickness correlates with gestational age in the second and third trimesters and may be used as an alternative method for the evaluation of latter.[5] we conducted this study to evaluate the correlation between placental thickness and gestational age. methods: this was an observational, cross-sectional, and analytical study carried out in the department of radiodiagnosis, lumbini medical college teaching hospital (lmcth), palpa, nepal. the study was conducted after the ethical approval from institutional review committee of the institute. it was conducted over a period of six months from november 2017 to april 2018. during the study period, consecutive singleton pregnant women who underwent obstetric usg in second or third trimester were included in the study. pregnant women with diabetes, hypertension or anemia were excluded. those with fetal anomalies, placental anomalies or poor visualization of placenta were also excluded. acusonx300 from siemens with a 3.5 mhz convex array transducer was used for obstetric evaluation. each woman underwent usg only once during the study. scanning technique: all trans-abdominal obstetric usg were done in supine position using 3.5mhz curvilinear probe by the principal investigator. fetal growth parameters i.e. fl, bpd, hc, and ac were measured to estimate ga. placental thickness (pt) was also measured at the same time. the antero-posterior diameter of placenta was measured at the level of insertion of umbilical cord.[6,7] the uterine myometrium and retro placental veins were excluded. bpd was estimated as the distance between the outer edge of the cranium nearest to the usg probe and inner edge of the cranium distal to the transducer at the level of paired hypoechoic thalami and cavum septum pellucidum.[8] using the elliptical calipers, hc was estimated over the four points; two points of bpd and other two points of occipital frontal diameter in the same plane as bpd.[9] ac was estimated as the circumference of fetal abdomen in a transverse plane 900 to the fetal spine at the level of umbilical vein junction with the portal vein.[10] fl was estimated as the length of fetal femur from the greater trochanter to the femoral condyles.[11] the data was collected using microsoft excel 2007 and imported it to statistical package for the social sciences (spsstm), version 16, for statistical analysis. results: a total of 249 pregnant ladies in their second and third trimesters were studied. 39.8% of the patients were of 21-25 years followed by 15-20 years (23.3%) and 26-30 years (22.5%). out of all cases, 103 women were in the second trimester (14-27 weeks) and 146 were in the third trimester (28-40 weeks). the most common location of placenta was anterior (55%) followed by posterior in 35%, fundoposterior in 6% and fundo-anterior in 4%. the maximum pt was 50 mm at 37 weeks and minimum (14.5 mm) at 14 weeks. the mean pt of ladies in the second trimester was found to be 22.3±3.7 mm, and 39±4.4 mm in the third trimester. cumulative mean of pt in both trimesters was 29±7.2 mm. there was a positive correlation between pt and ga (r = 0.89, n=249, p < 0.001) as shown in fig. 1. pearson correlation coefficient between the two variables at second and third trimesters were 0.81 and 0.49 respectively. fisher r-to-z transformation was used to analyze the difference between those two coefficients and was found to be statistically significant (z = 4.6, p < 0.001). this indicates that there was a significant overall relationship between pt and ga. as ga increases, pt also increases. fig. 1: scatter plot diagram showing distribution between pt and ga (n=249) this strength of relationship was however different in second and third trimester. it was much stronger in the second trimester as compared to the third. discussion: our study evaluated relationship between pt acharya s. et al. placental thickness and its correlation with gestational age and fetal growth parameters jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 and ga. a total of 249 patients in second and third trimesters were included in the study. evaluation of ga is essential to assess the wellbeing of the fetus and to plan an appropriate obstetric management of the pregnant ladies.[12] ga can be precisely determined by usg and can be more reliable than one calculated by lmp, provided multiple parameters are used in the usg for ga estimation.[1] it was observed that most of the patients in our study were in the age group of 21-25 years (39.8%), followed by 15-20 years (23.3%) and 2630 years (22.5 %). in the study of kakumanu pk et al.[13] 48% patients were in the age group of 2025 years. similarly, study of adhikari r. et al.[14] also found that 20-30 years was the predominant age group with 73% antenatal women, and 27.3% were below 20 years of age. findings from these studies are comparable to ours. in our study 12% of patients presented at 37th week of gestation (wog), followed by 34th wog (8.8%), and 36th wog (8.4%). this might be explained by the lack of knowledge regarding antenatal care (anc) in nepalese women in the sub-urban or rural areas, and their hesitancy to seek medical advice during pregnancy. who recommends a minimum of 8 anc visits, with the first visit in the first trimester, two visits in the second trimester (20 and 26 wog), and five visits in the third trimester (30, 34, 36, 38 and 40 wog).[15] in our study, most common placental location was anterior (55%) followed by posterior in 35%, fundoposterior in 6% and fundo-anterior in 4% of the women. similar to the finding of our study, saxena s. et al.[16] also witnessed anterior located placenta in most of the women (50.1%). in contrary, adhikari r. et al.[14] reported most of the placenta (46%) were in the posterior location. possibly, placental location may vary among population according to the geography. the maximum pt observed in this study was during 38th wog with mean pt of 36.3±1.9 mm. previous studies of hoddick wk et al.[17], weerakkody y. et al.[18], and benirschke k. et al.[19] also suggested that pt was not more than 40 mm at any time of gestation. this shows that pt in nepalese women is comparable to that of indian, nigerian and caucasian women. according to agwuna kk et al.,[12] pt can be a reflection of any abnormalities in the fetus. diabetes mellitus, fetal hydrops and intra-uterine fetal infections are associated with increased pt for corresponding ga, whereas decreased pt is associated with intrauterine fetal growth retardation. thus, assessment of pt can be helpful in assessing the fetal condition and to plan a proper medical care for the fetus. the mean pt in the second, third and both trimesters were 22.3 mm, 33.9 mm and 29.2 mm respectively. the mean pt was higher in the third trimester as compared to the second trimester. there was a linear increase in pt with ga and the maximum pt was seen in the 38th wog. however, the mean pt was decreased during the 35-36th wog by less than 1 mm. the increase in size of the placenta correspond to the increasing age of fetus, as suggested by other similar studies by ohagwu cc[20] and agwuna kk.[12] in the current study, a positive correlation was noted between pt and ga ( r=0.89, n=249, p<0.001). these findings of our study are comparable to the observations made by authors in previous studies [13,14,16, 21, 22] as depicted in table 1. in our study, serial measurement of the placental growth was not carried out over a different period of time, thus were not plotted into a longitudinal growth curve. estimating pt by usg at a single point of time and its correlation with ga has its own shortcomings. besides this, placental volume would have been better in assessing the studied by published in correlation of pt with ga (r value) p-value trimester 1st 2nd 3rd karthikeyan et al.(21) j clin diagn res. 2012 0.609 0.812 0.814 <0.01 ahmed et al.(22) j.app.med.sci.2014 not studied not done 0.85 <0.01 adhikari r et al.(14) int. j of med imaging, 2015 not studied 0.914 0.946 <0.001 saxena s et al.(16) ijcmaas, 2016 0.859 0.993 not studied <0.001 kakumanu pk et al. (13) ijcmsr,2018 not studied 0.99 0.99 <0.01 present study not studied 0.811 0.487 <0.001 table 1. correlation of placental thickness (pt) and gestational age (ga) in various studies acharya s. et al. placental thickness and its correlation with gestational age and fetal growth parameters jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 placental growth rather than pt, but it requires a three dimensional usg, which is expensive and time consuming to perform. moreover, pt differs among different population group. a large sample is essential to derive a population specific nomogram. conclusion: our study observed a positive correlation between the pt and ga in second and third trimesters. thickness of placenta can thus be used as a reliable parameter for the estimation of ga during the second and third trimesters, and can be used as a supplementary usg parameter along with fl, bpd, hc and ac. references: 1. mathai bm, singla sc, nittala pp, chakravarti rj, toppo jn. placental thickness: its correlation with ultrasonographic gestational age in normal and intrauterine growth-retarded pregnancies in the late second and third trimester. the journal of obstetrics and gynecology of india. 2013 aug 1;63(4):230-3. pmid: 24431647 doi: 10.1007%2fs13224-0120316-8 [publisher full text] 2. azpurua h, funai ef, coraluzzi lm, doherty lf, sasson ie, kliman m, kliman hj. determination of placental weight using two-dimensional sonography and volumetric mathematic modeling. american journal of perinatology. 2010 feb 1;27(2):151-5. doi: 10.1055/s-00291234034 [publisher full text] 3. jehan i, zaidi s, rizvi s, mobeen n, mcclure em, munoz b, pasha o, wright ll, goldenberg rl. dating gestational age by last menstrual period, symphysis-fundal height, and ultrasound in urban pakistan. international journal of gynecology & obstetrics. 2010 sep 1;110(3):231-4. pmid: 20537328 doi: 10.1016%2fj.ijgo.2010.03.030 [publisher full text] 4. wolfson rn, zador ie, halvorsen p, andrews b, sokol rj. biparietal diameter in premature rupture of membranes: errors in estimating gestational age. journal of clinical ultrasound. 1983 sep;11(7):371-4. pmid: 6415121 doi: 10.1002/jcu.1870110705 5. pant s, dashottar s. a correlative study to evaluate the gestational age by sonological measurement of placental thickness in normal second and third trimester pregnancy. international journal of advances in medicine. 2017 nov 22;4(6):1638-44. doi: doi: 10.18203/23493933.ijam20175181 [publisher full text] 6. mital p, hooja n, mehndiratta k. placental thickness: a sonographic parameter for estimating gestational age of the fetus. indian journal of radiology and imaging. 2002 nov 1;12(4):553-4. [publisher full text] 7. hanretty kp. obstetrics illustrated. 6th ed. endiburgh: churchill livingstone; 2003. pp. 9–12. 8. hadlock fp, deter rl, harrist rb, park sk. fetal biparietal diameter: rational choice of plane of section for sonographic measurement. american journal of roentgenology. 1982 may 1;138(5):871-4. pmid: 6979175 doi: 10.2214/ ajr.138.5.871 9. chitty ls, altman dg, henderson a, campbell s. charts of fetal size: 2. head measurements. bjog: an international journal of obstetrics & gynaecology. 1994 jan 1;101(1):35-43. pmid: 8297866 doi: 10.1111/j.1471-0528.1994. tb13007.x 10. campbell s, wilkin d. ultrasonic measurement conflict of interest: none declared. financial disclosure: no funds were available. https://dx.doi.org/10.1007%2fs13224-012-0316-8 https://dx.doi.org/10.1007%2fs13224-012-0316-8 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3763054/pdf/13224_2012_article_316.pdf https://dx.doi.org/10.1055/s-0029-1234034 https://dx.doi.org/10.1055/s-0029-1234034 https://pdfs.semanticscholar.org/c055/f4e4bdc17778a893c43ba4323b009160e1dc.pdf https://dx.doi.org/10.1016%2fj.ijgo.2010.03.030 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2914118/pdf/nihms209671.pdf https://doi.org/10.1002/jcu.1870110705 http://dx.doi.org/10.18203/2349-3933.ijam20175181 http://dx.doi.org/10.18203/2349-3933.ijam20175181 http://www.ijmedicine.com/index.php/ijam/article/viewfile/819/772 http://www.ijri.org/printarticle.asp?issn=0971-3026;year=2002;volume=12;issue=4;spage=553;epage=554;aulast=mital https://doi.org/10.2214/ajr.138.5.871 https://doi.org/10.2214/ajr.138.5.871 https://doi.org/10.1111/j.1471-0528.1994.tb13007.x https://doi.org/10.1111/j.1471-0528.1994.tb13007.x acharya s. et al. placental thickness and its correlation with gestational age and fetal growth parameters jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 of fetal abdomen circumference in the estimation of fetal weight. bjog: an international journal of obstetrics & gynaecology. 1975 sep;82(9):68997. pmid: 1101942 11. chitty ls, altman dg, henderson a, campbell s. charts of fetal size: 4. femur length. bjog: an international journal of obstetrics & gynaecology. 1994 feb 1;101(2):132-5. pmid: 8305387 doi: 10.1111/j.1471-0528.1994. tb13078.x 12. agwuna kk, eze cu, ukoha po, umeh ua. relationship between sonographic placental thickness and gestational age in normal singleton fetuses in enugu, southeast nigeria. annals of medical and health sciences research. 2016;6(6):335-40. pmid: 28540100 doi: 10.4103/amhsr.amhsr_457_15 [publisher full text] 13. kakumanu pk, kondragunta c, gandranr,yepuri h. evaluation of placental thickness as an ultrasonographic parameter for estimating gestational age of the fetus in 2nd and 3rd trimesters. international journal of contemporary medicine surgery and radiology. 2018;3(1):128-32. [publisher full text] 14. adhikari r, deka pk, tayal a, chettri pk. ultrasonographic evaluation of placental thickness in normal singleton pregnancies for estimation of gestation age. international journal of medical imaging. 2015;3(6):143-7. [publisher full text] 15. world health organization. who recommendations on antenatal care for a positive pregnancy experience. world health organization; 2016. available from: h t t p : / / a p p s . w h o. i n t / i r i s / b i t s t r e a m / h a n d le/10665/250796/9789241549912-engpdf;jsessio nid=df8b7fef544fd24f5a866de6e82c0f5f ?sequence=1 16. saxena s, rao.a , nigam rk, madan gs, yadu n: ultrasonographic measurement of placental thickness and its correlation with gestational age : a cross-sectional study. international journal of current medical and applied sciences. 2016;10(3):138-43 17. hoddick wk, mahony bs, callen pw, filly ra. placental thickness. journal of ultrasound in medicine. 1985 sep;4(9):479-82. pmid: 3903201 18. thurston m, weerakkody y. placental thickness. obstetrics gynaecology radiopaedia 2001;16:6770 19. benirschke k, kaufmann p. pathology of the human placenta.2nd ed. 2nd ed. new york: spring-verlag; 1990. pp. 234–42 20. ohagwu cc, abu po, ezeokeke uo, ugwu ac. relationship between placental thickness and growth parameters in normal nigerian foetuses. african journal of biotechnology. 2009;8(2). [publisher full text] 21. karthikeyan t, subramaniam rk, johnson wm, prabhu k. placental thickness & its correlation to gestational age & foetal growth parameters-a cross sectional ultrasonographic study. journal of clinical and diagnostic research. 2012 dec;6(10):1732. pmid: 23373039 doi: 10.7860%2fjcdr%2f2012%2f4867.2652 [publisher full text] 22. ahmed a, alrashid rahim ho, elgyoum aa, elzaki a. the correlation between placental thickness and fetal age among the pregnant in sudan. scholars journal of applied medical sciences. 2014;2:395-8. 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https://www.ajol.info/index.php/ajb/article/download/59751/48031 https://dx.doi.org/10.7860%2fjcdr%2f2012%2f4867.2652 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3552215/pdf/jcdr-6-1732.pdf https://pdfs.semanticscholar.org/2eda/6e2da80194798b5f3eeb8740006ad39103df.pdf licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 9, no 2, july-dec 2021 _______________________________________________________ ____________________________ submitted: 06 november, 2021 accepted: 20 december, 2021 published: 14 january, 2022 a assistant professor, department of radiology b assistant professor, department of obsterics and gynecology c lecturer, department of radiology d resident, department of radiology e lumbini medical college and teaching hospital, pravas, palpa corresponding author: dr. rupesh sharma, md-radiodiagnosis assistant professor, department of radiology lumbini medical college and teaching hospital (lmc-th) pravas, palpa, province 5, nepal. email: roopskarma@gmail.com orcid: https://orcid.org/0000-0002-3422-6150 _______________________________________________________ — – — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — abstract: introduction: ovarian cancer is the fifth most common cancer in nepalese females and the tenth overall, accounting for 5% of the total new cases of cancer in females in 2020. ultrasonography (usg) remains the primary tool for diagnosis and characterization of ovarian masses in which many grey-scale and doppler characteristics are evaluated. various scoring systems have been described incorporating different usg parameters to differentiate benign and malignant nature of the ovarian masses. alcazar scoring system includes both grey-scale as well as doppler characteristics of the ovarian masses and is one of the more widely used systems worldwide. methods: this was an observational crosssectional study based on 52 consecutive patients who were clinically suspected to have ovarian mass and referred for usg evaluation and who subsequently underwent surgery. results: as confirmed by histopathology, 37 cases were benign and 15 were malignant masses. alcazar system of scoring identified 34 out of 37 benign cases and 15 out of 15 malignant cases with sensitivity and specificity for diagnosing malignant cases of 83.3% and 91.1% respectively. conclusion: alcazar system of scoring is a highly effective tool to differentiate between benign and malignant ovarian masses and can be of great help in diagnosis, characterization and effective preoperative planning. keywords: alcazar scoring system, doppler, histopathology, ovarian mass original research articlehttps://doi.org/10.22502/jlmc.v9i2.468 rupesh sharmaa,e deepak shresthab,e, krishna thapac,e kiran bhandarid,e evaluation of alcazar scoring system to differentiate between benign and malignant ovarian massesa nepalese perspective introduction: ovarian cancer ranks fifth in cancer among nepalese females and tenth overall. it accounted for 5% of total new cases of cancer in females in 2020.[1] worldwide it ranks fifth in cancer deaths in females[2]. ultrasonography (usg) remains the primary tool for diagnosis and characterization of ovarian masses in which many grey-scale and doppler characteristics are evaluated. the grey-scale characteristics correlate with gross morphology of the mass. the color doppler in combination with spectral doppler evaluates the how to cite this article: sharma r, shrestha d, thapa k, bhandari k. evaluation of alcazar scoring system to differentiate between benign and malignant ovarian massesa nepalese perspective. journal of lumbini medical college. 2021;9(2):4 pages. doi: 10.22502/jlmc.v9i2.468. epub: 2021 dec 30. qualitative and quantitative blood flow measurements of the masses and thus increases the overall sensitivity. there is a substantial overlap of morphological features between the benign and malignant ovarian masses and as such no single parameter can be deterministic. hence, various scoring systems have been described incorporating different usg parameters to differentiate between benign and malignant nature of the ovarian masses. among them are the alcazar scoring system[3], de priest scoring system[4], sassone scoring system[5] and ferrazzi scoring system[6] commonly used in clinical practice. alcazar scoring system includes both grey-scale as well as doppler characteristics of the ovarian masses and is one of the more widely used systems worldwide. this study was done to evaluate the alcazar scoring system in a tertiary care center in nepal. methods: this was an observational cross-sectional study based on 52 consecutive patients who underwent usg mailto:roopskarma@gmail.com https://orcid.org/0000-0002-3422-6150 sharma r. et al. evaluation of alcazar scoring system jlmc.edu.np evaluation between september 2019 to august 2020 in the usg unit of the department of radiodiagnosis and imaging in lumbini medical college and teaching hospital (lmcth). all the patients who were clinically suspected to have ovarian mass and referred for usg evaluation and who subsequently underwent surgery were included in the study after ethical approval from the institutional review committee (irc-lmc 01-f/021). the cases where histopathology was not available were excluded from the study. all the patients were examined by transabdominal sonography (tas) in supine position wherein whole of the abdomen and pelvis was scanned using acuson nx3 usg machine (siemens, germany). any ovarian masses were identified and evaluated using both grey-scale and doppler flow imaging. transvaginal scanning (tvs) was done in cases where tas was doubtful or suboptimal as it is proven to have a higher sensitivity[7]. the grey scale parameters included size of the mass, echogenicity, presence or absence of solid components, thick papillary projections (>3 mm), and septation and its thickness. the doppler parameters evaluated were presence or absence of blood flow, location of flow (central or peripheral), peak systolic velocity (psv, considered high flow when >10cm/sec), resistive index (ri, considered low when <0.45). when more than one vessel was noted, the highest psv and lowest ri were considered. the data were entered and analyzed using statistical package for social sciences (spsstm) software version 20. the data thus obtained were used to calculate the individual score of each patient according to alcazar scoring system (table 1) which was then compared with the histopathological diagnosis to evaluate its diagnostic efficacy in terms of sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv). the descriptive results were presented in terms of mean, standard deviation, frequency and percentage. chi square test was used for inferential statistics. a p-value <0.05 was considered statistically significant. table 1. alcazar scoring system j. lumbini. med. coll. vol 9, no 2, july-dec 2021 results: a total of 52 cases were evaluated during the study period out of which 37 cases were benign masses and 15 were malignant masses confirmed by histopathology considered as the gold standard. the age of the patients ranged from 19 to 78 years with a mean age of 40.56 (+ 14.9) years. alcazar system of scoring identified 34 out of 37 benign cases and 15 out of 15 malignant cases as shown in table 2. the sensitivity and specificity for diagnosing malignant cases were 83.3% and 91.1% respectively. moreover the ppv and npv for malignant masses were 83.3% and 100% respectively as shown in table 3. table 2. socio-demographic and behavioral characteristics of the study population (n=243) score thick papillary projections solid areas or purely solid echogenicity blood flow location velocimetry 0 absent absent absent or peripheral other 2 present high velocity or low resistance 4 present central benign:score <6; malignant: score >6 alcazar score histopathology benign malignant total 0-5 (benign) 34 (34/37=91.9%) 0 (0%) 34 (65.4%) >6 (malignant) 3 (3/37=8.1%) 15 (15/15=100%) 18 (34.6%) total 37 15 52 (100%) sharma r. et al. evaluation of alcazar scoring system jlmc.edu.npj. lumbini. med. coll. vol 9, no 2, july-dec 2021 table 3: efficacy of alcazar system in diagnosing malignant cases discussion: many different scoring systems have been formulated in an attempt to differentiate benign and malignant ovarian masses like depriest scoring system, sassone scoring system and ferrazzi scoring system. these scoring systems however consider only the grey-scale parameters. alcazar scoring system on the other hand uses both the grey-scale as well as the doppler flow parameters and thus has been found to have better results in different studies. our study found a high sensitivity and specificity of alcazar scoring system in diagnosing malignant ovarian masses and this finding was similar to studies done by desai et al.[8], sahu m et al.[9] and chaudhari et al.[10]. we found that there was a statistically significant correlation between thick papillary projections and malignancy of the ovarian mass (p=0.03). this observation is similar to the studies done by alcazar et al.[3] and chaudhari et al.[10] serous cystadenoma, dermoid and hemorrhagic cysts are the few benign masses which showed papillary projections. although papillary projections are considered typical of the epithelial stromal tumors of the ovary, clots and other amorphous material can easily mimic them. in a study by hassen et al.[11], it was found that vascularity within the papillary projections was significant for malignancy and calcification within the papilla was suggestive of benign nature. however, alcazar system considers size of the papilla and not the vascularity. we also observed a statistically significant correlation between solid components of the tumor mass with its malignant nature (p<0.05) as was reported by chaudhari et al.[10] and sahu m et al.[9] some benign masses such as dermoid cysts and chocolate cysts can present with solid areas and increased echogenicity which may result into false positive cases. similarly central blood flow and high velocity/low flow were also noted to be statistically significant (<0.05) individual predictors of the malignant nature of the masses. these findings were similar to those of alcazar et al.[3], sahu m et al.[9] and desai et al.[8] the major limitation of our study was its small sample size. therefore further studies with larger sample size would be desirable. a more elaborate study comparing different scoring systems would be more conclusive. conclusion: alcazar system of scoring is a highly effective tool to differentiate between benign and malignant ovarian masses. because of its simplicity and easy availability with no associated radiological hazards, this system can be of great help in diagnosis, characterization and effective preoperative planning for ovarian masses. acknowledgement ms. reema thapa, ms. srijana neupane, ms. kalpana saru. conflict of interest: none declared. financial disclosure: no funds were available. statistical parameters percentage sensitivity 83.3% specificity 91.1% positive predictive value (ppv) 83.3% negative predictive value (npv) 100% sharma r. et al. evaluation of alcazar scoring system jlmc.edu.np references: 1. international agency for research on cancer. nepal: globocan 2020 [internet]. geneva: who; 2021. 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https://dx.doi.org/10.18203/2320-1770.ijrcog20150415 https://www.jsafog.com/doi/jsafog/pdf/10.5005/jp-journals-10006-1246 https://www.jsafog.com/doi/jsafog/pdf/10.5005/jp-journals-10006-1246 https://pubmed.ncbi.nlm.nih.gov/21606312/ https://doi.org/10.2214/ajr.10.5014 https://doi.org/10.2214/ajr.10.5014 j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np parajuli sb, et al. the cost of menstrual cycle in young nepali women: a cross-sectional study ___________________________________________________________________________________ submitted: 09 august, 2021 accepted: 22 november, 2021 published: 02 december, 2021 aassistant professor, department of community medicine blecturer, department of community medicine cmedical student d-lecturer, department of nursing ebirat medical college teaching hospital, biratnagar, nepal. f-research fellow, cvd translational research program, kathmandu university school of medical sciences, kathmandu, nepal. corresponding author: surya bahadur parajuli e-mail: drsathii@yahoo.com orcid: https://orcid.org/0000-0003-0386-9273_______________________________________________________ abstract introduction: every woman must have safe access to clean water and menstrual products. they have to spend more or less money to buy menstrual products or to alleviate menstrual symptoms. cost of a menstrual cycle is often associated with period poverty. we found a research gap on this issue. the objective of this study was to find the cost of menstrual cycle and their perceptions on menstrual cost among young nepali women. methods: we conducted a cross sectional study from 15 august 2019 to 15 february 2020. total enumeration sampling technique was used to enroll 157 female medical students. ethical clearance was obtained from institutional review committee of birat medical college teaching hospital. open data kit (odk) collect software was used for data collection. the collected data was extracted in microsoft excel 2016 and analyzed by spss version 23. results: majority (33.8%) had menarche at 13 years and 47.8% had regular menstrual cycle. total average cost of items used in last menstrual period was npr 480.41 (npr 40-1850) and lifetime cost was npr 219066.96. sanitary pads/ tampons/menstrual cups etc. should cost less money (85.4%) and tax currently put on it should be removed by government (91.1%) were the perceptions of the participants. conclusion: menstrual cycle added additional cost in women's life. participants perceived that cost is high and it should be tax free. nepal constitution already passed sanitation as basic fundamental right. so, the cost of sanitary items needs to be minimized by removing the government tax. keywords: menstrual cycle; menstrual hygiene products; sanitation; young nepali women original research articlehttps://doi.org/10.22502/jlmc.v9i2.458 surya bahadur parajuli,a,e,f anjali mishra,b,e anish luitel,c,e tshering wangchu sherpa,c,e heera kc d,e the cost of menstrual cycle in young nepali women: a cross-sectional study how to cite this article:how to cite this article: parajuli sb, mishra a, luitel a, sherpa tw, kc h. the cost of menstrual cycle in young nepali women: a cross-sectional study. journal of lumbini medical college. 2021;9(2):5 pages. doi: https:// doi.org/10.22502/jlmc.v9i2.458. epub: december 2, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: menstruation is a natural process in females influenced by hormonal changes that occurs each month to prepare for a possible pregnancy. regular menstrual periods from puberty to menopause reflect good function of the body.[1] women’s monthly period adds up extra costs because they have to buy sanitary pads, tampons, pain relievers and heating pads to soothe the aches. the cost may vary due to local price changes.[2] period poverty refers to having a lack of access to sanitary products due to financial constraints.[3] in period poverty, they are not able to afford sanitary wear during menstruation. women have to deal with consequences like lack of confidence, poor participation, school/work absenteeism, depression and diseases resulting from poor hygiene.[4] on average, a woman has her period from three to seven days and the average woman menstruates from age 13 to 51 years. that means the average woman endures some 456 total periods over 38 years, or roughly 2,280 days which is about 6.25 years of her life.[5] a new survey by plan international uk has found that 10% of girls have been unable to afford sanitary products. [6] menstrual care is a human right and one that needs to be addressed by the government. there are more conversations on policies (tax free and/ or subsidy on sanitary products) to enhance access to sanitary products and gender fairness.[7] united j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np parajuli sb, et al. the cost of menstrual cycle in young nepali women: a cross-sectional study nation (un) declared sustainable development goal 2016-2030 as a global agenda of which nepal is a signatory which raised the issue of poverty, health, sanitation etc.[8] the constitution of nepal also mandates that sanitation is the basic fundamental right of every citizen. period poverty is also a growing concern for human rights. in our country, where people have to struggle to fulfill daily basic needs, buying sanitary pads for menstrual use is of less importance. even the girls and women still lack basic sanitation hygiene during menstrual periods. we found a research gap on the issue of cost of the menstrual cycle from our nepali context. hence, we conducted this study with an objective to find the cost of the menstrual cycle and their perceptions on menstrual cost among young nepali women. methods: a cross sectional study was conducted from 15 august 2019 to 15 february 2020 among the medical students of birat medical college teaching hospital. total enumeration sampling was used to enroll 157 nepali female medical students who were studying at different semester of bachelor of medicine and bachelor of surgery (mbbs) at birat medical college teaching hospital. ethical clearance was obtained from the institutional review committee of birat medical college teaching hospital. written informed consent was taken from each participant. the cost of the menstrual cycle was operationalised as the cost spent for sanitary pads, tampons, new underwear or bedsheets, painkillers, acne medication, heating pads and other items needed for the last menstrual period. the perceptions in different attributes of the cost of menstruation includes current cost of sanitary items and government taxation on those items. pretested questionnaire was used. about 10% of total sample size was used for pre testing from higher secondary level health students of naragram school, tankisinuwari, morang, nepal. the content validity of the tool was established by reviewing related literature and seeking opinions with the experts on the subject and appropriate modifications were made. open data kit (odk) collect software was used to collect data by self-administered questionnaire. the completeness of the data was checked every day. the confidentiality and anonymity of data were maintained. the collected data was extracted in microsoft excel 2016 and analysed by statistical package for social sciences (spss) software version 23. results: the mean and standard deviation of study participants was 19.5 years and 1.5 years. one third (33.8%) had their menarche at 13 years of age with the mean (sd) of 12.99 (1.26) years. regarding menarche of their mother, more than one third (35%) had menarche at 13 years of age with the mean (sd) of 13.52 (1.21) years. almost half (47.8%) had their regular menstrual cycle (table 1). table 1: baseline characteristics of the study participants (n=157). characteristics category n (%) age at menarche of participants (years) mean=12.99, median=13, sd=1.26 9 1 (0.6) 10 1 (0.6) 11 13 (8.3) 12 41 (26.2) 13 53 (33.8) 14 27 (12.7) 15 17 (10.8) 16 4 (2.5) age at menarche of their mothers (years) mean=13.52, median=13, sd=1.21 10 1 (0.6) 11 2 (1.2) 12 27 (17.3) 13 55 (35) 14 39 (24.9) 15 22 (14) 16 11(7) regularity of menstrual period regular 75 (47.8) sometimes irregular 64 (40.8) always irregular 18 (11.4) different sanitary items are required during the menstrual period. we found use of sanitary pads (100%), tampons (0.6%), pain relief medicine (38.2%), panty liner (19.7%), new underwear (6.4%), chocolate/sweets/crisps (44.6%), silicone heat pack (26.1%), and extra bed sheets (4.5%). the cost of different items used in their last menstrual period varied. the total average cost of items used in the last menstrual period was npr 480.41 which varied from minimum npr 40 to maximum npr 1850. the detailed breakdown of cost of different items are mentioned in table 2. the total lifetime menstrual period cost was calculated considering a total of 456 menstrual j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np parajuli sb, et al. the cost of menstrual cycle in young nepali women: a cross-sectional study periods in lifetime.[5] it was found npr 480.41 per menstrual cycle and npr 2,19,066.96 for lifetime menstrual cycle cost. participants had different perceptions in different attributes of the cost of menstruation. about 85.4% thought the cost of sanitary pads/tampons/ menstrual cups etc. should cost less money than they do at present. about 91.1% thought the tax currently put on sanitary pads/tampons/menstrual cups etc. should be removed by the government (table 3). table 3: participants’ perception on cost of menstruation (n=157). characteristics category n (%) do you think sanitary pads/ tampons/menstrual cups etc. should cost less money than they do at present? yes 134 (85.4) do you think the tax currently put on sanitary pads/tampons/ menstrual cups etc. should be removed by the government? yes 143 (91.1) discussion: menstrual health is an important component of healthcare system. there are several characteristics of menstrual health in different phases of life. the advocacy for menstrual health is increasing. the cost associated with menstrual health is another agenda of period poverty. we had accessed the cost of the menstrual cycle and its attributes among young medical students in nepal. they represent young nepali women of different ethnicity and geography. we found the majority (33.8%) had their menarche at 13 years with the mean (sd) of 12.99 (1.26) years. in a study from pokhara of western nepal, it was reported the age at menarche was 12.69 (0.95) years.[9] in a study from india, the mean age of menarche was 12.52 years.[10] it was reported to be 11.9 years in the usa.[11] there is a similar age of onset of menarche in both nepali studies which is also similar with india. this might be due to similar socioeconomic characteristics with nepal. the usa reported menarche at earlier ages than us. that might be due to the good nutritional status of the american adolescents. good nutrition and modern dietary patterns are associated with early menarche.[12] regarding menarche of their mother, we found a mean (sd) of 13.52 (1.21) years. previous study from nepal reported mean (sd) of 14.80 (1.67) years.[9] in both studies age of menarche of study participants were less than of their mother. this might be due to improved nutrition status and modern dietary pattern of this generation. different sanitary items are required during menstrual period. we found use of sanitary pads (100%), tampons (0.6%), pain relief medicine (38.2%), panty liner (19.7%), new underwear (6.4%), chocolate/sweets/crisps (44.6%), silicone heat pack (26.1%), extra bed sheets (4.5%). similar types of sanitary items were reported by other studies as well. [13,14,15] the cost of different items used in their last menstrual period varied. we found total lifetime menstrual period cost was npr 219066.96. a project calculated total lifetime menstrual period cost was npr 87552.[16] it is less than our study because of calculation of only the sole cost of sanitary pads, without including the cost of pain relievers, heat pads, reproductive health check-ups and other visits to the doctor. the lifetime cost of menstrual period in table 2: cost (npr) of different items used in last menstrual period (n=157). characteristics n (%) mean median range standard deviation sanitary pad 157 (100) 190.79 150 40-450 122.44 tampons 1 (0.6) 200 200 na na pain relief medicine 60 (38.2) 29.58 22 3-70 18.62 panty liner 31 (19.7) 108.07 100 50-300 57.25 new underwear 10 (6.4) 235 200 85-500 126.72 chocolate/sweets/crisps 70 (44.6) 243.13 200 20-900 198.78 silicone heat pack 41 (26.1) 409.02 450 200-500 96.10 extra bed sheet 7 (4.5) 571.43 600 200-1000 275.16 total cost 480.41 350 40-1850 413.61 j. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np parajuli sb, et al. the cost of menstrual cycle in young nepali women: a cross-sectional study a study reported $6360.[17] different research from different places reported the average lifetime cost of having a period is about £4800, $17000 and £18450. [5,18,19] the cost of not maintaining menstrual hygiene is also remarkable. this leads to infection, infertility and even cancer.[20] many leading organisation are advocating for financial burden of menstrual cost.[21] even for women who have good socio-economic status who do not experience period poverty, they experienced high sticker prices for high-quality feminine hygiene products.[21] the gross margin on feminine hygiene related products is as high as 70%.[21] even the policymakers of developed countries are silent about period cost. [22] the high cost of sanitary items also restricts the young students to attend school and college due to financial constraints of not having sanitary pads.[22] participants had different perceptions in different attributes of the cost of menstruation. about 85.4% thought the cost of sanitary pads/ tampons/menstrual cups etc. should cost less money than they do at present. about 91.1% thought the tax currently put on sanitary pads/tampons/menstrual cups etc. should be removed by the government. in a canadian survey of 1,500 participants, 65% think governments should subsidize feminine hygiene products like tampons, pads, or menstrual cups.[23] the issue of period poverty is not just a form of inequity, but also one of the few examples of years of suppression of issues and basic needs of women. in a country like ours, where menstruation remains a taboo, considering costs on menstrual products may not be suitable to all the girls and women of the country. this eventually will lead to reuse of damped, uncleaned clothes due to unaffordability of the increasing cost of sanitary pads. further it may deteriorate the perineal hygiene and may cause pelvic diseases eventually increasing morbidities during menstrual periods. unclean and unsafe use of menstrual pads and illness during menstruation thus plays a vicious cycle leading to increased cost directly and indirectly. in addition, this increasing cost has caused inequity in health service utilization, and in parts of girl’s education also. we had limitations in our study. we were not able to explore the indirect cost of academic loss, healthcare consultation cost. that might significantly increase the lifetime menstrual cost. we also failed to adjust the cost of the menstrual cycle during amenorrhea due to pregnancy in women’s lives. the answer related to cost may have subjective variations. we recommend the extra cost due to the menstrual cycle in women’s life need to be considered by concerned authorities. as sanitation is the basic human right as per constitution of nepal, the sanitary pads need to be freely available or at minimum cost. the government tax used for sanitary pads needs to be removed. we also recommend large scale studies including multiethnicity from different geography. conclusions: the menstrual cycle added additional cost in women’s life. the participants perceived that the cost is high and it should be tax free. nepal constitution already passed sanitation as the basic fundamental right. so, the cost of sanitary items needs to be minimised by removing the government tax. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. references: 1. office on women’s health. menstrual cycle . u.s. department of health & human services. [cited 2021 july 30]. available from: www. womenshealth.gov/menstrual-cycle. 2. kane j. here’s how much a woman's period will cost her over a lifetime. the huffington post uk. 2017 [cited 2021 july 30]. available from:www.huffpost.com/entry/period-costlifetime_n_7258780. 3. royal college of nursing. period poverty. [cited 2021 july 29]. available from: https:// www.rcn.org.uk/clinical-topics/womens-health/ promoting-menstrual-wellbeing/period-poverty. 4. period poverty: what is it and what can we do? . lunette. [cited 2021 jul 30]. available from: https://store.lunette.com/blogs/news/periodpoverty-what-is-it-and-what-can-we-do. 5. lee g. period poverty is real. but the average woman isn’t spending £500 a year on menstruation . channel 4 news. 2018 [cited 2021 jul 30]. available from: www.channel4. com/news/factcheck/period-poverty-is-real-butj. lumbini. med. coll. vol 9, no 2, july-dec 2021 jlmc.edu.np parajuli sb, et al. the cost of menstrual cycle in young nepali women: a cross-sectional study the-average-woman-isnt-spending-500-a-yearon-menstruation. 6. media center. 1 in 10 girls have been unable to afford sanitary wear survey finds . plan international uk. 2017 [cited 2021 jul 30]. available from: https://plan-uk.org/mediacentre/1-in-10-girls-have-been-unable-toafford-sanitary-wear-survey-finds. 7. end period poverty . sdg action awards. [cited 2021 jul 30]. available from: https:// sdgactionawards.org/initiative/711. 8. national planning commission. national review of sustainable development goals . 2020 [cited 2021 jul 30]. available from: https://www.npc. gov.np/images/category/1__sdg_report_final_ version.pdf. 9. sunuwar l, saha cg, anupa kc, upadhyay dk. age at menarche of subpopulation of nepalese girls. nepal med coll j. 2010;12(3):183-6. pmid: 21446369 10. pandey m, pradhan a. age of attainment of menarche and factors affecting it amongst school girls of gangtok, sikkim, india. international journal of contemporary pediatrics. 2017;4(6):2187–92. doi: http://dx.doi. org/10.18203/2349-3291.ijcp20174754 11. martinez gm. trends and patterns in menarche in the united states: 1995 through 2013–2017. centers for disease control and prevention; 2020 [cited 2021 jul 31]. report no.: 146. available from: https://www.cdc.gov/nchs/data/ nhsr/nhsr146-508.pdf . 12. duan r, chen y, qiao t, duan r, chen m, zhao l, et al. modern dietary pattern is prospectively associated with earlier age at menarche: data from the chns 1997–2015. nutr j. 2020;19(1):1– 9. doi: https://doi.org/10.1186/s12937-02000622-z. 13. kaur r, kaur k, kaur r. menstrual hygiene, management, and waste disposal: practices and challenges faced by girls/women of developing countries. j environ public health. 2018. doi: https://doi.org/10.1155/2018/1730964. 14. poirier p. guide to menstrual hygiene materials. unicef; 2019 [cited 2021 july 31]. available from:https://www.unicef.org/media/91346/ f i l e / u n i c e f g u i d e m e n s t r u a l h y g i e n e materials-2019.pdf. 15. period products. new zealand family planning. [cited 2021 july 31]. available from: https:// www.familyplanning.org.nz/advice/periods/ period-products. 16. menstrual math: how expensive are periods in nepal? 2020 [cited 2021 july 31]. available f r om:ht t p s://w w w.p a d 2gone p a l.c om /p o st / menstrual-math-how-expensive-are-periods-innepal 17. behavior n. the cost of menstruation . necessary behavior; 2020 [cited 2021 july 31]. available from: https://www.necessarybehavior. com/blogs/news/the-cost-of-menstruation 18. mah j. ladies, here’s how much your period costs you over your lifetime. dollars and sense. 2019 [cited 2021 july 29]. available from: https://dollarsandsense.sg/ladies-heres-muchperiod-costs-lifetime/ 19. moss r. women spend more than £18,000 on having periods in their lifetime, study reveals. the huffington post uk. 2015 [cited 2021 july 30]. available from: https://menstrual-matters. com/blog/top-mops/. 20. the cost of not maintaining menstrual hygiene. the economic times. [cited 2021 july 31]. available from:https://economictimes. indiatimes.com /td mc/you r-money/thecosto f n o t m a i n t a i n i n g m e n s t r u a l h y g i e n e / tomorrowmakersshow/68387779.cms 21. kidron e. periods shouldn’t be a financial burden. here’s how one retailer is helping. world economic forum. 2021. [cited 2021 july 31]. available from: https://www.weforum.org/ agenda /2021/03/inter national-womensdayperiods-f inancial-burden-how-retailers-canhelp/. 22. goldberg e. many lack access to pads and tampons. what are lawmakers doing about it? the new york times. 2021 [cited 2021 july 31]. available from:https://www.nytimes. com/2021/01/13/us/tampons-pads-period.html . 23. gurman e. how much do canadian women actually spend on tampons and pads each year? chatelaine. 2017 [cited 2021 jul 31]. available from: https://www.chatelaine.com/ living/how-much-do-periods-cost/. ajay article final (except ref).docx https://doi.org/10.22502/jlmc.v10i1.495 original research article clinical profile and short-term outcome of heart failure patients in a tertiary hospital in kaski, nepal: a cross-sectional study ajay adhikaree,a,c arjun kumar budha,b,c gobind rawat,b,c choodamani nepal,b,c umesh dhungana,b,c suwas chandra gautam,b,c prayas bidarib,c abstract: introduction: heart failure is one of the leading causes of hospitalization. the aim of this study was to evaluate the epidemio-clinical profile and short-term outcome of hospitalized heart failure patients in a tertiary care hospital. methods: this descriptive cross-sectional study was conducted at pokhara academy of health sciences, kaski, nepal from october 1, 2021 to january 31, 2022. all the hospitalized heart failure patients aged 18 years or above were included. relevant history, examination, laboratory and pertinent findings were noted. descriptive statistics were used for qualitative and quantitative data. paired t-test was used for comparison of pre-and post-hospitalization data. a p-value <0.05 was taken for statistical significance. results: there were a total of 116 patients (65.5% females) with a mean age of 64.20 ± 16.35 years. most of them had shortness of breath (97.4%) and orthopnea (72.4%) and presented with pedal/sacral edema (81.9%) and bilateral basal crepitations (69.8%) in the chest. heart failure with preserved ejection fraction was the most prevalent (61.2%) type and dilated cardiomyopathy (27.6%) was the commonest etiology of heart failure. the median duration of hospitalization was five days and the in-hospital mortality was 2.6%. loop diuretics and vasodilators (angiotensin-converting enzyme inhibitor/angiotensin receptor blocker) were the most commonly used medications. conclusions: dilated cardiomyopathy was the most common etiology and heart failure with preserved ejection fraction was the predominant type of heart failure. with a short length of stay and low in-hospital mortality, the short-term outcome was good. keywords: clinical profile, heart failure, hospitalization. submitted: 27 july, 2022 accepted: 09 october, 2022 published: 20 october, 2022 a: assistant professor, department of internal medicine b: md resident, department of internal medicine c: pokhara academy of health sciences, pokhara, kaski, nepal corresponding author: ajay adhikaree assistant professor devdaha medical college and research institute, bhaluhi-9, devdaha municipality, rupandehi, nepal e-mail: ajay.bijay@gmail.com orcid: https://orcid.org/0000-0001-5125-7365 introduction: state of the art heart failure (hf) diagnostics and therapeutics have increased both the prevalence and longevity in hf, making frequent hf hospitalization a universal health concern [1,2,3] and it is expected to rise in how to cite this article: adhikaree a, budha ak, rawat g, nepal c, dhungana u, gautam sc, bidari p. clinical profile and short-term outcome of heart failure patients in a tertiary hospital in kaski, nepal: a cross-sectional study. journal of lumbini medical college. 2022;10(1):14 pages. doi: https://doi.org/10.22502/jlmc.v10i1.495 epub: 2022 october 20 j. lumbini. med. coll. vol 10, no 1, jan-june 2022 https://doi.org/10.22502/jlmc.v10i1 https://orcid.org/0000-0001-5125-7365 adhikaree a, et al. clinical profile and short-term outcome of heart failure patients coming days.[4,5] erewhile in lowand middle income countries, valvular heart diseases were frequent. however, in prevailing time due to shift of paradigm in epidemiology, ischemic heart disease takes humongous share.[6,7] few publications only mention sparsely the commonest cause, different risk factors, outcome of those heart failure hospitalizations in our setting.[6,7,8,9,10,11,12,13] hence this study was conducted to evaluate the epidemio-clinical profile of heart failure patients and their short-term outcome in our setting. methods: this descriptive cross-sectional study was carried out at pokhara academy of health sciences (poahs) from 1st october 2021 to 31st january 2022 after approval from the institutional review committee, poahs (ref. no. 68/078). all hospitalized patients aged 18 years or above with the diagnosis of heart failure were enrolled. the patients who could not undergo cardiac evaluation including necessary investigations and post operative patients ( ≤ 3 months of surgery) were excluded. the sample size was calculated using the formula: minimum sample size (n) = z2pq/ e2. taking prevalence (p) as 7.5% from the study of sharma et al.[8], z=1.96 at 95% confidence interval and e=5%, the minimum sample size was calculated to be 107. recent european society of cardiology guidelines for diagnosis and treatment of acute and chronic heart failure (2021) were adopted for defining, classifying and diagnosing heart failure.[1] patients data were collected from medical history sheets acquired during admission, stay and discharge from the hospital. a comprehensive history, essential physical examination and obligatory laboratory investigations were noted in a working proforma which was formulated after discussion with all the team members and after careful review of various literatures. quantitative n-terminal pro brain natriuretic peptide (nt-pro bnp) estimation was processed using the chemiluminescence immunoassay (clia) approach. a focused systemic cardiovascular assessment along with chest x-ray (cxr), electrocardiogram (ecg) and echocardiogram were carried out. antero-posterior view cxr was repeated to postero-anterior view whenever feasible and cardiomegaly was labeled only when cardiothoracic ratio was > 50% in postero-anterior view. updated guideline on standardization and interpretation of ecg laid by respective heart rhythm society was exercised for calibration and other technicalities of ecg.[14] recent european association of cardio-thoracic surgery protocol (2020) was followed for identifying atrial fibrillation.[15] american college of cardiology and american heart association diagnostic criteria were adopted for detecting bundle branch block pattern and translating other ecg abnormalities.[16] likewise, recent instructions of american society of echocardiography and the european association of cardiovascular imaging were preferred for summarizing echocardiographic results.[17] european society of cardiology working group classification of the cardiomyopathies (2008) guideline was used for defining cardiomyopathies.[18] all these data were noted in statistical package for social sciences (spss) for further analysis. quantitative data were expressed in terms of number, percentage, mean ± standard deviation. preand post hospitalization data were compared using paired t-test. a p value < 0.05 was designated significant. results: there were a total of 116 patients with female j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np adhikaree a, et al. clinical profile and short-term outcome of heart failure patients table 1: baseline characteristics, clinical presentations and risk factors (n=116) characteristics frequency (%) sex female 76 (65.5%) male 40 (34.5%) symptoms sob: nyha 3 51 (44%) nyha 4 62 (53.4%) pnd/orthopnoea 84 (72.4%) chest pain 54 (46.6%) palpitation 54 (46.6%) sweating 38 (32.8%) epigastric pain 32 (27.6%) pre-syncope 16 (13.8%) clinical signs edema (pedal/sacral) 95 (81.9%) b/l basal crepitations 81 (69.8%) distended neck veins 56 (48.3%) raised jvp 35 (30.2%) s3 30 (25.9%) hepatomegaly 14 (12.1%) risk factors tobacco (smoking/chewing) 83 (71.6%) htn 44 (37.9%) copd 42 (36.2%) dm-ii 22 (19.0%) anemia 17 (14.7%) past history of heart failure 15 (12.9%) obesity 13 (11.2%) arrhythmia (excluding sinus arrhythmia) 12 (10.3%) renal disease 06 (5.2%) cad/pci/cabg 03 (2.6%) note: bilateral (b/l), chronic obstructive pulmonary disease (copd), coronary artery bypass graft (cabg), coronary artery disease (cad), diabetes mellitus-type ii (dm-ii), hypertension (htn), jugular venous pressure (jvp), new york heart association (nyha) grading for dyspnoea, paroxysmal nocturnal dyspnoea (pnd), percutaneous coronary intervention (pci), shortness of breath (sob), third heart sound (s3). j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np adhikaree a, et al. clinical profile and short-term outcome of heart failure patients predominance of 65.5% and mean age of 64.20 ± 16.35 years. most of them presented with shortness of breath (sob). tobacco consumption (71.6%) either in the form of smoking or chewing was the most common risk factor. these baseline findings are depicted in more detail in table 1. table 2: investigations findings in the study population (n=116) laboratory parameters mean ± standard deviation haemoglobin (g/dl) 12.72 ± 2.22 urea (mg/dl) 36.68 ± 26.69 creatinine (mg/dl) 1.31 ± 1.26 sodium (meq/l) 136.84 ± 4.57 potassium (meq/l) 4.11 ± 0.66 random blood sugar (mg/dl) 134.66 ± 63.48 nt pro-bnp* (pg/ml) 4946.47 ± 454.21 nt pro-bnp in hfpef** (pg/ml) 4235.72 ± 388.90 nt pro-bnp in hfref*** (pg/ml) 7171.54 ± 549.74 *n-terminal pro brain natriuretic peptide, **heart failure with preserved ejection fraction ***heart failure with reduced ejection fraction the mean values of hemoglobin, creatinine and random blood sugar are shown in table 2. the mean serum n-terminal pro brain natriuretic peptide (nt-pro bnp) level was 4946.47 ± 454.21 pg/ml. chest x-ray (cxr) showed pleural effusion in 65.5% and cardiomegaly in 36.2% of the patients. the most common ecg abnormalities were sinus tachycardia (91.38%) followed by st/t changes (62.06%). echocardiography demonstrated distinctive left ventricular diastolic dysfunction (lvdd) in 87.9%, followed by tricuspid regurgitation (78.4%). table 3 highlights various investigation findings of those patients. almost all heart failure hospitalizations were from the emergency department (96.6%). the most common cause of heart failure was dilated cardiomyopathy (27.6%). table 4 illustrates all these heart failure hospitalization parameters in detail. clinical variables like heart rate (hr), respiratory rate (rr), systolic blood pressure (sbp), diastolic blood pressure (dbp), and body weight mean values were significantly reduced when compared between preand post hospitalization (table 5). j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np adhikaree a, et al. clinical profile and short-term outcome of heart failure patients table 3: investigations findings in the study population (n=116) laboratory parameters number (%) chest x-ray findings: pleural effusion u/l 23 (19.8%) b/l 53 (45.7%) cardiomegaly 42 (36.2%) electrocardiographic findings: sinus tachycardia 106 (91.38%) st/t changes 72 (62.06%) lbbb 35 (30.17%) a. fib. 15 (12.93%) rbbb 12 (10.34%) lafb 05 (4.31%) echocardiographic findings: lvdd 102 (87.9%) tr 91 (78.4%) mr (excluding trace mr) 71 (61.2%) ar 48 (41.4%) lvsd 45 (38.8%) pr 31 (26.7%) pericardial effusion 17 (14.7%) note: aortic regurgitation (ar), atrial fibrillation (a. fib.), bilateral (b/l), left anterior fascicular block (lafb), left bundle branch block (lbbb), left ventricular diastolic dysfunction (lvdd), left ventricular systolic dysfunction (lvsd), mitral regurgitation (mr), pulmonary regurgitation (pr), right bundle branch block (rbbb), tricuspid regurgitation (tr), unilateral (u/l). j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np adhikaree a, et al. clinical profile and short-term outcome of heart failure patients table 4: heart failure hospitalization parameters (n=116) parameters frequency (%) admission ed 112 (96.6%) opd 4 (3.4%) diagnosis hfpef (lvef ≥ 50%) 71 (61.2%) hfmef (lvef: 41-49%) 11 (9.5%) hfref (lvef ≤ 40%) 34 (29.3%) etiology dcm (including ppcm) 32 (27.6%) cor pulmonale with rhf 27 (23.3%) htn 21 (18.1%) vhd (including rhd, ie) 19 (16.4%) cad 13 (11.2%) structural heart disease (asd) 02 (1.7%) arrhythmia 02 (1.7%) median length of stay (days) ward 4.0 icu (n=15) 3.0 status of patient discharged 111 (95.7%) death 03 (2.6%) referred 02 (1.7%) medications loop diuretics 76 (65.5%) acei/ arb 55 (47.4%) β-blocker 44 (37.9%) bronchodilator 39 (33.6%) aspirin 35 (30.2%) mra 23 (19.8%) statin 19 (16.4%) ccb 16 (13.8%) ada (including insulin) 08 (6.9%) digoxin 07 (6.0%) penicillin 04 (3.5%) antibiotics (other than penicillin) 03 (2.6%) note: angiotensin converting enzyme inhibitor (acei), angiotensin receptor blocker (arb), anti-diabetic agents (ada), atrial septal defect (asd), beta blocker (β-blocker), calcium channel blocker (ccb), coronary artery disease (cad), dilated cardiomyopathy (dcm), emergency (ed), heart failure with mildly reduced ejection fraction (hfmef), heart failure with preserved ejection fraction (hfpef), heart failure with reduced ejection fraction (hfref), hypertension (htn), infective j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np adhikaree a, et al. clinical profile and short-term outcome of heart failure patients endocarditis (ie), intensive care unit (icu), mineralocorticoid receptor antagonist (mra), outpatient department (opd), peripartum cardiomyopathy (ppcm), rheumatic heart disease (rhd), right heart failure (rhf), valvular heart disease (vhd) table 5: preand posthospitalization clinical parameters parameters pre-hospitalization (mean ± sd) post-hospitalization (mean ± sd) p value* systolic blood pressure (mm hg) 121.03 ± 20.19 113.53 ± 21.15 0.001 diastolic blood pressure (mm hg) 78.28 ± 13.66 72.84 ± 13.50 <0.001 body weight (kg) 58.00 ± 9.59 54.97 ± 9.67 <0.001 *paired t test discussion: heart failure is a hyperonym for any deterioration of ventricular filling and ejection fraction of the heart and consists of a myriad of symptoms and signs with diverse clinical presentations and ranges of laboratory and radiological changes. multitude criteria and algorithms have been formulated for diagnosis and management. however, paucity of resources compels rigorous integrated algorithmbased management of heart failure inapplicable especially in lowand middle income countries. moreover, keeping abreast with recent heart failure guidelines, gross pragmatic evaluation and management is practiced universally. this study tried to highlight some of these issues. the mean age of the patients in this study was 64.20 ± 16.35 years which was similar to recent national studies done by shrestha et al.[9] (63.7 years) and adhikari et al.[10] (62.8 years). however, compared to preceding studies done in nepal, this was slightly an elder age which illustrated accelerated epidemiological transition towards longevity. [4,6,7,9,13] when these data were compared to international database studies, kyoto congestive heart failure registry [19] had mean age of 80 years, japanese diagnosis procedure combination database [20] had mean age of 79 years, china peace retrospective heart failure study [21] had mean of 73 years and biostatchf study [2] had mean of 68 years. the mean age of our study was comparatively less which is consistent with low national life expectancy. female to male ratio in this study was 1.9, suggesting possibility of higher prevalence of heart failure in female which was also consistent with previous national publications.[4,6,9,11,12.13] the patients presented with the gamut of complaints of which shortness of breath (sob) was present in almost all of the cases j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np adhikaree a, et al. clinical profile and short-term outcome of heart failure patients (97.4%). patients with decompensated heart failure presented with either new york heart association (nyha) class iii or iv symptoms possibly suggesting higher threshold for inpatient admission of high-acuity patients and a trend of seeking medical attention at late stage because of lack of medical awareness or limited access to health facility or health insurance policy. orthopnoea and paroxysmal nocturnal dyspnoea (pnd) were also in substantial frequency in this study. antecedent studies showed various severity of sob including orthopnea and pnd.[7,9,10,12] congestion is regarded as one of the cardinal features of heart failure. edema (pedal and/or sacral) was present in four-fifths of the patients compared to bilateral basilar crepitations which was present in about two-third of the patients. both the signs of systemic as well as pulmonary venous congestion were profound in this study. contrary to this, frequent pulmonary congestion was observed in other studies.[7,21] raised jvp, third heart sound (s3) and tender hepatomegaly were also present in conspicuous extent in this study. tobacco consumed in any form; either smoking or chewing, was the most common associated risk factor in this study. tobacco is considered one of the major health burdens of developing nations. tobacco is a traditional cardiovascular risk factor and shares fellowship with other conventional risk factors like hypertension, diabetes, coronary artery disease and atrial fibrillation, all of which have equal potential of decompensating heart failure. nicotine, a noxious compound found in tobacco, thereby activating the sympathetic nervous system, increases the heart rate and blood pressure and by virtue of increasing myocardial demand results into heart failure. generation of reactive oxygen species, accumulation of unhealthy lifestyle and unhealthy feeding habits in tobacco consumers lead to structural changes in the heart ensuing heart failure.[22] available national literatures also have suggested that tobacco, anemia and chronic obstructive pulmonary disease (copd) are predominant risk factors associated with heart failure.[4,10,12,13] this inculpable finding needs a large sample randomized control trial study for validation. hypertension (htn) and diabetes mellitus type-ii (dm-ii) were present in 37.9% and 19% of the patients respectively in this study. there was a striking difference in prevalence of htn and dm-ii in international studies where htn was the most common associated comorbidity. in a japanese database cohort study,[20] the prevalence of htn and dm-ii was 76.7% and 38.3% respectively. the china peace study [21] showed a prevalence of 53.8% for htn and comparable prevalence of 19.9% for dm-ii. this shift in trend in risk factors from developing to developed nations is the root cause for emergence of cardiovascular disease epidemics. heart failure and copd can coexist together and is thought to be a dangerous liaison. resemblance in clinical presentations, sharing same risk factors and association with similar comorbidities make the picture complicated. more than one-third (36.2%) of the patients in this study had copd. similar reports were narrated in previous studies. similarly, heart failure is more common in patients with atrial fibrillation (a. fib) and is related with unfavorable outcomes including mortality and longer stay in hospital. the prevalence of a. fib in this study was 12.93% which was much less compared to japanese database cohort study [20] (41.8%), kyoto registry [19] (41%), and the china peace study [21] (35.9%). this difference was postulated to occur due to difference in age group and other associated risk factors between our patients and those registries. j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np adhikaree a, et al. clinical profile and short-term outcome of heart failure patients there were only 12.9 % of patients having past history of heart failure which was much lower compared to around 60% reported in the china, europe and the united states.[21,23,24] as many of our patients were from rural community with limited access to health services, there is a possibility that many of them remained undiagnosed or there may be incomplete documentation regarding previous admission or outpatient department visits. additionally, as our patients were younger, they have less chance of having heart failure in the past compared to international registries. the strength of this study was inclusion of biomarker n terminal pro-brain natriuretic peptide (nt pro-bnp) in the diagnostic algorithm of heart failure. these high levels of nt pro-bnp observed in this study definitely vowed for worsening/severe heart failure and ruled out confounding errors resulting from elderly age, anemia, renal failure, infection or arrhythmia. the level of nt pro-bnp noted in this study was similar to other studies. [2,19,21,24,25] incorporation and interpretation of all investigatory modality in heart failure is novelty of this study. pleural effusion was visible in almost two-third of the chest x-ray (cxr) in this study. pleural effusion is the result of pulmonary venous congestion. similarly, cardiomegaly was noticed only in one-third of the patients. the study done by shrestha et al.[9] had illustrated a higher percentage for cardiomegaly compared to pleural effusion. this flip flop in percentages may be due to inclusion of severely symptomatic patient in this study and large number of patients with echocardiography proven dilated left ventricle on shrestha et al.[9] the most common electrocardiographic (ecg) findings observed was sinus tachycardia (91.38%) followed by st segment and t wave (st/t) changes, which was observed in almost two-thirds of the patients. atrial fibrillation and bundle branch block (bbb) were present in varying proportions in this study. various arrhythmia and blocks are characteristics of heart failure. these ecg changes are a consequence of counter-regulatory neuro-endocrine and maladaptive sympathetic over activation of the heart. risk factors like htn, copd, anemia and various other etiology of heart failure including myocardial ischemia, associated features like electrolyte disturbances or structural changes in the heart can contribute to ecg changes. similar ecg findings were noted in antecedent researches.[4,12] echocardiography remains one of the cornerstones in diagnosis and management of heart failure. in this study, left ventricular diastolic dysfunction (lvdd) was the most common (87.8%) echocardiographic finding which was then followed by valvular regurgitation. similar echocardiographic profiling was documented in previous studies.[12,25,26] contrary to that, left ventricular systolic dysfunction (lvsd) was present only in about one-third of the patients in this study. these findings later explain the predominant prevalence of heart failure with preserved versus reduced ejection fraction in this study. pericardial effusion is recognized as a yardstick for presence of heart failure. pericardial effusion was noted in a considerable number of patients in this study. as most of the patients in this study were hospitalized with severe symptoms, almost all (96.6%) patients landed up in ed while only a few showed up in opd. categorically, about two-third of the patients were diagnosed as heart failure with preserved ejection fraction (hfpef) while remaining one-third were classified as heart failure with reduced ejection fraction (hfref). this study found that dilated cardiomyopathy (dcm) was the j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np adhikaree a, et al. clinical profile and short-term outcome of heart failure patients most common cause of heart failure similar to few previous studies.[4,10] cor pulmonale with right heart failure was placed in second position elaborating the fact that copd and its consequences are still the predominant deciding factor in heart failure. valvular heart disease (vhd) including rheumatic heart disease (rhd) was also a contributing cause for heart failure in some percentage of patients but not as much in that frequency as explained in literatures.[6,11,13] coronary artery disease (cad) accounted for only a small percentage (11.2%) of heart failure in this study which is in contrast to few national[7,9,12] and other international studies where cad was the dominant etiology. the diverse etiology of heart failure observed in those previous national studies corresponds to different time frames of those studies and different medical services those hospitals provide including comprehensive cardiac services. the median length of hospital stay was 5 days with a stay of 3 days in intensive care unit (icu) for a few patients. international registries had documented longer duration of stay for heart failure hospitalization.[25,26,28] this could be due to financial constraints, high bed occupancy rate indicating crisis of bed in government hospitals, lower age of the patient, low prevalence of comorbidities. compared to the available data and other disease admission rates, the length of stay documented in this study denotes that guideline directed medical therapy for heart failure has prompt response resulting in shorter stay in hospital. the in-hospital mortality of 2.6% documented in this study was lower compared to international data and registries.[21, 27] most of the patients (95.7%) were discharged out from the hospital in this study. reason for this could be many but less number of worsening or advanced failure in this study compared to those registries. loop diuretics were the most common medications used. diuretics by relieving congestion produce symptomatic relief as well as maintain hemodynamic harmony. this balanced hemodynamics makes way for other heart failure medications to act effectively. use of angiotensin converting enzyme inhibitor (acei), angiotensin receptor blocker (arb), beta-blocker and mineralocorticoid receptor antagonist (mra) were in increasing trend compared to previous study but suboptimal compared to international registries suggesting that there is still a long way to go.[2, 10,11,13, 19-21, 28] there is still a huge potential regarding application of novel therapy like angiotensin receptor neprilysin inhibitor (arni) and sodium glucose cotransporter-2 (sglt2) inhibitor. several limitations ought to be considered. because of the design of the study, its data could not be generalized; neither can it be extrapolated to find causal relationship of heart failure with any other entities. as patients included in this study were symptomatic, the other half of heart failure, i.e., asymptomatic and compensated heart failure patients was not taken into consideration. limited sample size and inability to look for other parameters of short term outcome were also its limitations. conclusion: dilated cardiomyopathy was the most common etiology and heart failure with preserved ejection fraction dominated heart failure hospitalization. this shift of paradigm in epidemics of heart failure resulted due to accumulation of risk factors like tobacco consumption, hypertension and diabetes. moreover, the length of stay was short and the short term outcome of hospitalized heart failure patients was good, representing the favorable response of anti-heart failure medications. however, to achieve optimal j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np adhikaree a, et al. clinical profile and short-term outcome of heart failure patients response, use of novel as well as adequate anti-heart failure medications is desired. conflict of interest: none declared. source of fund: no funds were available. references: 1. ponikowski p, voors aa, anker sd, bueno h, cleland jgf, coats ajs, et al. 2016 esc guidelines for the diagnosis and treatment of acute and chronic heart failure: 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https://doi.org/10.1016/j.echo.2014.10.003 18. elliott p, andersson b, arbustini e, bilinska z, cecchi f, charron p, et al. classification of the cardiomyopathies: a position statement from the european society of cardiology working group on myocardial and pericardial diseases. eur heart j. 2008;29(2):270-6 pmid: 17916581 doi: https://doi.org/10.1093/eurheartj/ehm342 19. yaku h, ozasa n, morimoto t, inuzuka y, tamaki y, yamamoto e, et al. demographics, management, and in-hospital outcome of hospitalized acute j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np https://doi.org/10.3126/jonmc.v6i2.19568 https://doi.org/10.3126/jonmc.v6i2.19568 https://doi.org/10.3126/jonmc.v8i1.24477 https://doi.org/10.3126/jonmc.v8i1.24477 https://pubmed.ncbi.nlm.nih.gov/17322457/ https://doi.org/10.1161/circulationaha.106.180200 https://doi.org/10.1161/circulationaha.106.180200 https://doi.org/10.1161/circulationaha.106.180200 https://pubmed.ncbi.nlm.nih.gov/32860505/ https://doi.org/10.1093/eurheartj/ehaa612 https://doi.org/10.1093/eurheartj/ehaa612 https://pubmed.ncbi.nlm.nih.gov/19281930/ https://pubmed.ncbi.nlm.nih.gov/19281930/ https://doi.org/10.1016/j.jacc.2008.12.013 https://doi.org/10.1016/j.jacc.2008.12.013 https://pubmed.ncbi.nlm.nih.gov/25559473/ https://doi.org/10.1016/j.echo.2014.10.003 https://doi.org/10.1016/j.echo.2014.10.003 https://pubmed.ncbi.nlm.nih.gov/17916581/ https://pubmed.ncbi.nlm.nih.gov/17916581/ https://doi.org/10.1093/eurheartj/ehm342 https://doi.org/10.1093/eurheartj/ehm342 adhikaree a, et al. clinical profile and short-term outcome of heart failure patients heart failure syndrome patients in contemporary real clinical practice in japan-observations from the prospective, multicenter kyoto congestive heart failure (kchf) registry. circ j. 2018;82:2811-9 pmid: 30259898 doi: https://doi.org/10.1253/circj.cj-17-1386 20. mitani h, funakubo m, sato n, murayama h, rached ra, matsui n, et al. in-hospital resource utilization, worsening heart failure, and factors associated with length of hospital stay in patients with hospitalized heart failure: a japanese database cohort study. j cardiol. 2020;76(4):342-9 pmid: 32636125 doi: https://pubmed.ncbi.nlm.nih.gov/32636125 / 21. yu y, gupta a, wu c, masoudi fa, du x, zhang j, et al. characteristics, management, and outcomes of patients hospitalized for heart failure in china: the china peace retrospective heart failure study. j am heart assoc. 2019;8(17):e012884 pmid: 31431117 doi: https://doi.org/10.1161/jaha.119.012884 22. aune d, schlesinger s, norat t, riboli e. tobacco smoking and the risk of heart failure: a systematic review and meta-analysis of prospective studies. eur j prev cardiol. 2019;26(3):279-88 pmid: 30335502 doi: https://doi.org/10.1177/2047487318806658 23. nieminen ms, brutsaert d, dickstein k, drexler h, follath f, harjola vp, et al. euro heart failure survey ii (ehfs ii): a survey on hospitalized acute heart failure patients: description of population. eur heart j. 2006;27(22):2725-36 pmid: 17000631 doi: https://doi.org/10.1093/eurheartj/ehl193 24. steinberg ba, zhao x, heidenreich pa, peterson ed, bhatt dl, cannon cp, et al. trends in patients hospitalized with heart failure and preserved left ventricular ejection fraction: prevalence, therapies, and outcomes. circulation. 2012;126(1):65-75 pmid: 22615345 doi: https://doi.org/10.1161/circulationaha.111.0 80770 25. al-tamimi ma-a, gillani sw, abd alhakam me and sam kg. factors associated with hospital readmission of heart failure patients. front pharmacol. 2021;12(0):732760 pmid: 34707497 doi: https://doi.org/10.3389/fphar.2021.732760 26. amran im, alias sa, shahril ns, basuki hf, salleh azz, khalil fa, et al. heart failure admissions and its associated factors, complications and treatment. international journal of cardiology. 2019;297(suppl):22-23 doi: https://doi.org/10.1016/j.ijcard.2019.11.062 27. cleland j, dargie h, hardman s, mcdonag t, mitchell p. national heart failure audit, april 2012-march 2013. london: national institute for cardiovascular outcomes research (nicor), institute of cardiovascular science, university college; 2013 nov. 86p. (accessed on: 25th july 2022) available from: http://www.wales.nhs.uk/sitesplus/docume nts/862/national%20heart%20failure%20 audit%20april%202012-march2013.pdf 28. lawson ca, zaccardi f, squire i, ling s, davies mj, lam csp, et al. 20-year trends in cause-specific heart failure outcomes by sex, socioeconomic status, and place of diagnosis: a population-based study. lancet public health. 2019;4(8):e406-e420 pmid: 31376859 doi: https://doi.org/10.1016/s2468-2667(19)301 08-2 j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np https://pubmed.ncbi.nlm.nih.gov/30259898/ https://doi.org/10.1253/circj.cj-17-1386 https://doi.org/10.1253/circj.cj-17-1386 https://pubmed.ncbi.nlm.nih.gov/32636125/ https://pubmed.ncbi.nlm.nih.gov/32636125/ https://pubmed.ncbi.nlm.nih.gov/32636125/ https://pubmed.ncbi.nlm.nih.gov/32636125/ https://pubmed.ncbi.nlm.nih.gov/31431117/ https://doi.org/10.1161/jaha.119.012884 https://doi.org/10.1161/jaha.119.012884 https://pubmed.ncbi.nlm.nih.gov/30335502/ https://pubmed.ncbi.nlm.nih.gov/30335502/ https://doi.org/10.1177/2047487318806658 https://doi.org/10.1177/2047487318806658 https://pubmed.ncbi.nlm.nih.gov/17000631/ https://pubmed.ncbi.nlm.nih.gov/17000631/ https://doi.org/10.1093/eurheartj/ehl193 https://doi.org/10.1093/eurheartj/ehl193 https://pubmed.ncbi.nlm.nih.gov/22615345/ https://pubmed.ncbi.nlm.nih.gov/22615345/ https://doi.org/10.1161/circulationaha.111.080770 https://doi.org/10.1161/circulationaha.111.080770 https://doi.org/10.1161/circulationaha.111.080770 https://pubmed.ncbi.nlm.nih.gov/34707497/ https://doi.org/10.3389/fphar.2021.732760 https://doi.org/10.3389/fphar.2021.732760 https://doi.org/10.1016/j.ijcard.2019.11.062 https://doi.org/10.1016/j.ijcard.2019.11.062 http://www.wales.nhs.uk/sitesplus/documents/862/national%20heart%20failure%20audit%20april%202012-march2013.pdf http://www.wales.nhs.uk/sitesplus/documents/862/national%20heart%20failure%20audit%20april%202012-march2013.pdf http://www.wales.nhs.uk/sitesplus/documents/862/national%20heart%20failure%20audit%20april%202012-march2013.pdf http://www.wales.nhs.uk/sitesplus/documents/862/national%20heart%20failure%20audit%20april%202012-march2013.pdf https://pubmed.ncbi.nlm.nih.gov/31376859/ https://pubmed.ncbi.nlm.nih.gov/31376859/ https://doi.org/10.1016/s2468-2667(19)30108-2 https://doi.org/10.1016/s2468-2667(19)30108-2 https://doi.org/10.1016/s2468-2667(19)30108-2 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 6, no 2, july-dec 2018 ___________________________________________________________________________________ submitted: 12 july, 2018, accepted: 02 october, 2018 published: 26 october, 2018 a assistant professor, ophthalmologist b ophthalmologist c lecturer d lumbini eye institute, bhairahawa, rupandehi, nepal e reiyukai eiko masunaga eye hospital, banepa, nepal f lumbini medical college teaching hospital, palpa, nepal corresponding author: manita sunam godar, e-mail: manitagodar@gmail.com orcid: https://orcid.org/0000-0003-0883-132x how to cite this article: godar ms, shrestha r, godar kc. ectopic eyelid in a 15 years old girl: a rare presentation. journal of lumbini medical college. 2018;6(2):2 pages. doi: https://doi.org/10.22502/jlmc.v6i2.166 epub:2018 october 26. _______________________________________________________ — – — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — abstract: introduction: eyelashes are unique hair follicles normally found at the eyelid margin. the spectrum of cilial anomalies includes cilial row duplication, agenesis and ectopic placement. ectopic cilia are the rarest of cilial anomalies. case report: a 15 years old girl presented with the complaints of eyeache and headache for three months. she also complained of extra lashes over left upper eyelid with secretion of tears while crying from the area of extra lashes. she was a diagnosed case of epilepsy under treatment for three months. on examination, visual acuity was 6/6p in right eye and 6/6p in left eye with best corrected visual acuity being 6/6 with -0.25ds in both the eyes. the anterior and posterior segment findings were normal except for presence of extra bunch of cilia on the temporal side of the left upper eyelid two mm above the upper lid crease with dimpling of the underlying skin. conclusion: ectopic cilia, a rare congenital condition, is asymptomatic and surgical treatment can be done for cosmetic correction. keywords: cilia, ectopic, eyelid ——————————————————————————————————————————————— case reporthttps://doi.org/10.22502/jlmc.v6i2.166 manita sunam godar,a,d ruchi shrestha,b,e krishna chandra godarc,f ectopic eyelid cilia in a 15 years old girl: a rare presentation introduction: ectopic cilia, a rare entity, are the congenital disturbance of the position of the eyelashes, usually on the lateral quadrant of the upper eyelid or conjunctival surface of the eyelid. the origin is not clear. the theory of meibomian gland substitution has been refuted and an embryologic origin suggested. in most cases, it causes no apparent medical morbidity and there is no positive family history. treatment is surgical excision, mostly for cosmetic reasons. [1] no case of ectopic eyelid cilia has been reported till date from nepal. case report: a 15 years old girl presented with the complaints of eyeache and headache for three months. she also complained of extra lashes over left upper eyelid with secretion of tears while crying from the area of extra lashes since birth. she was a diagnosed case of epilepsy under treatment for three months. her birth history was uneventful. there was no history of systemic dermatologic condition. on examination, visual acuity (va) was 6/6p in right eye and 6/6p in left eye with best corrected visual acuity (bcva) being 6/6 with -0.25ds in both the eyes. slit lamp biomicroscopy of the anterior segment was normal and the dilated fundus examination with +90d lens revealed the normal posterior segment findings. the upper eyelid of the left side had extra bunch of cilia on the temporal side two mm above the upper lid crease with dimpling of the underlying skin. there was no tenderness. there was no discharge on compression. lid eversion showed the normal tarsal conjunctiva with no such anomaly. the patient was comfortable with the condition and did not want to undergo surgical excision. discussion: congenital ectopic cilia of the eyelid, a rare entity, have been observed to protrude from the anterior surface of the eyelid skin and the posterior aspect of the tarsal plate. all anterior examples of ectopic cilia have been located in the lateral aspect of the upper eyelid.[2] the first reported case of ectopic cilia was described in 1936 by weigmann in godar ms. et al. ectopic eyelid cilia in a 15 years old girl: a rare presentation jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 a patient who had aberrant cilia emanating from the palpebral conjunctiva. it is typically an isolated congenital finding in otherwise healthy children without a known family history. however, baquestani reported a case with positive family history demonstrating evidence of an inherited genetic disorder.[3] cordon et al. reported a complex choristoma containing ectopic cilia and functioning aberrant lacrimal gland tissue, intermittently producing tears.[4] fig 1. ectopic cilia on left upper lid in primary gaze fig 2. ectopic cilia on left upper eyelid on down gaze histologic examination of the specimens demonstrated the presence of apocrine and pilosebaceous glands.[5] ectopic cilia adherent to the underlying tarsus during surgical excision have been reported.[6] no satisfactory explanation has been proposed to account for the development of congenital ectopic foci of cilia. some authors have postulated that these lesions arise in an area of the eyelid in which the normal mesodermal tissue is absent or as a result of a vascular accident.[5, 6] recently macquillen et al.[6] and chen et al.,[5] have proposed that the anomaly is likely due to inappropriate differentiation during embryogenesis, given its congenital presentation and its predilection for the lateral portion of the upper eyelid as in our case. similar to our case the onset of copious tearing triggered by environmental irritants that arose from the base of several ectopic cilia had been described in an 8-year-old boy by mcculley et al[7] and in a 19 years old girl by micheal et al.[2] the presence of sebaceous and apocrine glands in the ectopic cilia and the absence of lacrimal acini or ducts suggest that the secretion from the aberrant cilia is not derived from the lacrimal gland and is not tear. instead, the moisture represents a mixture of the by products of sebaceous and apocrine glands.[2] the preferred treatment for ectopic cilia is surgical excision. one case has been reported for recurrence that may have been due to incomplete excision.[8] conclusion: ectopic cilia, a rare congenital condition, is usually asymptomatic. surgical excision is the treatment for cosmetic correction. acknowledgement: rima verma, dr. binod neeta kandel, eye hospital, parasi conflict of interest: none declared. references: 1. fabricio l da fonseca,patricia k yamanaka, patricia p lima, suzana matayoshi. a 6 years old girl with ectopic cilia and hypochromic nevus. clin ophthalmol 2014; 8: 1256-1261. doi: 10.2147/opth.s63313 2. michael c. chappell, william spencer,susan h. day,rona z. silkiss. congenital ectopic cilia of theupper eyelid. ophthal plast reconstr surg 2011; 27(2):42-44. doi: 10.1097/iop.0b013e3181e17501 3. baghestani s, banihashemi sa. ectopic cilia in a 14 year-old boy.pediatr dermatol. 2011 jan-feb; 28(1):55-6. pmid:21276055 doi:10.1111/j.1525-1470.2010.01354.x 4. cordon aj, patrinely jr, knupp ja, font rl. complex choris toma of the eyelid containing ectopic cilia and lacrimal gland.ophthalmology.1991; 98:1547-1550. doi: 10.1016/s0161-6420(91)32090-6 5. chen ts, mathes ef, gilliam ae. ectopic eyelashes (ectopic cilia) in a 2-year-old girl: brief report and discussion of possible embryologic origin. j pediatr dermatol. 2007; 4(4):433-5. pmid:17845181 doi:10.1111/j.1525-1470.2007.00473.x 6. macquillan a, hamilton s, grobbelarr a. angiosomes, clefts, and eyelashes. plast reconstr surg. 2004; 113:1400 –3. doi:10.1097/01.prs.0000112793.45806.7a 7. mcculley tj, yip cc, kersten rc, kulwin dr. an ectopic site of lacrimal gland secretion mimicking epiphora.arch ophthalmol.2002; 120:1586–7. [publisher full text] 8. tanuj nakra, sean m. blaydon,vikram d. durairaj, roman shinder. congenital upper eyelid ectopic cilia. pediatr ophthalmol strabismus 2011; 48:16-18. doi: 10.3928/01913913-20110208-08 https://doi.org/10.2147/opth.s63313 https://doi.org/10.1097/iop.0b013e3181e17501 https://www.ncbi.nlm.nih.gov/pubmed/?term=baghestani s%5bauthor%5d&cauthor=true&cauthor_uid=21276055 https://www.ncbi.nlm.nih.gov/pubmed/?term=banihashemi sa%5bauthor%5d&cauthor=true&cauthor_uid=21276055 https://www.ncbi.nlm.nih.gov/pubmed/21276055 https://doi.org/10.1111/j.1525-1470.2010.01354.x https://doi.org/10.1016/s0161-6420(91)32090-6 https://www.ncbi.nlm.nih.gov/pubmed/?term=chen ts%5bauthor%5d&cauthor=true&cauthor_uid=17845181 https://www.ncbi.nlm.nih.gov/pubmed/?term=mathes ef%5bauthor%5d&cauthor=true&cauthor_uid=17845181 https://www.ncbi.nlm.nih.gov/pubmed/?term=gilliam ae%5bauthor%5d&cauthor=true&cauthor_uid=17845181 https://doi.org/10.1097/01.prs.0000112793.45806.7a https://jamanetwork.com/journals/jamaophthalmology/article-abstract/272428 https://doi.org/10.3928/01913913-20110208-08 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 7, no 1, jan-june 2019 ___________________________________________________________________________________ submitted: 11 november, 2018 accepted: 01 march, 2019 published: 05 june, 2019 a lecturer, department of forensic medicine & toxicology b professor and head, department of forensic medicine & toxicology clumbini medical college and teaching hospital, pravas, palpa corresponding author: sanjay kumar sah e-mail: drsanjayshah99@gmail.com orcid: https://orcid.org/0000-0002-9356-2517_______________________________________________________ —–————————————————————————————————————————————— abstract: introduction: amongst the various parameters of identification, sex is one of the most important elements. figuring out hand index from measurement of hand dimensions is a convenient way to determine sexual dimorphism. this study aims to find out sexual dimorphism from hand dimensions, obtain cut off points for male and female and check percentage accuracy of sex determination from hand dimensions in nepalese population. methods: the data was collected from 400 asymptomatic, healthy working staff (229 males and 171 females) above 23 years in the department of forensic medicine and toxicology of a tertiary care center of western nepal. measurements of hand length and hand breadth were taken using standard instruments and hand index was calculated therefrom. results: the mean (+sd) right hand lengths for male and female were found to be 17.87 cm (+0.87) and 16.93cm (+0.58) respectively. the mean (+sd) left hand lengths for male and female were 17.85 cm (+0.86)and 16.97 cm (+0.56) respectively. the average hand breadth for male was 1.00 cm greater for right hand and 0.96 cm greater for left hand as compared to female hand breadth. differences in length and breadth of hands for both sexes were statistically significant (p<0.001) with no statistically significant difference of hand dimensions in the same sex. cut off point for right hand index was found to be 42.32 cm and for left hand, 42.30 cm. conclusion: hand dimensions and hand index can be reliably used to determine sex in medicolegal cases, especially where isolated hand is obtained. keywords: anthropometry, hand index, sex determination —————————————————————————————————————————————— original research articlehttps://doi.org/10.22502/jlmc.v7i1.272 sanjay kumar saha,c, bashir ahmed jeelanib,c hand index a forensic tool for sexual dimorphism introduction: determination of sex is considered a major element among the “big four” in forensic anthropology including determination of race, age and stature.[1,2] trends are changing in the field of forensic anthropology, as earlier anthropologists had to depend exclusively upon pelvic and skull bones to determine the sex whereas now, they are able to determine sex from long bones as well.[3,4,5] it is not much difficult to determine sex when complete body parts are available as external and internal genitalia can directly give the clue; however it will be challenging when only dismembered parts are available.[6] it is common to find peripheral body parts such as hands in case of mass disasters , natural calamities, aircraft accidents and bombings. in many situations a criminal dismembers the body parts to conceal identification of victim. [7] hands are more expedient and suitable part of the body for forensic experts to examine upon. figuring out hand index from measurement of hand dimensions is a convenient way to determine sexual dimorphism.[8] considerable anthropometric works have been carried out to assess the stature from hand dimension, foot dimension, nasal length and craniometric analysis in nepalese population. [9-12] this study mainly focuses to find out sexual dimorphism from hand index, to obtain cut off points for male and female and to check percentage accuracy of sex determination from hand index of nepalese population. how to cite this article: sah sk, jeelani ba. hand index a forensic tool for sexual dimorphism. journal of lumbini medical college. 2018;6(2):5 pages. doi: 10.22502/jlmc.v7i1.272. epub: 2019 june 05. https://orcid.org/0000-0002-9356-2517 sah sk. et al. hand index a forensic tool for sexual dimorphism jlmc.edu.npj. lumbini. med. coll. vol 7, no 1, jan-june 2019 methods: the present cross sectional descriptive study was carried out in the department of forensic medicine and toxicology, lumbini medical college and teaching hospital. the sample size was calculated using slovin's formula as: sample size (n)=n/(1+ne2). for n=800 and e=0.05, n=266. a total of 400 right handed subjects (229 males and 171 females) aged more than 23 years were selected by non-probability convenient sampling among the nepalese staff working in tertiary center. age more than 23 years was taken as the maximum growth of bone is already attained by this age. right handed subjects were taken to avoid effects of handedness. the study was carried out after obtaining ethical approval from the institutional review committee (irc-lmc 14-e/018). an informed consent was taken prior to examination from all participants. females were examined in the presence of a female attendant. all the measurements were carried out by the same observer and the same instruments to avoid errors. subjects with deformities, injuries and amputation of the hand, deformities of vertebral column or limbs and with chronic illness were excluded. fig. 1: sliding calliper procedure for examination: subjects were asked to place hand on flat surface in such a way that forearm was aligned in a line with mid-finger. hand length: a distance from tip of mid-finger to the distal crease of wrist joint measured by sliding caliper (fig. 1) was taken as the hand length ( fig. 2). hand breadth: distance between the lateral most part of the head of second metacarpal bone and the medial most part of the fifth metacarpal bone at full stretch of hand was taken as the hand breadth(fig. 3). fig. 3: measurement of hand breadth fig. 2: measurement of hand length sah sk. et al. hand index a forensic tool for sexual dimorphism jlmc.edu.npj. lumbini. med. coll. vol 7, no 1, jan-june 2019 hand index: hand index was calculated by applying the following formula; hand index= (hand breadth / hand length ) x 100 statistical analysis: the collected data were entered to microsoft excel spreadsheet and imported to statistical package for social sciences (spsstm) software version 21 for analysis. student’s independent t-test and paired t-test were applied to compare the hand length, hand breadth and hand index and bilateral variations respectively. p value less than 0.05 was considered statistically significant. sectioning point or cut off point was derived as; sectioning point= (mean male value + mean female value)/2 receiver operating characteristic (roc) curve analysis was applied to determine the discriminating potentials of hand index for right and left hands. results: a total of 400 participants were enrolled into the study. among them, 229(57.25%) were males and 171(42.75%) were females with the male: female ratio of the study population being 1.34:1. table 1 presents the descriptive statistics for hand length and breadth of both male and female participants. there existed statistically significant difference in length of male and female hands (p<0.001). however, difference between right and left hand was not significant statistically. there was no statistical significant bilateral difference in hand breadth but sex wise difference was significant (p<0.001). the mean right hand index (+sd) for males and females were 43.97(+2.22) and 40.68 (+2.61) respectively. the difference in means was tested with t test and found to be statistically significant (t=13.571, df=398, n=400, p<0.001). similarly, the difference in means of left hand index for males and females was also found to be statistically significant (t=14.813, df=398, n=400, p<0.001). cut off points derived was 42.32 for right hand and 42.30 for left hand. with this observation, in 77.30 % of cases it determines sex of male and in 75 % of cases it determines sex of females for right hand. similarly for left hand its accuracy in determining the sex was 79.90% and 72.5 % for male and female respectively. figures 4 to 7 show receiver operating characteristics (roc) curve for right hand and left hand for both sexes. from the roc curve, areas under curve were 0.839 with standard error 0.020 and 0.839 with standard error of 0.020 for right hand index of characteristics mean + sd statistics right hand breadth (cm) male 7.87+0.54 t (df=398, n=400)=19.265, p<0.001female 6.87+0.47 length (cm) male 17.87+0.87 t (df=398, n=400)=12.292, p<0.001female 16.93 +0.58 left hand breadth (cm) male 7.85+0.52 t (df=398, n=400)=6.301, p<0.001female 6.89+0.45 length (cm) male 17.85 +0.86 t (df=398, n=400)=11.505, p<0.001female 16.97 +0.56 table 1. comparison of hand dimensions for male and female participants characteristics mean + sd statistics right hand index male 43.97 +2.22 t (df=398, n=400)=13.571, p<0.001female 40.68 +2.61 left hand index male 43.99 +2.10 t (df=398, n=400)=14.813, p<0.001female 40.61 +2.44 table 2. comparison of hand index for male and female participants. fig. 4: roc curve for right hand index of male fig. 5: roc curve for right hand index of female fig. 6: roc curve for left hand index of male. male and female respectively. for left hand, areas under curve were 0.865 with standard error of 0.018 and 0.865 with standard error of 0.018 for male and female respectively. this result signifies higher potential of sexual discrimination by hand index. discussion: the advent of dna technology has made the issue of identification much simpler and easier. however, in low income countries like nepal, due to the cost of diagnosis and lack of skilled human resources, anthropometric studies can be applied for medicolegal purpose as the study of bones is less costly. in this study, male hand length and breadth were found to be larger as compared to the female hand length and breadth. but the length and breadth of the right and left hands showed no statistical significant differences. this result is in accordance with study conducted by ibrahim ma et al. in north fig. 7: roc curve for left hand index of female saudi population,[8] dey s and kapoor ak in north indian population,[13] pandeya a and atreya a in students of medical college in nepal.[9] this may be due to smaller bone dimension in females as a result of earlier fusion of bones. in the present study, value of hand index for male is greater than the value of hand index for female, both for right and left sides. this is in accordance with the findings observed by various studies.[15,16] value of cut off point obtained by this study is greater than that obtained by kanchan t et al. in north indian and south indian population[16], aboul-hagag et al. in egyptian population[14] and lesser than that obtained by varu pr et al.[6], and jaynath sh in south indian population.[17] influence of race and ethnicity results in variation of hand dimensions that might have led to different values of hand index for male and female. there are some limitations of this study. it was conducted on population working in the institute only. since hand dimension differs in different population residing in different geographical locations, results from our study can be generalized to the nepalese population around the study region only. conclusion: hand dimensions and hand index can be reliably used to determine the sex in medico-legal cases where isolated hand is obtained. the values of cut off points for right hand index and left hand j. lumbini. med. coll. vol 7, no 1, jan-june 2019 jlmc.edu.np sah sk. et al. hand index a forensic tool for sexual dimorphism references: 1. krishan k, sharma a. estimation of stature from dimensions of hands and feet in a north indian population. journal of forensic and legal medicine. 2007;14(6):327-32. pmid: 17239650. doi: https://doi. org/10.1016/j.jcfm.2006.10.008 2. kanchan t, kumar gp, menezes rg. index and ring finger ratio: a new sex determinant in the south-indian population. forensic science international. 2008;181(13):53.-e1-4. pmid: 18814978. doi: https://doi. org/10.1016/j.forsciint.2008.08.002 3. case dt, ross ah. sex determination from hand and foot bones lengths. journal of forensic sciences. 2007;52(2):264-70. pmid: 17316220. doi: https://doi. org/10.1111/j.1556-4029.2006.00365.x 4. tatarek ne, sciulli pw. anthropological analysis of the lower extremity. in: rich j, dean de, powers rh (eds) forensic medicine of the lower extremity. forensic science and medicine;2005; 69-98. doi: https://doi. org/10.1385/1-59259-897-8:069 5. iscan my. forensic anthropology of sex and body size. forensic science international. 2005;147(2-3):107-112. doi: https://doi.org/10.1016/j.forsciint.2004.09.069 6. varu pr, gajera cn, mangal hm, modi pm. determination of sex using hand dimensions. international journal of medical toxicology and forensic medicine. 2016;6(1):23-8. doi: https://doi.org/10.22037/ ijmtfm.v6i1(winter).10023 7. kanchan t, krishan k, sharma a, menezes r. a study of correlation of hand and foot dimensions for personal identification in mass disasters. forensic science international. 2010;199(1-3):112.el-6. pmid: 20382487. doi: https://doi.org/10.1016/j.forsciint.2010.03.002 8. ibrahim ma, khalifa am, hagras am, alwakid ni. sex determination from hand dimensions and index/ ring finger length ratio in north saudi population: medico-legal view. egyptian journal of forensic sciences. 2016;6(4):435-444. doi: https://doi.org/10.1016/j. ejfs.2016.11.002 9. pandey a, atreya a. estimation of stature from percutaneous hand length among the students of a medical college. journal of nepal medical association. 2018;56(211):687-90. doi: https://doi.org/10.31729/ jnma.3624 10. sah sk, karki n, jeelani ba. estimation of height from foot dimensions. journal of lumbini medical college. 2018;6(1):27-31. doi: https://doi.org/10.22502/jlmc. v6i1.182 11. shrestha rn, banstola d, nepal d, baral p. estimation of stature from nasal length. journal of nepal medical association. 2016;55(204):76-78. doi: https://doi. org/10.31729/jnma.2859 12. shrestha r, shrestha pk, wasti h, kadel t, kanchan t, krishan k. craniometric analysis for estimation of stature in nepalese populationa study on autopsy sample. forensic science international. 2015;(248):187.e1-187.e6. doi: https://doi.org/10.1016/j.forsciint.2014.12.014 13. dey s, kapoor ak. sex determination from hand dimensions for forensic identification. international journal of research in medical sciences. 2015;3(6):146672. doi: http://dx.doi.org/10.18203/2320-6012. ijrms20150169 14. aboul-hagag ke, mohamed sa, hilal ma, mohamed ea. determination of sex from hand dimensions and index/ring finger length ratio in upper egyptians. egyptian journal of forensic sciences. 2011;1(2):80-86. doi: https://doi.org/10.1016/j.ejfs.2011.03.001 15. asha kr, prabha lr, rajagopal gm. sex determination from hand dimensions in indian population. indian journal of public health research & development. 2012;3(3):27-30. available from: http://www.i-scholar.in/ index.php/ijphrd/article/view/46424 16. kanchan t, rastogi p. sex determination from hand dimensions of north and south indians. journal of forensic sciences. 2009;54(3):546-550. doi: https://doi. org/10.1111/j.1556-4029.2009.01018.x 17. hosahally js, hugar b, chandra gy. determination of sex from hand dimensions in south indian population. indian journal of forensic medicine and toxicology. 2017;11(1):256-260. doi: http://dx.doi.org/10.5958/09739130.2017.00051.2 j. lumbini. med. coll. vol 7, no 1, jan-june 2019 jlmc.edu.np sah sk. et al. hand index a forensic tool for sexual dimorphism index are 42.32 and 42.30 respectively. hand index value more than 42.30 is suggestive of male hand and less than 42.30 is suggestive of female hand. acknowledgement: department of forensic medicine and toxicology and all the participants who volunteered for this study. conflict of interest: the authors declare that no competing interests exist. source of funds: no funds were available. https://doi.org/10.1016/j.jcfm.2006.10.008 https://doi.org/10.1016/j.jcfm.2006.10.008 https://doi.org/10.1016/j.forsciint.2008.08.002 https://doi.org/10.1016/j.forsciint.2008.08.002 https://doi.org/10.1111/j.1556-4029.2006.00365.x https://doi.org/10.1111/j.1556-4029.2006.00365.x https://doi.org/10.1016/j.forsciint.2004.09.069 https://doi.org/10.22037/ijmtfm.v6i1(winter).10023 https://doi.org/10.22037/ijmtfm.v6i1(winter).10023 https://doi.org/10.1016/j.forsciint.2010.03.002 https://doi.org/10.1016/j.ejfs.2016.11.002 https://doi.org/10.1016/j.ejfs.2016.11.002 https://doi.org/10.31729/jnma.3624 https://doi.org/10.31729/jnma.3624 https://doi.org/10.22502/jlmc.v6i1.182 https://doi.org/10.22502/jlmc.v6i1.182 https://doi.org/10.31729/jnma.2859 https://doi.org/10.31729/jnma.2859 https://doi.org/10.1016/j.forsciint.2014.12.014 http://dx.doi.org/10.18203/2320-6012.ijrms20150169 http://dx.doi.org/10.18203/2320-6012.ijrms20150169 https://doi.org/10.1016/j.ejfs.2011.03.001 http://www.i-scholar.in/index.php/ijphrd/article/view/46424 http://www.i-scholar.in/index.php/ijphrd/article/view/46424 https://doi.org/10.1111/j.1556-4029.2009.01018.x https://doi.org/10.1111/j.1556-4029.2009.01018.x http://dx.doi.org/10.5958/0973-9130.2017.00051.2 http://dx.doi.org/10.5958/0973-9130.2017.00051.2 clinical study of ectopic pregnancy in a tertiary care hospital in nepal narinder kaura, shreyashi aryalb —–————————————————————————————————————————— abstract: introduction: ectopic pregnancy is a cause of pregnancy related mortality and its incidence is on the rise. the aim of modern management of ectopic pregnancy should be to diagnose ectopic pregnancy accurately, so that women can seek prompt diagnosis and treatment and optimize their future fertility. methods: this prospective study was done for a period of one year in patients suspected clinically to have ectopic pregnancies which were subsequently confirmed by pregnancy test and ultrasonography (n=17). the following parameters: age and parity of the patient, relevant past medical and surgical history, significant clinical findings at presentation, management done and outcome of the management were noted. results: most patients 13 (76.47%) were in the age group of 20-25 years and 16 (94.11%) of them presented with acute pain abdomen. in all cases, emergency laparotomy was performed. there were 16 cases of tubal ectopic and one of ovarian pregnancy. right side was affected in 14 (82.35%) cases including one right sided ovarian ectopic. tubal rupture was found in 10 (58.82%) patients. the most common 12 (75%) site of tubal pregnancy was ampullary. salpingectomy was performed in 14 (82.35%) cases. all patients were discharged by seventh postoperative day. conclusion: ectopic pregnancy can be suspected clinically by history and associated risk factors. women presenting with acute pain abdomen with a positive urine β-hcg test should be promptly diagnosed and treated without undue delay to reduce maternal morbidity and mortality. keywords: ectopic pregnancy • emergency laparotomy • salpingectomy —————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, department of obstetric and gynecology lumbini medical college teaching hospital b resident, department of obstetric and gynecology kathmandu medical college teaching hospital corresponding author: dr. narinder kaur e-mail: drkaurnarinder@gmail.com how to cite this article: kaur n, aryal s. clinical study of ectopic pregnancy in a tertiary care hospital in nepal. journal of lumbini medical college. 2014;2(2):37-40. doi: 10.22502/jlmc.v2i2.55. ___________________________________________________________________________________ j. lumbini. med. coll. vol 2, no 2, july-dec 2014 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v2i2.55 introduction: pregnancy which occurs outside its normal location in the uterine cavity has always presented as an interesting problem. at the same time its management often demands emergency operative procedures. these facets of the condition, coupled with the knowledge that this disease, if unrecognized and inadequately treated, may terminate fatally, makes it one of the most challenging gynecological subjects. ectopic pregnancy means a pregnancy that develops outside the uterus, usually in one of the fallopian tubes, but might also occur in the cervix, ovary or the abdominal cavity. the increasing incidence of this condition is concerning because of an associated increase in pregnancy-related morbidity and mortality rates during the first trimester in women of childbearing age. in spite of the comparatively high incidence of ectopic pregnancy, early detection can be difficult. unless considered in the differential diagnosis, ectopic pregnancy can go unidentified at the initial medical evaluation. this study was done to determine the clinical features, risk factors, treatment and outcome associated with ectopic pregnancy in a tertiary care hospital. methods: a prospective study between july 2012 to june 2013 was carried out with ectopic pregnancies that presented at lumbini medical college, obstetrics and gynaecology department, either through emergency or outpatient department. data was collected on chief presenting 37 j. lumbini. med. coll. vol 2, no 2, july-dec 2014 jlmc.edu.np kaur n. et al. clinical study of ectopic pregnancy in a tertiary care hospital in nepal. complaints, age and parity of the patient, relevant past medical and surgical history, significant clinical findings at presentation, management and outcome. the data was analyzed using spss version 9.0. result: during our study period of one year, we found 17 ectopic pregnancies out of total 1317 deliveries with a proportion of 1.3%. the incidence being 12.9 per thousand deliveries per year. mean age at presentation was 27 years (sd=3.12) with 13 (76.47%) in the age group of 20-25 years. nine (52.94%) patients were multiparous and the remaining eight (47.05%) were nulliparous. none of the patients were using any form of contraceptives, and seven cases (41.17%) revealed secondary subfertility as the major predisposing factor. mean marital years was 9.8 (sd=1.2). three (17.6%) out of 17 patients had history of previous surgeries. one (5.88%) of them had history of laparotomy for tubal ectopic on the opposite side two years back. in one patient, the histopathological report of the removed tube (present ectopic site) showed chronic salpingitis, thus suggesting pelvic inflammation as the causative factor. one patient had undergone caesarean section eight years back for breech presentation and one patient had history of laparotomy for which indication was not known. regarding the symptoms, 15 (88.23%) patients gave history of varying periods of amenorrhea with a mean of 10 weeks (sd=1.1) in comparison to no history of amenorrhea in two cases. all of them presented with pain abdomen. pain was of acute onset in 16 cases, of which 8 (47.05%) explained pain to be of tearing type, while only one had pain of insidious onset. all of them had tenderness over suprapubic region, 13 (76.47%) cases had abdominal rigidity and 10 (58.8%) cases had rebound tenderness. ill defined mass was felt in eight (47.05%) of them. on per vaginal examination, boggy masses of variable sizes were palpable in 10 (59%) patients and cervical motion tenderness could be elicited in 14 (82%) cases. β hcg was positive in urine in all cases and ultrasound was diagnostic in all 17 patients. all cases were treated surgically. they underwent laparotomy under general anesthesia except for one who received spinal anesthesia. this patient had prolonged spinal hypotension in the post operative period. intraoperative details are listed in table 1. intraoperative findings n (%) haemoperitoneum 10 (58.82) <3000ml 9 >3000ml 1 tubal rupture 10 (58.82) tubal abortion 5 (29) unruptured 1 (6) site of ectopic pregnancy fallopian tube 16 (94.11) ampulla 12 (75.0) isthmus 3 (18.75) interstitial 1 (6.25) fimbrial 0 ovary 1 (5.89) procedure done salpingectomy 14 (82.35) salpingo-oophorectomy 2 (11.77) partial oophorectomy 1 (5.88) table 1: intraoperative details of women undergoing laparotomy variables n (%) icu admission 5 (29.41) ≤24 hours 4 >24 hours 1 blood transfusion 17 (94.12) ≤2 units 16 >2 units 1 table 2: post operative management during our study we found that the right fallopian tube was affected in 14 (82.35%) of them including one right sided ovarian ectopic pregnancy. the post operative period details are listed in table 2. one patient had to be kept in the icu for five days due to spinal hypotension where her blood pressure was corrected with intravenous dopamine. all the patients were discharged by seventh post operative day after removing the skin sutures. discussion: the incidence of ectopic pregnancy is on the rise. it is thought to be related to increasing maternal age, tubal surgery, pelvic inflammatory disease, practice of induced abortion, assisted reproductive techniques and perhaps more importantly increased ability to accurately ascertain the condition.1 according to the american college of obstetricians and gynaecologists (2008), two percent of all first trimester pregnancies in the united 38 j. lumbini. med. coll. vol 2, no 2, july-dec 2014 kaur n. et al. clinical study of ectopic pregnancy in a tertiary care hospital in nepal. jlmc.edu.np states are ectopic.2 various other studies also show that the prevalence of ectopic pregnancy is 2% of all pregnancies in the united states which is consistent with our study where the incidence is 1.2%.3-5 there was one case of ovarian ectopic, which is a rare entity with incidence of 0.75/1000 deliveries. the reported incidence is in between 1/2000 and 1/3500 deliveries in other studies.4 the suspicion of an ectopic pregnancy should be raised from history of risk factors and triad of symptoms: pain in lower abdomen (95100%), amenorrhea (75%) and vaginal bleeding (70%). this may vary in intensity from a dull aching or occasional sharp stabbing pain to a recurrent crampy labor-like discomfort. in our study, 16 (94.11%) women presented with acute pain abdomen and 15 (88.23%) with amenorrhea which is consistent with these findings. in its more extreme form it is a sudden, severe pain coming on acutely and often associated with syncope or the onset of shock.6 dorfman and associates reported that with more advancing gestation, gastrointestinal symptoms and dizziness were common.7 with rupture, pain may be anywhere in the abdomen.7 in this study, all women presented with pain abdomen of varying severity. while a great variety of causes have been suggested to explain ectopic pregnancy, most authorities agree that mechanical obstruction of the tubal lumen is the most common cause. this may be the result of previous inflammatory disease or may be due to various types of external pressure causing distortion or pocketing in the tube. the problem of pre-existent pelvic inflammation may be intimately associated with abortions and previous pelvic or abdominal operations.8 in the present study three out of 17 patients (17.6%) had history of previous surgeries. most ectopic pregnancies are located in the ampullary region of the tube, so are seen above and medial to ovary.9 in our study too, ampullary site was the most common 12 (75%). though unruptured isthmic pregnancy is rare, there are cases reported in nepal with isthmic pregnancy upto 11 weeks of gestation.10 in our study there was one unruptured isthmic pregnancy at 6 weeks of gestation. vaginal examination still has a role where there is no facility for timely ultrasound and clinical decision has to be made regarding the emergency surgery or where clinical picture and ultrasound diagnosis do not correspond.2 in this study also, clinical suspicion was made by findings of vaginal examination followed by confirmation on ultrasonography. the aim of modern management of ectopic pregnancy should be to diagnose ectopic pregnancy accurately, so that women can seek prompt treatment and optimize their future fertility. the first reported open salpingectomy was performed in 1920, but it was not until 1950 that salpingostomy was considered an alternative to salpingectomy for preserving fertility.2 in our study, salpingectomy was performed in 82.35% because most cases were of ruptured ectopic and most women were multipara with no desire for future fertility. till date there has been no clear consensus on the type of surgery that should be performed either salpingectomy or salpingostomy. salpingostomy should be reserved for those women with pathology in contralateral tube or with only one tube.11 salpingectomy is the treatment of choice where tube is extensively damaged and contralateral tube is healthy. if tube is not removed serial measurement of β-hcg is necessary.12 ectopic pregnancy can be managed both medically and surgically. in present study laparotomy was done in all cases as 16 women presented as acute ectopic and one with intact sac of more than 6cms. though laparoscopy is the gold standard on diagnosis and management of ectopic pregnancy, the facility for laparoscopy was not available in our institution during the study period. ectopic pregnancy is the fifth common cause of maternal mortality according to the most recent triennial report and most common cause of death in first trimester, hence the utility of prompt diagnosis and accurate treatment.13 conclusion: ectopic pregnancy is common in young women in reproductive age group. the suspicion of an ectopic pregnancy should be roused by clinical history and associated risk factors. diagnosis should be confirmed using sensitive β-hcg testing and ultrasonography. the clinical signs and symptoms take precedence over biochemical results. the maternal morbidity and mortality decreases if early diagnosis and prompt treatment is done. references: 1. jurkovic d, wilkinson h. diagnosis and management of ectopic pregnancy. bmj. 2011;342:d3397. doi: 10.1136/ 39 kaur n. et al. clinical study of ectopic pregnancy in a tertiary care hospital nepal. jlmc.edu.npj. lumbini. med. coll. vol 2, no 2, july-dec 2014 bmj.d3397. 2. william d, william ll (ed). recent advances in obstetrics and gynaecology 24. 24 ed. the royal society of medicine press 2008;p.288. 3. houry de, salhi ba. acute complications of pregnancy. in: marx ja (ed). rosen's emergency medicine: concepts and clinical practice (7th ed). philadelphia: mosby elsevier 2009;p.176. 4. barnhart kt. clinical practice. ectopic pregnancy. n engl j med. 2009;361(4): 379-87. 5. defrances cj, lucas ca, buie vc, golosinskiy a. 2006 national hospital discharge survey. natl health stat report. 2008 jul;(5).1-30. 6. webster hd jr, barclay dl , fischer ck. ectopic pregnancy: a seventeen-year review. am j obstet gynecol. 1965 may;92:23-34. 7. dorfman sf, grimes da, cates w jr, binkin nj, kafrissen me, o’reilly kr. ectopic pregnancy mortality, united states, 1979 to 1980: clinical aspects. obstet gynecol. 1984;64(3): 386-90. 8. blanchet j, sparling dw, macfarlane kt. ectopic pregnancy : a statistical review of 360 cases. can med assoc j. 1967 jan:96(2):71-7. 9. kirk e. ultrasound in the diagnosis of ectopic pregnancy. clin obstet gynecol. 2012 jun; 55(2):395-401. doi: 10.1097/grf.0b013e31824e35fe. 10. aryal s, thapa m, karki c. a rare case of unruptured tubal pregnancy at ten weeks of gestation. journal of kathmandu medical college. 2013 jul-sep;2(5):148-51. 11. newbatt e, beckels z, ullman r, lumsden ma, guideline development group. ectopic pregnancy and miscarriage; summary of nice guidance. bmj. 2012 dec;345:e8136. doi: 10.1136/bmj.e8136. 12. arulkamaran s, sivanesaratnam v, chatterjee a, kumar p (ed). essentials of obstetrics. 2nd ed. new delhi: jaypee brothers medical publishers (p) ltd 2004;15:p.127-34. 13. cantwell r, clutton-brock t, cooper g, dawson a, drife j, garrod d, et al. saving mothers’ lives: reviewing maternal deaths to make motherhood safer:2006-2008. the eight report of the confidential enquiries into maternal deaths in the united kingdom. bjog. 2011 mar;118 (suppl 1):1203. doi: 10.1111/j.1471-0528.2010.02847.x. 40 clinical results of surgically treated medial humeral epicondylar apophyseal avulsion injury in children and adolescent ruban raj joshi,a,c gabriel david sundararajb,c —–————————————————————————————————————————————— abstract: introduction: fractures of the medial humeral epicondyle represent approximately 10% of all paediatric elbow fractures. objective of our study was to assess treatment outcomes of children and adolescent with medial epicondylar fracture of the elbow using standard operative protocols. methods: twenty surgically treated fractures of the medial humeral epicondyle were analysed & reviewed for their epidemiological, clinical and surgical parameters. a valgus stress test was performed under general anesthesia or sedation. all patients underwent open reduction internal fixation using a similar technique. the medial epicondylar fragment was anatomically reduced and fixed in all cases with screws, kirshner wires or tension band wiring. at final evaluation, union (radiologically) and elbow function [mayo elbow performance score (meps)] was assessed. results: an evaluation of all of our patients after a mean follow-up of 8.75 months (sd=4.76) after initial surgery was possible. the mean age of patients at the time of injury was 10.8 years (sd=2.3). fifteen (75%) dominant elbows were injured in our study and 12(60%) elbows had an associated elbow dislocation. on examination in operating room post anaesthesia, all of the elbow injuries revealed some degree of valgus instability. all of our patients(n=20) showed good to excellent results in the mayo elbow performance score (meps). radiographically, union was achieved in all cases. three patients developed postoperative ulnar nerve neuropraxia, all recovered at time of final follow up. one patient developed mild lateral heterotrophic ossification but did not require any additional surgical intervention. conclusion: our results suggest that open reduction internal fixation of displaced medial epicondyle fractures leads to satisfactory motion and function. a valgus stress test in operating room can reveal the true nature of joint instability that can warrant operative stabilization of medial epicondylar injuries. keywords: children • dislocation • humerus • internal fixation • open reduction —————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer b professor and head c department of orthopaedic surgery & traumatology, lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. ruban raj joshi e-mail: rubanjoshi@hotmail.com how to cite this article: joshi rr, sundararaj gd. clinical results of surgically treated medial humeral epicondylar apophyseal avulsion injury in children and adolescent. journal of lumbini medical college. 2014;2(2):31-6. doi: 10.22502/jlmc.v2i2.54. ___________________________________________________________________________________ j. lumbini. med. coll. vol 2, no 2, july-dec 2014 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v2i2.54 introduction: medial epicondylar avulsion fractures account for 11-20% of pediatric elbow injuries and 1.3% of all fractures in children.1 this type of fractures occurs typically between ages of 9 and 14 and boys are four times more affected.2 half of the cases are associated with an acute traumatic elbow dislocation and intra articular incarceration of medial epicondylar fragment within the elbow occurs in 15-18% of children.2 10-16% of children with these injuries are associated with ulnar nerve dysfunction.2,3 there is a wide agreement on conservative treatment for undisplaced or minimally displaced medial epicondyle fractures.4 such injuries are simply treated with immobilization and early motion to obviate stiffness.5 however opinions differ regarding management of displaced medial epicondyle fractures. moreover, the definition of displacement varies between studies; some denominate the displaced fractures if >2 mm, but others, rely on >5 mm.1 some literatures testify excellent to good results with conservative 31 j. lumbini. med. coll. vol 2, no 2, july-dec 2014 jlmc.edu.np joshi rr. et al. clinical results of surgically treated medial humeral epicondylar apophyseal avulsion injury in children and adolescent. management, but above 60% of patients demonstrate radiographic nonunion that may lead to valgus instability.4 here, we present 20 cases of surgically managed elbow medial epicondyle avulsion injuries in children and adolescents. we aimed to characterize functional outcome, range of motion, ulnar nerve dysfunction, heterotopic ossification, and any other complications. methods: in this retrospective study between october 2011 and october 2014 from lumbini medical college teaching hospital, 28 children (18 boys and 10 girls) with medial epicondyle fractures were reviewed. we excluded eight children with type-i fractures and selected 20 displaced medial epicondyle fractures that were surgically treated. clinical signs of anteromedial ecchymosis were recorded and documented. under general anesthesia, a valgus stress test was performed which was considered positive when there was medial laxity and instability based on further displacement of the fracture. radiographic analysis was done using plain elbow posteroanterior, lateral and oblique views which provided information regarding fracture anatomy, its displacement, whether incarcerated in the joint and whether associated with elbow dislocation. on the basis of extent of displacement and articular instability, four types of medial epicondyle fractures are distinguished. 1. type-i: with no or minimal displacement (excluded of this study). 2. type-ii: moderate displacement, of more than half of the metaphyseal fracture area and a positive valgus stress test. 3. type-iii: major displacement associated with obvious dislocation of the elbow or dislocation during the valgus stress test; the medial epicondyle remains at the level of the articular line. 4. type-iv: posterior displacement of the epicondyle with intra-articular incarceration of the epicondylar muscles; a tight digastric structure made up of the epicondyle, its epicondylar muscular attachments above and the periosteum and triceps layer detached from the humeral diaphysis below, lies in the humeroulnar joint and resists any attempt at reduction of the elbow dislocation. 5. type-v: entrapment of the epicondyle in the joint with associated elbow dislocation or subluxation which may spontaneously reduce and mask the incarceration. all of our patients underwent open reduction internal fixation of the medial epicondyle fracture. average time between injury and indexed surgery was 2.5 days (sd=1.73, range 0-12 days). a medial approach to the elbow through an incision just posterior to the epicondyle was performed. the ulnar nerve was always isolated and protected. the medial epicondylar fragment was retrieved, anatomically reduced and fixed with two k wires in five cases (fig 1), tension band wiring in two cases. single or double 4 mm cannulated screws were implant of choice in 10 and three cases respectively (fig 2, 3). after fracture repair, ulnar nerve was examined in their typical posteromedial location for subluxation and potential hardware irritation. the ulnar nerve was transposed during indexed surgery in three cases. post-operative immobilization of the elbow was at flexed 90º and neutral pronosupination of the forearm for a mean of 11 days (range 6-21) followed with elbow mobilization. removal of k wires was performed between 4 to 8 weeks postoperatively and between 4 to 8 months in case of the screws and tbws. at postoperative clinic visits, we concluded detailed physical and radiographic examination. the mayo clinic performance index for the elbow was used for functional assessment in 4 areas: pain (maximum 45 points, from no pain to severe pain), stability (maximum 10 points, from stable to grossly unstable), range of movement (maximum 20 points, from >100º to <50º), and activities of daily living (maximum 25 points). score greater than 90 was considered excellent, 75-89 good, 60-74 fair, less than 60 poor.6 other studies have used the mayo elbow score for children and adolescents.7,8 plain radiography was used to assess the union, detect pseudarthrosis or ectopic calcification. any postoperative complications like ulnar nerve palsy, heterotrophic ossification, cubitus varus or valgus, and wound or implant-related were documented. details of the patients are presented in table 1. results: mean follow up was 8.75 months (range 4-20). the fracture was fall related in all of our cases. the most common mechanism of injury was a fall from height on the outstretched hand with the elbow extended or partially flexed. thirteen (65%) were boys and 7 (35%) were girls. average age of children was 10.8 years (sd=2.3, range 8-16). twelve (60%) fractures were associated with an elbow dislocation out of which five cases reduced spontaneously 32 j. lumbini. med. coll. vol 2, no 2, july-dec 2014 joshi rr. et al. clinical results of surgically treated medial humeral epicondylar apophyseal avulsion injury in children and adolescent. jlmc.edu.np fig 1: a,b. representative pre-reduction radiographs (patient 1) showing a displaced medial epicondyle fracture in association with a posterolateral elbow dislocation; c. injured elbow; d. 2 months postoperative radiographs showing fracture by 2 k wires. note mild lateral heterotrophic ossification; clinical picture showing 950 flexion and extension lag of 400. and remaining 15 elbows were reduced either in emergency department or in operating room. the dominant elbow was injured in 14(70%) patients. the injuries were categorized in: six type ii, nine type iii, two type iv and three type v. three cases had incarceration of medial epicondyle after elbow dislocation that were surgically retrieved. two children had ulnar nerve dysfunction among which one (patient 16) had concomitant medial condyle fracture who underwent external neurolysis and kirschner wire fixation simultaneously. at final follow-up, all patients had clinical and radiographic signs of healing. there was no radiographic evidence of loss of reduction at interval or final follow-up. clinically, there were no cases of residual deformity or valgus instability. average arc of motion of elbow was 80º to 121º. our patients had mean forearm rotation from 83º supinations to 84º pronation. average mayo elbow score was 93.5 (sd=4.89). three patients developed postoperative ulnar nerve neuropraxia, which recovered at time of final follow up. despite screw removal, the patient who had preoperative ulnar symptoms and underwent ulnar nerve neurolysis in the index procedure (patient 15) had intermittent residual numbness and tingling in the little and ring fingers and mild weakness of the little and ring fingers at final follow up (13 months). the symptoms were mild enough that and family decided not to seek intervention. one patient developed mild heterotrophic ossification but did not require any additional surgical intervention and had forearm rotation of 80º supination, 75º pronation and elbow arc of 15º-100º. radiographically, union was achieved in all cases. mean consolidation time was 4.5 weeks (range 3.4–8). five cases had a fibrous union with a gap three mm between the medial epicondyle and the distal humeral metaphysis with no obvious change on valgus stress views. no cases of cubitus valgus more than 10° were noticed in our patients. discussion: medial epicondyle is a traction apophysis of distal humerus which is constantly under pull during various elbow motions by the strong flexor pronator muscles and the strong medial collateral ligament. whenever a valgus force is applied with elbow extended or partially flexed, apophyseal avulsion of medial epicondyle and elbow dislocation occurs.9 such an injury occurs as a result of tear of the capuloligamentous and anteromedial soft tissues. the valgus stress test complements a good way to detect and evaluate the extent of elbow instability. in case of children, the bony constraints of the elbow are not fully developed, the stability of the elbow depends mainly on the soft tissue integrity. as a result, elbow dislocations in children will 33 j. lumbini. med. coll. vol 2, no 2, july-dec 2014 jlmc.edu.np joshi rr. et al. clinical results of surgically treated medial humeral epicondylar apophyseal avulsion injury in children and adolescent. fig 3: a. 9year-old girl(patient 19) who had a medial epicondyle fracture type v; b,c. dynamic anteroposterior radiograph (valgus stress test) showing dislocation with entrapment of the medial epicondyle; d. anatomic reduction of the epicondyle and screw fixation; note the importance of the soft tissue damage in the antero-medial aspect of the joint; e,f. postoperative radiographs showing anatomic reduction with screw in situ; g,h. clinical results were graded as excellent according to the mayo elbow performance score, with no instability or impairment of range of motion 9 months after surgery; i,j. healed medial epicondyle radiographs (9 months). g h i i j fig 2: a,b. antero-posterior and lateral x ray showing (patient 3) medial epicondylar fracture; c. intraoperative picture showing a screw fixation following valgus stress test uncovering a postero-lateral dislocation of the elbow; d. peroperative fluoroscopic images with anatomic reduction and fixation with screw. e,f. immediate postopreative x-rays. g,h. 9 months follow up radiographs showing bony healing of avulsed medial epicondylar fragment; i,j. no deformity appeared in the elbow region at the final follow up, while full movement of the elbow was restored completely. causes extensive damage of the soft tissue structures of the elbow. damage to the medial stabilizing soft tissues structures of the elbow rather than the medial epicondyle displacement has a far greater consequence on joint stability and outcome.10,11 woods and tullos described the importance of assessing instability by using the "gravity valgus with or without stress" test.12 in our series, valgus stress test was performed in operating room under anaesthesia and was found to ba a reliable diagnostic test and a good indication for surgical fixation in the presence of signifcant acute medial elbow instability in all cases of medial epicondyle. treatment of medial epicondyle fractures is controversial. hines et al. recommended that all fractures with displacements over two mm required fixation.1 absolute indications for open reduction and internal fixation of incarcerated medial epicondylar fractures into the elbow joint, suspected entrapment and ulnar nerve dysfunction, marked instability, or open fracture. there is ongoing debate about the management of cases that do not meet the above indications based on the degree of displacement, handedness, and athletic and performance demands. chronic elbow instability following non operative treatment was described by woods and tullos, and schwab et al.11,12 case and hennrikus reported excellent results following open reduction and rigid internal fixation of acute displaced medial epicondyle fractures in adolescent athletes.15 in our series, elbow stability was achieved in all patients as a result of surgical fixation. for some orthopaedic surgeons, our treatment may be too much surgical oriented. our study allows to imply that the clinical outcomes as measured by range of motion and mayo elbow score after surgery is very satisfactory. the consistent good results were achieved by operated fixation as reported by hines et al., lee et al. and fowles et al. along with our own series would advocate surgical intervention when there is a displacement.1,4,16 operative management allows for anatomic reduction internal fixation of the fragment and incase of incarceration, removal a b c 34 j. lumbini. med. coll. vol 2, no 2, july-dec 2014 joshi rr. et al. clinical results of surgically treated medial humeral epicondylar apophyseal avulsion injury in children and adolescent. jlmc.edu.np patient age (yrs) sex injury side (dominant) mechanism of injury associated injuries type preop unar neropraxia time to sugery (days) implants follow up, month hardware removal elbow position forearm rotation mayo elbow score complications e xt * fl ex ** su p* ** pr o* ** * 1 8 m r t( r t) fa ll fr om tr ee d is lo ca tio n ii n o 1 k -w ir e 4 y es 15 11 0 80 75 90 m ild la te ra l h o 2 10 m r t( r t) fa ll fr om c yc le ii i n o 0 t b w 4 y es 5 12 0 80 90 10 0 3 15 m r t( r t) fa ll du ri ng p la y d is lo ca tio n ii n o 2 1 ( 4 m m c an nu la te d sc re w s) 9 n o 0 14 0 75 90 95 4 12 m l t( r t) fa ll fr om tr ee d is lo ca tio n ii i n o 0 1 ( 4 m m c an nu la te d sc re w s) 8 y es 0 12 0 90 75 10 0 u ln ar n eu ro pr ax ia 5 11 f r t( r t) fa ll fr om tr ee d is lo ca tio n ii n o 1 1 (4 m m c an nu la te d sc re w s) 12 y es 10 15 0 80 80 95 6 11 f r t( r t) fo ot ba ll in ju ry d is lo ca tio n iv n o 3 1 ( 4 m m c an nu la te d sc re w s) 12 y es 0 14 0 75 80 90 7 9 m r t( r t) fa ll fr om tr ee ii i n o 5 t b w 4 y es 10 12 0 90 90 90 8 10 m r t( r t) fa ll fr om tr ee ii i n o 1 k -w ir e 7 y es 15 11 0 90 90 90 su pe rfi ci al p in tr ac k in fe ct io n 9 14 f l t( r t) fa ll fr om c yc le d is lo ca tio n iv n o 2 2 ( 4 m m c an nu la te d sc re w s) 20 y es 10 12 0 90 75 10 0 u ln ar n eu ro pr ax ia 10 8 m l t( r t) fa ll fr om tr ee d is lo ca tio n ii i n o 1 2, k w ir es 5 y es 0 15 0 75 85 90 11 9 f r t( l t) fa ll fr om c yc le ii i n o 1 1 ( 4 m m c an nu la te d sc re w s) 6 y es 20 11 0 80 90 95 12 10 f r t( r t) fa ll du ri ng p la y d is lo ca tio n ii n o 2 1 ( 4 m m c an nu la te d sc re w s) 1 y es 10 11 0 80 90 95 13 12 m r t( r t) fa ll du ri ng p la y v n o 4 2, k w ir es 12 y es 10 12 0 85 90 10 0 pi n lo os en in g 14 12 m l t( r t) fa ll du ri ng p la y ii i n o 3 2, k w ir es 18 y es 0 12 0 90 95 10 0 15 10 m r t( r t) fa ll du ri ng p la y o pe n, d is lo ca tio n, u ln ar n er ve ne ur op ra xi a v y es 5 2 ( 4 m m c an nu la te d sc re w s) 13 y es 10 11 0 90 90 95 16 10 f r t( r t) fa ll du ri ng p la y d is lo ca tio n, m ed ia l c on dy la r fr ac tu re ii i y es 6 1 ( 4 m m c an nu la te d sc re w s) 13 y es 0 14 0 75 90 95 17 9 m r t( r t) fa ll fr om tr ee d is lo ca tio n ii i n o 4 1 ( 4 m m c an nu la te d sc re w s) 4 n o 15 95 75 90 85 18 8 m r t( r t) fa ll fr om tr ee ii n o 3 1 ( 4 m m c an nu la te d sc re w s) 5 n o 15 11 0 85 85 90 19 13 f r t( r t) fa ll fr om tr ee d is lo ca tio n v n o 3 1 ( 4 m m c an nu la te d sc re w s) 8 n o 20 12 0 90 75 85 20 16 m r t( r t) fa ll fr om tr ee ii n o 4 2 ( 4 m m c an nu la te d sc re w s) 5 n o 15 10 0 80 75 90 u ln ar n eu ro pr ax ia ta bl e 1: p at ie nt c ha ra ct er is tic s a nd o ut co m es ex t* ex te ns io n; f le x* * f le xo n; s up ** * s up in at io n; p ro ** ** pr on at io n 35 joshi rr. et al. clinical results of surgically treated medial humeral epicondylar apophyseal avulsion injury in children and adolescent. jlmc.edu.npj. lumbini. med. coll. vol 2, no 2, july-dec 2014 of the offending fragment under direct visualization followed by stabilization. surgical reduction and fixation of medial epicondyle along with its strong flexor pronator muscle origin and medial collateral ligament may contribute to critical restraint against valgus instability and allow for early elbow movements. however, the findings of other variables may be affected by smaller sample size, which was one of the limitations of our study and a point that could be evaluated in future studies. conclusions: fractures of the medial epicondyle of the humerus are often associated with elbow dislocation. the valgus stress test performed at the time of surgery for all epicondyle fractures regardless of the degree of its displacement can unmask true nature of extensive medial soft tissue injuries. in view of good results and presumably lower rate of nonunion and joint instability, we recommend operative intervention as a good management of these injuries and results in an anatomic reduction, a solid bone union and prevents valgus instability. references: 1. hines rf, herndon wa, evans jp. operative treatment of medial epicondyle fractures in children. clin orthop relat res. 1987;223:170–4. 2. beaty jh, kasser jr. the elbow-physeal fractures, apophyseal injuries of the distal humerus, osteonecrosis of the trochlea, and t-condylar fractures. in: beaty jh, kasser jr, editors. rockwood & wilkins’ fractures in children. 7th ed. philadelphia:wolters kluwer health; 2012. 3. patel nm, ganley tj. medial epicondyle fractures of the humerus: how to evaluate and when to operate. j pediatr orthop. 2012; 32(1):s10–3. doi: 10.1097/ bpo.0b013e31824b2530. 4. lee hh, shen hc, chang jh, lee ch, wu ss. operative treatment of displaced medial epicondyle fractures in children and adolescents. j shoulder elbow surg. 2005;14(2):178–85. 5. smith fm. medial epicondyle injuries. jama. 1950;142:396–402. 6. morrey bf, an kn, chao eys. functional evaluation of the elbow. in: morrey bf, ed. the elbow and its disorders. 2nd ed. philadelphia:w.b. saunders; 1993. 7. moraleda l, valencia m, barco r, gonzález-moran g. natural history of unreduced gartland type-ii supracondylar fractures of the humerus in children: a two to thirteen-year follow-up study. j bone joint surg am. 2013;95(1):28-34. 8. bowakim j, marti r, curto a. elbow septic arthritis in children: clinical presentation and management. j pediatr orthop b. 2010;19(3):281-4. 9. kilfoyle rm. fracture of the medial condyle and epicondyle of the elbow in children. clin orthop relat res. 1965;41:43–50. 10. lechevallier j, lefort j. les fractures du coude : les fractures de l’épitrochlée. rev chir orthop. 1987;73:441–7. 11. schwab gh, bennet jb, woods gw, tullos hs. biomechanics of elbow instability: the role of the medial collateral ligament. clin orthop relat res. 1980;146:42–52. 12. woods gw, tullos hs. elbow instability and medial epicondyle fractures. am j sports med. 1977;5:23-30. doi: 10.1177/036354657700500105 . 13. josefsson po, danielsson lg. epicondylar elbow fracture in children. 35-year follow-up of 56 unreduced cases. acta orthop scand. 1986;57:313-5. doi: 10.3109/17453678608994399. 14. kobayashi y, oka y, ikeda m, munesada s. avulsion fracture of the medial and lateral epicondyles of the humerus. j shoulder elbow surg. 2000;9(1):59–64. 15. case sl, hennrikus wl. surgical treatment of displaced medial epicondyle fractures in adolescent athletes. am j sports med. 1997;25(5):682–6. 16. fowles jv, slimane n, kassab mt (1990) elbow dislocation with avulsion of the medial humeral epicondyle. j bone joint surg br. 72:102–104. 36 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 6, no 2, july-dec 2018 ___________________________________________________________________________________ submitted:15 june, 2018 accepted: 02 october, 2018 published: 03 november, 2018 a lecturer b assistant professor c professor and head d department of anesthesia and critical care e kathmandu university school of medical sciences, dhulikhel f lumbini medical college teaching hospital, palpa, nepal corresponding author: kalpana kharbuja e-mail: kalpanarkoju@gmail.com orcid: https://orcid.org/0000-0002-6127-5556_______________________________________________________ —–————————————————————————————————————————————— abstract: introduction: though the development of minimally invasive surgery has revolutionized the field of surgery, postoperative pain is still a significant issue. unlike in the past, concerns about adverse effects have limited the role of opioids in post-operative pain management. this study aims to compare the effectiveness of intravenous paracetamol and diclofenac as post-operative analgesia in laparoscopic cholecystectomy. methods: one hundred and twenty eight patients of american society of anesthesiologists (asa) categories i and ii included in this study were divided into two groups. anesthesia induction and maintenance were standardized. the first group received 15mg/kg (maximum 1gm) intravenous paracetamol and the second group received 2mg/kg (maximum 75mg) intravenous diclofenac 30 minutes prior to ending of surgery. a questionnaire was responded by patients and chart was maintained by visual analogue scale. data management and analysis were done using computer softwares ms excel and spss version 20. mann whitney u test was used to analyze quantitative data and chi-square test for categorical data. p value <0.05 was considered statistically significant. results: profiles of hemodynamic changes were almost similar in both groups with respect to heart rate and blood pressure. however, paracetamol infusion provided hemodynamic stability in post-operative period. we observed statistically significant differences in visual analogue scale between the two groups. most of the patients in paracetamol group had low mean pain scores in post-operative period and provided an extended analgesia compared to diclofenac. no serious postoperative complication was observed in paracetamol group. conclusion: administration of intravenous paracetamol has better and prolonged analgesic effect with low mean pain score and less requirement for rescue analgesia compared to diclofenac. keywords: diclofenac, laparoscopic cholecystectomy, paracetamol, post-operative analgesia, visual analogue scale (vas) ——————————————————————————————————————— original research articlehttps://doi.org/10.22502/jlmc.v6i2.248 kalpana kharbujaa,d,e, mahesh sharmab,d,f, nil raj sharmac,d,f comparative evaluation of effectiveness of intravenous paracetamol and intravenous diclofenac as post-operative analgesia in laparoscopic cholecystectomy introduction: the advent of minimally invasive surgery has revolutionized the field of surgery. laparoscopic surgery has become popular in recent days. patients are more motivated to undergo laparoscopic surgery because of small incision, less blood loss and decreased length of hospital stay. however, pain is still the most common complaint after surgery. post operative pain following surgical insult is mostly nociceptive. inadequate pain control after surgeries is significant in terms of both physical and psychological trauma. adequate analgesia is therefore of utmost importance for early ambulation and discharge, reduced hospital stay and cost. post operative pain differs from patient to patient depending upon the site and nature of surgery. individual variations in response to pain are influenced by the genetic makeup, cultural background and gender.[1] till last decade, opioids how to cite this article: kharbuja k, sharma m, sharma nr. comparative evaluation of effectiveness of intravenous paracetamol and intravenous diclofenac as post-operative analgesia in laparoscopic cholecystectomy. journal of lumbini medical college. 2018;6(2):6 pages. doi: 10.22502/jlmc. v6i2.248. epub: 2018 nov 3. kalpana k. et al. comparative evaluation of effectiveness of intravenos paracetamol and intravenous diclofenac jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 were the mainstay for managing severe pain, mostly via intramuscular route. however, fluctuating plasma levels of opioids result in sedation and other adverse effects.[2] fear of addiction and dependence result in under-treatment of pain as well. to avoid all these side effects , non-opioids like paracetamol and diclofenac are being increasingly used as alternatives. paracetamol and diclofenac both belong to nonsteroidal anti-inflammatory drugs (nsaids) group which inhibits cyclo-oxygenase enzymes thereby decreasing peripheral and central prostaglandin production. this in turn reduces inflammation and associated pain following tissue injury.[3,4,5,6] however, the question of superiority of paracetamol over diclofenac or vice-versa has been poorly resolved and needs to be further clinically tested, especially in set-ups like ours. this study was therefore conducted to compare the effectiveness of intravenous paracetamol and diclofenac as postoperative analgesia in patients undergoing laparoscopic cholecystectomy. methods: the present study was conducted in lumbini medical college and teaching hospital (lmcth) over a period of 12 months from 15th may, 2016 to 14th may, 2017 with prior permission from the institutional review committee (irc-lmc). with alpha error of 0.05, power of 80%, medium effect size (0.5), and equal participants (ratio =1), minimum sample size in each group was calculated to be 64. a total of 128 patients of asa i and ii categories, aged between 20-60 years undergoing laparascopic cholecystectomy were selected. informed consent was obtained from the participants prior to enrollment to the study. visual analogue scale (vas) and pain severity were explained. patients were randomized into two groups irrespective of age and gender and randomization was done according to computer generated random number. those with history of renal dysfunction, bleeding disorder, liver dysfunction, use of nsaids and opioids prior to surgery were excluded from the study. patients and nursing staff in ward were blinded about drugs. following a detail preanaesthetic examination, preoperative investigations were sent and reports assessed. all the patients were pre-medicated with tablet lorazepam 2 mg the night before surgery. on arrival at operation theatre, an intravenous line was secured with 18 gauze cannula in dorsal aspect of either hand. patients were connected to standard monitors. pre-oxygenation was done for three minutes. induction was done with injection fentanyl 1-2 mcg/kg, propofol 1.5-2.5mg/ kg followed by intubation with injection vecuronium 0.1mg/kg. maintenance of anaesthesia was done by oxygen, isoflurane and vecuronium. patient was put on mechanical ventilation and etco2 was maintained at 35-40 mmhg. surgical incision time was noted as time zero and parameters as pulse rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure and oxygen saturation were recorded at an interval of every five minutes till the end of surgery. the ecg was constantly monitored. two anesthesiologists were involved in the study. the drugs were labeled as a and b. the anesthesiologist who administered the drug in the intraand post-operative period was not involved in the process of data collection. the second anesthesiologist, blinded to study drug, recorded vitals at different intervals in post operative period. group a received injection paracetamol 15 mg/ kg maximum 1 gm in 100ml infusion over 15–20 minutes 30 minutes prior to ending of the surgery as the first dose of analgesia and subsequent dose was given at eight hourly interval after the patient was shifted to ward. group b received injection diclofenac 2 mg/kg maximum 75 mg in 100ml normal saline similarly as first dose of analgesia and subsequent dose was given at 12 hourly interval. duration of surgery was noted.. extubation was done after reversing effect of muscle relaxant with injection neostigmine 50 mcg/kg with glycopyrolate 20 mcg/kg. after completion of surgery patient was shifted to postoperative ward without prescribing any analgesia. in post operative period pulse rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure and respiratory rate were recorded at two hours, four hours, six hours, 12 hours and 24 hours. vas was recorded at the same interval. the patients were asked to mark the line to indicate pain intensity in relation to 0no pain to 10worst pain. mild pain was considered when vas score was between one and three; moderate pain when vas score was between four and six and severe pain when vas score was seven and above. rescue analgesic was given when vas score was between seven to ten or on patient demand. injection pethidine 25-100 mg intramuscularly was given as rescue analgesia. any complication like nausea, vomiting, pruritus, sedation or others were recorded. kalpana k. et al. comparative evaluation of effectiveness of intravenos paracetamol and intravenous diclofenac jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 statistical analysis: the data were entered in microsoft excel and analyzed using statistical package for social sciences (spss™) software version 20. descriptive results were presented in frequencies, percentages, mean, and standard deviation (sd). quantitative data were analyzed with mann whitney u test and categorical data were analyzed by chi square test. p value less than 0.05 was considered statistically significant. results: during the study period, a total of 228 patients underwent laparoscopic cholecystectomy. out of them, 128 patients were enrolled into the study. there were 11(17.2%) males and 53(82.8%) females in group a whereas seven (10.9%) males and 57(89.1%) females in group b (table1). on analyzing the demographic data, we found no statistically significant variation in age, sex, asa classification 1). pulse rate was higher at two and six hours post-operative in both groups. this was possibly due to anxiety rather than pain. there was mild decrease in pulse rate in both groups afterwards. the comparison of mean systolic blood pressure (sbp) and mean diastolic blood pressure (dbp) between the two groups showed no significant variations at different time intervals except that the mean dbp at two and four hours post operative period were higher in group b (figures 2 and 3). the mean dbp was 71.14 ±9.31 mm hg at two hours and 74.06±11.23 mm hg at four hours in group a whereas 74.52±5.96 mm hg at two hours and 76.45±5.95 mm hg at four hours in group b. the difference in mean values was statistically significant (mann whitney u=1613.000, n=128, p=0.035 for two hours and mann whitney u=1602.500, n=128, p=0.032 for six hours). the comparison of mean respiratory table 1. comparison of demographic variables between the two groups. and weight between the two groups (table1). the mean pulse rate was lower in group a but there was no statistically significant variation in mean pulse rate between the two groups (fig. fig 1. comparison of mean pulse rate (min-1) at different time periods. fig 2. comparison of mean sbp at different time periods rate between the two groups showed higher mean respiratory rate in group b throughout the post-operative period (fig. 4). in our study, the mean vas score was lower in 108 110 112 114 116 118 120 122 124 126 128 130 132 0hrs 2hrs 4hrs 6hrs 12hrs 24hrs m ea n sb p group a group b variables group a group b statistics sex male 11(17.2%) 7(10.9%) x2 (df=1,n=128) =1.034 , p=0.309 female 53 (82.8%) 57(89.1%) asa i 49 (76.6%) 56 (87.5%) x2 (df=1,n=128) =2.597, p=0.107 ii 15 (23.4%) 8 (12.5%) mean age + sd ( years) 43.84+10.40 40.97+10.86 mann whitney u=1697.000, n=128, p=0.094 mean weight + sd ( kg) 55.14+8.215 55.13+11.16 mann whitney u=1977.500, n=128, p=0.736 kalpana k. et al. comparative evaluation of effectiveness of intravenos paracetamol and intravenous diclofenac jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 the paracetamol group (group a) in comparison to the diclofenac group (group b) at all the post-operative time periods. these differences in mean vas scores were found to be statistically significant (table 2). the requirement for rescue analgesia in group a i.e. 10 (15.6%) patients was significantly lower than in group b i.e. 21 (32.8%) patients. this difference was found to be statistically significant fig 4. comparison of mean respiratory rate (min-1) at different time periods table 2. comparison of mean vas scores between group a and group b table 3. requirement of rescue analgesia in two groups. seven patients complained of post-operative nausea in group b. discussion: post-operative pain is one of the primary concerns because of its close ties with clinical outcome and acute post-operative well being.[7,8] pain is often associated with autonomic, endocrine-metabolic, physiological and behavioral response.[9] pain after laparoscopic surgery has three different components: incisional pain (somatic pain), visceral pain (deep intra-abdominal pain) and shoulder pain (referred pain).[10] despite overwhelming rationale for effective post-operative pain control, the clinical reality is unfortunately still far from satisfactory. as nsaids are being increasingly used to avoid the adverse effects of opioids, this study aimed to compare the effectiveness of intravenous paracetamol and diclofenac as post-operative analgesic. in our study, 82.8% patients in group a and 89.1.% patients in group b were females. the higher prevalence in females correlates to the fact that gall stone diseases are more common in females. the comparison of mean pulse rate showed no statistically significant variation between the two both groups. the increase in mean pulse rate at two and six hours post-operatively in both groups implicates time interval group a (mean vas±sd) group b (mean vas±sd) statistics 0 hrs 5.11±0.99 5.73±0.78 mann whitney u=1372.000, p<0.001 2 hrs 4.52±0.89 5.34±1.37 mann whitney u =1301.500, p<0.001 4 hrs 3.95±1.44 4.50±1.39 mann whitney u=1611.000, p=0.021 6 hrs 3.06±1.17 3.36±1.39 mann whitney u=1568.000, p=0.012 12 hrs 2.08±0.62 2.55±1.00 mann whitney u=1560.500, p=0.002 24 hrs 1.59±0.72 1.92±0.72 mann whitney u=1617.500, p=0.006 groups requirement of rescue analgesia statistics yes (%) no (%) x2 (df=1,n=128) = 5.151, p = 0.023group a 10 (15.6%) 54 (84.4%) group b 21 (32.8%) 43 (67.2%) 68 70 72 74 76 78 80 82 84 0hrs 2hrs 4hrs 6hrs 12hrs 24hrs m ea n db p group a group b fig 3. comparison of mean dbp at different time periods (table 3). during the postoperative period, we observed no serious complications in either group. however, kalpana k. et al. comparative evaluation of effectiveness of intravenos paracetamol and intravenous diclofenac jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 that the initial increase was because of anxiety. amin et al in their comparative study observed no satisfactory variation in pulse rate in the paracetamol and diclofenac groups.[11] similar observations were made in the study by paul d et al. however in this study, they found low pulse rate in the patients administered with intravenous diclofenac.[12] our study observed statistically significant difference in dbp at two hours and six hours of post-operative period. similar observations were shown by paul d et al with higher dbp in diclofenac group. the predominant action of diclofenac is to inhibit the enzyme cyclo-oxygenase which mediates the conversion of arachidonic acid to prostaglandin and thromboxanes. the significant increase in dbp in diclofenac might be explained by this effect.[12] the differences in mean respiratory rate between the two groups is clinically significant. however respiratory rate is higher in diclofenac group throughout the post-operative period which might be due to inadequate pain relief. in our study, high vas score was recorded in diclofenac group throughout post-operative period. the mean vas score in paracetamol group was 3.39±0.79 whereas it was 3.95±1.11 in diclofenac group. similar finding was reported by paul d et al. however at four hour post-operative period, differences in vas score was insignificant in both groups. following that there was gradual increase in vas score leading to more analgesic requirement after four hours.[12] in 2013, goel et al. in their comparative study for pre-emptive analgesia with intravenous paracetamol and diclofenac in patients undergoing different surgical procedures found that the mean pain score was higher in diclofenac group for initial period followed by insignificant difference in pain score at four hours.[13] similar finding was reported by anka et al.[11] in our study we found that differences in 24 hours vas score was statistically significant (p value 0.006) . the mean vas score was higher in diclofenac group throughout postoperative period requiring more rescue analgesia. in a study by salihoglu et al, pre-emptive use of 1gm paracetamol caused similar decrease in post-operative pain score and requirement of analgesia.[14] another study by arici s et al. demonstrated significant lower post-operative pain score and consumption of rescue analgesia in patients who received one gram pre-emptive paracetamol compared to patients who received normal saline.[15] khan ah et al. observed that paracetamol had significantly lowered total analgesic consumption, postoperative pain and vas score as compared to tramadol.[16] in our study, we observed that there were 10 (15.6%) patients who required intravenous pethidine as rescue analgesia and 54 (84.4%) patients who didn't require rescue analgesia in group a. in group b, 21(32.8%) patients had received rescue analgesia whereas 43 (67.2%) did not. this difference was statistically significant. similar findings were reported by goel et al.[13] more requirement of rescue analgesia was also observed in the study of paul d et al.[12] paracetamol rapidly crosses the blood-brain barrier, reaches a high concentration in the cerebrospinal fluid and has an anti-nociceptive effect mediated by the central nervous system. [17] this central effect has been regarded primarily as an indirect and reciprocal influence through cyclo-oxygenase enzyme inhibition, and probably through the serotoninergic system as well. besides this central effect, it is accepted that paracetamol has a peripheral anti-inflammatory influence, although this effect is somewhat limited.[18] in this study, we observed that seven patients had post-operative nausea in diclofenac group while none in the paracetamol group. a related study done by apfel et al. concluded prophylactically administered intravenous acetaminophen reduced post-operative nausea and vomitting, mainly mediated through superior pain control.[19] conclusion: administration of one gram of intravenous paracetamol intra-and post-operatively conferred satisfactory analgesia with low mean pain scores and decreased post-operative rescue analgesia compared to intravenous diclofenac. no immediate side effects were observed with paracetamol. intravenous paracetamol was thus found to be more effective than diclofenac for post-operative analgesia in laparoscopic cholecystectomy. conflict of interest: none declared. financial disclosure: no funds were available. kalpana k. et al. comparative evaluation of effectiveness of intravenos paracetamol and intravenous diclofenac jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 references: 1. jahromi sa. effects of suppository acetaminophen, bupivacaine wound infiltration, and caudal block with bupivacaine on postoperative pain in pediatric inguinal herniorrhaphy. anesthesiology and pain medicine. 2012;1(4):243. pmid: 24904808 doi: 10.5812/ aapm.3551 [publisher full text] 2. yoganarasimhan n, ragavendra tr, radha mk, amitha s, sridhar k. comparison of paracetamol infusion with diclofenac infusion for perioperative analgesia. journal of medical & health sciences. 2012; 1(1):18-22. 3. hurley rw. acute post-operative pain. in rd miller, lj fleisher, jp weiner-kronish, w i young (ed) millers anaesthesia 7th ed (usa: ghurchil livingstone 2010). 2763. 4. anderson bj. paracetamol (acetaminophen): mechanisms of action. paediatranaesth. 2008;18:91521. pmid: 18811827 doi: 10.1111/j.14609592.2008.02764.x 5. graham gg, scott kf. mechanism of action of paracetamol. american journal of therapeutics. 2005 jan 1;12(1):46-55. 6. vane jr, botting rm. mechanism of action of anti-inflammatory drugs. scand j rheumatol. 1996;25 (sup 102):9-21 pmid: 8628981 7. carr d, goudas l. acute pain. lancet. 1999;353(9169):2051-8. pmid: 10376632 doi: 10.1016/s0140-6736(99)03313-9 8. breivik h, stubhaug a. management of acute postoperative pain: still a long way to go! pain. 2008;137(2):233-4. pmid: 18479824 doi: 10.1016/j. pain.2008.04.014 9. jorgen b.d., kehlet h. postoperative pain and its management. in: mcmohan sb, koltzenburg m, editors.  wall and melzack’s textbook of pain.  5th ed. philadelphia: elsevier churchill livingstone; 2006. 10. alexander ji. pain after laparoscopy. british journal of anaesthesia. 1997 sep 1;79(3):369-78. 11. amin a, najeeb r, parveen s, ommid m, shahnaz b. comparison of analgesic effect of intravenous paracetamol and intravenous diclofenac for perioperative analgesia in laparoscopic cholecystectomy. iosr journal of dental and medical sciences. 2016;15(2):26-31. [publisher full text] 12. paul d, jacob m, kulkarni sn. comparative evaluation of efficacy of 4 paracetamol & iv diclofenac as postoperative analgesia in laparoscopic cholecystectomy. international journal of biomedical research. 2015; 6(07):482-7. [publisher full text] 13. goel p, kothari s, gupta n, kumar a, chaturvedi sk. pre emptive analgesia with iv paracetamol and iv diclofenacsodium in patients undergoing various surgical procedures: a comparative study. international journal of biological & medical research. 2013; 4(3): 3294-300. 14. salihoglu z, yildirim m, demiroluk s, kaya g, karatas a, ertem m, aytac e. evaluation of intravenous paracetamol administration on postoperative pain and recovery characteristics in patients undergoing laparoscopic cholecystectomy. surgical laparoscopy endoscopy & percutaneous techniques. 2009 aug 1;19(4):321-3. 15. arici s, gurbet a, türker g, yavascaoglu b, sahin s. preemptive analgesic effects of intravenous paracetamol in total abdominal hysterectomy. agri. 2009;21:54-61. [publisher full text] 16. khan ah, sofi sa, bashir, rather ma. a comparative study showing efficacy of preemptive intravenous paracetamol in reducing postoperative pain and analgesic requirement in laparoscopic cholecystectomy. journal of evolution of medical and dental sciences. 2015;4(62):10771-77. doi: 10.14260/ jemds/2015/1555 [publisher full text] 17. piletta p, porchet hc, dayer p. central analgesic effect of acetaminophen but not of aspirin. clinical pharmacology & therapeutics. 1991;49:350-4. pmid: 2015724 [publisher full text] 18. pickering g, loriot ma, libert f, eschalier a, beaune p, dubrayc.analgesic effect of acetaminophen in humans: first evidence of a central serotonergic mechanism. clinical pharmacology & therapeutics. 2006;79:371-8. pmid: 16580905 doi: 10.1016/j.clpt.2005.12.307 19. cc apfel a,tarun k,souza j,pergolizzi c,hornuss c. intravenous acetaminophen reduces postoperative nausea & vomiting. a systemic review & meta-analysis, pain. 2013; 154:677-89. doi: 10.1016/j. pain.2012.12.025 [publisher full text] https://doi.org/10.5812/aapm.3551 https://doi.org/10.5812/aapm.3551 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4018710/pdf/aapm-01-243.pdf https://doi.org/10.1111/j.1460-9592.2008.02764.x https://doi.org/10.1111/j.1460-9592.2008.02764.x https://doi.org/10.1016/s0140-6736(99)03313-9 https://doi.org/10.1016/j.pain.2008.04.014 https://doi.org/10.1016/j.pain.2008.04.014 https://pdfs.semanticscholar.org/8c2d/78ef57d6ff58889c2d0d782ba7a1e83af347.pdf https://www.researchgate.net/profile/debashish_paul3/publication/282446858_comparative_evaluation_of_efficacy_of_intravenous_paracetamol_and_intravenous_diclofenac_as_post-operative_analgesia_in_laparoscopic_cholecystectomy/links/56b2abe208ae5ec4ed4b5939/comparative-evaluation-of-efficacy-of-intravenous-paracetamol-and-intravenous-diclofenac-as-post-operative-analgesia-in-laparoscopic-cholecystectomy.pdf https://www.journalagent.com/agri/pdfs/agri_21_2_54_61.pdf https://doi.org/10.14260/jemds/2015/1555 https://doi.org/10.14260/jemds/2015/1555 https://www.jemds.com/data_pdf/mushtaq%20ahmad%20rather-----vija,,gu.pdf https://www.researchgate.net/profile/pierre_piletta/publication/21139735_central_analgesic_effect_of_acetaminophen_but_not_of_aspirin/links/004635375ae794a460000000.pdf https://doi.org/10.1016/j.clpt.2005.12.307 https://doi.org/10.1016/j.pain.2012.12.025 https://doi.org/10.1016/j.pain.2012.12.025 https://ac.els-cdn.com/s0304395913000092/1-s2.0-s0304395913000092-main.pdf?_tid=1e03fe49-517a-4a18-a90b-270e49775034&acdnat=1541039782_690c63f6e6d380d540cb65a01971de2c https://doi.org/10.22502/jlmc.v10i1.456 original research article relationship among sex, pattern of weakness and treatment outcomes of post-stroke patients: a register-based longitudinal study shaligram chaudhary, a,c lok raj joshi, a,c bibek koju b,c abstract: introduction : differences in stroke care and health outcomes between males and females are debated globally. sex differences in functional outcomes after stroke rehabilitation are poorly investigated in the context of nepal. this study aimed to explore the relationship among patient’s sex, side of weakness, and post-stroke health outcome after rehabilitation in a hilly western region of nepal. methods : a register-based longitudinal study was conducted in a rehabilitation center including all consecutive patients with stroke who came for rehabilitation ( ayurvedic, homeopathic, acupuncture, and physiotherapy ) from march 2018 to march 2020. modified rankin scale score at a three-month follow-up after a visit to the center was the main outcome measure. it was reported using relative risk and 95% confidence intervals. results : the study included 384 stroke patients, among them 241 (62.8%) were males. right-sided weakness was 1.262 times (rr =1.262, 95% ci = 1.016-1.567) more likely in males than in females. male stroke patients were 1.104 times more likely to achieve a good outcome than females (rr=1.104, 95% ci = 1.007-1.211) and these findings were statistically significant. there was no association between the side of weakness and the outcome. conclusion : more males, compared to females, visited for rehabilitation and achieved a good outcome (mrs0-2) after three-months. right-sided weakness was more common in males than in females. keywords: health outcome, right sided-weakness, sex difference, stroke, stroke rehabilitation. introduction: stroke is the second leading cause of death worldwide [1] as well as in nepal after coronary heart disease.[2] stroke has been reported to affect males and females differently. age-specific stroke rates are greater in males as compared to females.[3] differences in hormonal submitted: 21 july, 2021 accepted: 01 august, 2022 published: 04 august, 2022 a lecturer, department of physiology b assistant professor, department of physiology c lumbini medical college and teaching hospital, prabhas, tansen-7, palpa, nepal corresponding author: shaligram chaudhary lumbini medical college and teaching hospital, palpa e-mail: shaligram20@gmail.com orcid: https://orcid.org/0000-0002-7242-1846 levels, lifestyle (smoking, alcohol consumption, exercise, diet), the prevalence of hypertension, diabetes, etc. are potential factors that can contribute to sex differences in the incidence of stroke.[4,5] the relationship of sex with the type of stroke, location of the lesion, side of limb weakness, and quality of life has also been studied.[6,7] a study found that the incidence of right-sided weakness is more common than left-sided weakness due to more frequent involvement of the left middle cerebral artery.[8] it has been observed that females have poorer health outcomes compared how to cite this article: chaudhary s, joshi lr, koju b. relationship among sex, pattern of weakness and treatment outcomes of post-stroke patients: a register-based longitudinal study. journal of lumbini medical college. 2022;10(1): 7 pages. doi: https://doi.org/10.22502/jlmc.v10i1.456 epub: 2022 august 04 j. lumbini. med. co ll. vol 10, no 1, jan-june 2022 https://doi.org/10.22502/jlmc.v10i1.456 mailto:shaligram20@gmail.com https://orcid.org/0000-0002-7242-1846 chaudhary s. et al. sex, pattern of weakness and treatment outcomes of post-stroke patients to males and patients with left hemiplegia tend to recover less well.[6] however, another study reported that there is no significant sex difference in health outcomes.[9] the literature reveals differences in findings regarding stroke care and health outcomes between males and females.[10,11] any differences in the outcomes may arise from the role of biologic sex or indirectly through the play of other factors. several factors such as history prior to the stroke, length of stay in the acute care hospital, types of stroke (hemorrhagic and ischemic), types of motor deficits, aphasia, neglect and dysphasia, types of rehabilitation (physiotherapy, acupuncture, speech therapy, neuropsychological stimulation or rehabilitation) and socioeconomic factors play a role in stroke recovery.[12] however, the data comparing post-stroke health outcomes between males and females in western nepal is less available. we, therefore, aimed to study the relationship among sex, pattern of weakness, and treatment outcomes of post-stroke patients in this region. methods: a register-based longitudinal study was conducted in the pyuthani acupuncture, tansen, palpa, a rehabilitation center. pyuthani acupuncture is a registered polyclinic where patients receive ayurvedic, homeopathic, acupuncture, and physiotherapy treatments. patients who come directly to the rehabilitation center for clinical signs and symptoms of a stroke are referred to the nearest tertiary health care center. mostly, stroke patients from the western hilly region directly approach the nearest tertiary care hospital where they receive initial medical care and treatment. after a stay in the hospital, they are referred to the rehabilitation center or by their own will, they reach the rehabilitation center for speedy recovery along with the treatment plan of the hospital. the initial records of consecutive patients with stroke registered in the center from march 2018 to march 2020 were studied. their three-months-follow-up records were also studied during that period. clinically diagnosed cases of stroke that met who criteria and were confirmed by computerized tomography (ct) scan or magnetic resonance imaging (mri) in the prior hospital were included in the study.[13] after approval of the rehabilitation center and institutional review committee of lumbini medical college protocol no: (irc-lmc 14-g/020) data was collected from september 12 to october 16, 2020. sample size was calculated to be 384 using the following formula: n = z 2 p(1-p)/e 2 .[14]where, n = sample size for infinite population, z = z-score for desired confidence level (95%) = 1.96, p = proportion of patients who achieve good outcome (assumed to be 50% = 0.5, for unknown population) , e = desired level of precision = ± 5% = 0.05. the case records of all adults aged above 18 years with a diagnosis of stroke (all stroke types presenting with hemiplegia or hemiparesis) and modified rankin scale (mrs) finding above 2 at the time of initial presentation to the rehabilitation center[14] were included in the study. to study the health outcome, patients with moderate to severe stroke (mrs>2) were required and we used the consecutive (non-probability) sampling technique. information about age, sex, history of the patient, side of weakness, the initial level of dependency before rehabilitation (mrs>2 were included), brain imaging data, laboratory reports, diagnosis, and treatment were collected in predesigned case proforma maintaining the confidentiality of the patients' personal information. patients’ health outcome at three-month after registration was evaluated by the mrs from the follow-up records that had been kept based on a telephone interview or follow-up visit to the center. the poor outcome is defined as mrs>2 and good outcome as mrs up to 2.[6] patients whose records were not complete regarding the information about the study parameters were excluded from the study. analysis of the relationship between categorical variables was conducted using the chi-square test. the difference in the mean age of the two groups (male and female) was tested using an independent t-test. most data were in the form of j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np chaudhary s. et al. sex, pattern of weakness and treatment outcomes of post-stroke patients categories sex (male and female), male (right and left-sided weakness), and female (right and left-sided weakness). the association between sex and clinical outcome at three-month was assessed by the chi-square test. to investigate the relationship between sex and the side of weakness too, a chi-square test was used. the final results were reported using relative risk (rr) and 95% confidence intervals. all statistical analyses were performed using statistical package for social sciences (spss tm ) software version 16.0. a two-sided p-value of <0.05 was considered statistically significant. results: a total of 384 stroke patients registered in the rehabilitation center during the two-year period were included in the study. the ratio of males and females visiting the rehabilitation center was 1.68:1. the average age for the occurrence of stroke was 62.4 ± 12.0 years. most of the stroke patients were in the age group 55-64 years (32.4%) followed by 65-74 years (26.6%). (table1). there was no significant difference in the mean age of occurrence of stroke between males and females [t(382) = -0.176, p = 0.860]. table1: baseline characteristics of the study population. variables male (n=241) frequency (%) female (n=143) frequency (%) total (n=384) frequency (%) age group (years) <44 23 (9.4) 6 (4.1) 29 (7.55) 45-54 31 (12.9) 28 (19.6) 59 (15.4) 55-64 78 (32.4) 48 (33.6) 126 (32.9) 65-74 64 (26.6) 44 (30.8) 108 (28.1) ≥ 75 45 (18.7) 17 (11.9) 62 (16.1) mrs* (after 3 months) good 214 (88.8) 115 (80.4) 329 (85.7) poor 27 (11.2) 28 (19.6) 55 (14.3) *modified rankin score table2: association between gender and side of weakness. gender right-sided weakness left-sided weakness statistics rr*(95%ci**) male 134 107 χ2=4.789,df=1, p=0.029 1.262 (1.016-1.567) female 63 80 * relative risk, **confidence interval j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np chaudhary s. et al. sex, pattern of weakness and treatment outcomes of post-stroke patients table 2 shows the findings regarding the side of weakness in relation to the sex of the patients. in male patients, right-sided weakness (55.60%) was slightly more common compared to left-sided weakness whereas left-sided weakness (55.94%) was more common in female patients. male patients were 1.26 times more likely (rr = 1.262, 95% ci = 1.016-1.567) to have right-sided weakness compared to female patients. between-sex contrast of outcome: we observed that the male sex was associated with a 10% greater chance of achieving a good three-month outcome compared to the female sex (rr=1.104,95% ci = 1.007-1.211) as shown in table 3. within-sex contrast of outcome: there was no significant difference in the health outcome between males who had left-sided weakness and males who had right-sided weakness (rr=1.0, 95% ci = 0.913-1.094). there was no significant relationship between the side of weakness and outcomes in the female group either (rr=1.024, 95% ci = 0.869-1.206) (table 3) table3: association of sex and side of weakness with functional outcome [modified rankin score (mrs) good or poor] at three-months. variables mrs0-2 (good) mrs >2 (poor) statistics mrs (good) rr*(95%ci**) male 214 27 χ2=5.132,df=1, p=0.023 1.104 (1.007-1.211) female 115 28 male (left-sided weakness) 95 12 χ2=0.00,df=1, p=0.996 1.000 (0.913-1.094) male (right-sided weakness) 119 15 female (left-sided weakness) 65 15 χ2=0.08,df=1, p=0.778 1.024 (0.869-1.206) female (right-sided weakness) 50 13 left-sided weakness (total) 160 27 χ2=0.004,df=1, p=0.950 0.997 (0.919-1.082) right-sided weakness (total) 169 28 *relative risk, **confidence interval moreover, right-sided weakness and left-sided weakness in the entire cohort had no significant difference in the health outcome (rr = 0.997,95% ci = 0.919-1.082) as shown in table 3. discussion: this study aimed to determine the relationship between the stroke patient’s sex and side of weakness, explore the relationship between the patient’s sex and post-stroke health outcome, and assess the relationship between the side of weakness and post-stroke health outcome. the ratio of the number of males and females visiting the rehabilitation center was 1.68:1. a higher incidence of stroke in males may be responsible for this sex difference. the difference in access to the facility cannot be ruled out though. previous studies have suggested that several factors such as hypertension, hyperlipidemia, type 2 diabetes mellitus, overweight, and obesity as well as genetic, hormonal, and anatomic factors add sex j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np chaudhary s. et al. sex, pattern of weakness and treatment outcomes of post-stroke patients differences in stroke. besides this, sex differences in lifestyle, level and pattern of dietary intake, smoking, and drinking behavior also contribute to risk for stroke.[4] a previous study has shown that the risk factors namely hypertension, chronic heart failure, and atrial fibrillation were more common in female patients. on the other hand, smoking and alcohol consumption were more common in male patients.[5] we observed that male patients were 1.26 times more likely to have right-sided weakness compared to female patients. the difference in the right and the left-sided weakness may be due to more frequent involvement of the left middle cerebral artery in ischemic stroke in general.[8] however, we were not able to assess this possibility directly in our sample. also, the cause of this sex difference is not clear. however, when observed, the difference in the side of involvement is important because the weakness of the dominant side (usually the right side) leads to more severe disability. our data showed that men and women both benefited from stroke rehabilitation as 85.67% of all patients (88.8% males and 80.4% females) achieved a good functional recovery (mrs<2). this finding is consistent with the previously published studies (85.7%, 88.5% overall good outcomes).[10,15] the present study showed that the patients suffering from a stroke who were males were 1.10 times more likely to achieve a good health outcome after stroke rehabilitation in three months compared to female patients. different factors, like genetic, sex hormones, lifestyle, clotting status, social relationship might separately or collectively help to describe gender differences in stroke.[16] a previous study explained that post-stroke depression [17] or post-stroke memory decline in the brain hemispheres was responsible for the poor outcome from a stroke.[18] it has been found that more women suffered depression after stroke which affected recovery and quality of life.[19] a previous study also showed that women experienced worse outcomes after stroke than men. [20] however, in another study, males and females recovered equally well after rehabilitation. many hypotheses have been formulated to explain the findings but all of them were insufficient.[21,22] condonnier et al. have reported sex differences in access to rehabilitation services and variation in stroke care across different countries.[21] our findings may not be generalized to all patients with stroke but are representative of moderate to severe stroke patients who undergo physiotherapy and acupuncture rehabilitation. some limitations need to be mentioned. first, our study was limited to a single center in the western hilly region of nepal. data of patients who had not come for follow-up and had not responded in the telephone interview at three months could not be obtained. second, the register-based study did not allow the collection of many important clinical determinants of functional outcomes. demographics, such as education, living conditions (alone or with others), and marital status, could not be determined from the available clinical records. we were also not able to consider important clinical outcomes such as quality of life and depression. these factors are known to influence the worse prognosis in women which is often reported in the available literature.[23] future studies are needed to assess the responsiveness of women and men to physical, cognitive, and social interventions during the post-stroke period. both subjective (i.e. quality of life) and objective (i.e. cognitive functioning, depression, disability) outcome measures will be useful for the purpose. conclusion: we observed that right-sided weakness was slightly more common than left-sided weakness in male patients whereas the reverse was true for females. we did not find any significant association between the side of weakness and outcome. however, male patients were slightly more likely to achieve good outcome compared to female patients. we hope that this knowledge is helpful to optimize the care of female patients and minimize the unequal burden of stroke in males and females. further studies are required j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np chaudhary s. et al. sex, pattern of weakness and treatment outcomes of post-stroke patients to determine the factors responsible for the observed sex differences. acknowledgement: authors express sincere gratitude to ● pyuthani acupuncture polyclinic, tansen, palpa . ● mr. arun bhadra khanal ● dr. surendra maharjan conflict of interest: none declared. source of fund: no funds were available. references: 1. gbd 2016 stroke collaborators. global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the global burden of disease study 2016. lancet neurol. 2019;18(5):439-58. pmid: 30871944 doi: https://doi.org/10.1016/s1474-4422(19)30 034-1 2. world life expectancy. nepal: stroke [internet]. available from: https://www.worldlifeexpectancy.com/nep al-stroke [cited 1 st jul 2020] 3. 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sohrabji f, bush rl. sex differences in stroke: review of current knowledge and evidence. vasc med. 2017;22(2):135-45. pmid: 27815349 doi: https://doi.org/10.1177/1358863x1666826 3 12. poggesi a, insalata g, papi g, rinnoci v, donnini i, martini m, et al. gender differences in post-stroke functional outcome at discharge from an intensive rehabilitation hospital. eur j neurol. 2021;28(5):1601-8. pmid: 33561883 doi: https://doi.org/10.1111/ene.14769 j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np https://pubmed.ncbi.nlm.nih.gov/30871944/ https://doi.org/10.1016/s1474-4422(19)30034-1 https://doi.org/10.1016/s1474-4422(19)30034-1 https://www.worldlifeexpectancy.com/nepal-stroke https://www.worldlifeexpectancy.com/nepal-stroke https://doi.org/10.3126/egn.v2i1.27462 https://pubmed.ncbi.nlm.nih.gov/23032484/ https://pubmed.ncbi.nlm.nih.gov/23032484/ https://doi.org/10.1038/jcbfm.2012.141 https://pubmed.ncbi.nlm.nih.gov/27333721/ https://doi.org/10.20471/acc.2016.55.01.11 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broderick jp, caplan lr, connors jjb, culebras an, et al. an updated definition of stroke for the 21st century: a statement for healthcare professionals from the american heart association/american stroke association. stroke. 2013;44(7):2064-89. pmid: 23652265 doi: https://doi.org/10.1161/str.0b013e318296a eca 14. specifications manual for joint commission national quality measures (v2018a). modified rankin score (mrs) [internet]. available from: https://manual.jointcommission.org/releas es/tjc2018a/dataelem0569.html [cited 8 th june 2020] 15. thapa a, kc b, shakya b, yadav dk, lama k, shrestha r. changing epidemiology of stroke in nepalese population. nepal journal of neuroscience. 2018;15(1):10-18. doi: https://doi.org/10.3126/njn.v15i1.20021 16. hiraga a. gender differences and stroke outcomes. neuroepidemiology. 2017;48(1–2):61–2. pmid: 28419999 doi: https://doi.org/10.1159/000475451 17. wang q, mejía-guevara i, rist pm, walter s, capistrant bd, glymour mm. changes in memory before and after stroke differ by age and sex, but not by race. cerebrovasc dis. 2014;37(4):235-43. pmid: 24686293 doi: https://doi.org/10.1159/000357557 18. silasi g, murphy th. stroke and the connectome: how connectivity guides therapeutic intervention. neuron. 2014;83(6):1354-68. pmid: 25233317 doi: https://doi.org/10.1016/j.neuron.2014.08.0 52 19. towfighi a, ovbiagele b, el husseini n, hackett ml, jorge re, kissela bm, et al. poststroke depression: a scientific statement for healthcare professionals from the american heart association/american stroke association. stroke. 2017;48(2):e30-43. pmid: 27932603 doi: https://doi.org/10.1161/str.0000000000000 113 20. phan ht, blizzard cl, reeves mj, thrift ag, cadilhac d, sturm j, et al. sex differences in long-term mortality after stroke in the instruct (international stroke outcomes study): a meta-analysis of individual participant data. circ cardiovasc qual outcomes.2017;10(2):e003436. pmid: 28228454 doi: https://doi.org/10.1161/circoutcomes.116.0 03436 21. cordonnier c, sprigg n, sandset ec, pavlovic a, sunnerhagen ks, caso v, et al. stroke in women from evidence to inequalities. nat rev neurol. 2017;13(9):521-32. pmid: 28731036 doi: https://doi.org/10.1038/nrneurol.2017.95 22. carcel c, woodward m, wang x, bushnell c, sandset ec. sex matters in stroke: a review of recent evidence on the differences between women and men. front neuroendocrinol. 2020;59:100870. pmid: 32882229 doi: https://doi.org/10.1016/j.yfrne.2020.10087 0 23. bushnell c, howard vj, lisabeth l, caso v, gall s, kleindorfer d, et al. sex differences in the evaluation and treatment of acute ischaemic stroke. lancet neurol. 2018;17(7):641-50. pmid: 29914709 doi: https://doi.org/10.1016/s1474-4422(18)30 201-1 j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np https://pubmed.ncbi.nlm.nih.gov/23652265/ https://doi.org/10.1161/str.0b013e318296aeca https://doi.org/10.1161/str.0b013e318296aeca 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https://doi.org/10.1016/j.yfrne.2020.100870 https://pubmed.ncbi.nlm.nih.gov/29914709/ https://doi.org/10.1016/s1474-4422(18)30201-1 https://doi.org/10.1016/s1474-4422(18)30201-1 jlmc.edu.np original research article —–————————————————————————————————————————— abstract: introduction: social support is the perception that one is cared for, has assistance available from significant others and its benefit is by buffering stress by influencing the ability to adjust and live with illness. social support can uplift the quality and subjective wellbeing of people. the objective of this study was to examine the perceived social support and factors influencing it among mentally ill patients. methods: a descriptive cross-sectional study was carried out. ninety cases aged more than 18 years visiting outpatient of psychiatric department and diagnosed as a case of mental illness for at least a year were included. instruments used were self-developed proforma and multidimensional scale of perceived social support. interview technique was used to collect the data. results: majority (60%) of the patients perceive social support from family, 28% of the patients perceive social support from significant others. regression analysis showed that the perceived social support is influenced by employment status, type of family one lives in and physical illness. it is not influenced by gender, subjective financial status and frequency of hospitalization. conclusion: perceived social support is influenced by employment status, type of family one lives in and physical illness. majority (60%) of the patients perceive social support from family. keywords: mentally ill • social support • employment • regression —–————————————————————————————————————————— j. lumbini. med. coll. vol 2, no 1, jan june 2014 ___________________________________________________________________________________ a lecturer, b nursing officer c college of nursing, lumbini medical college, palpa, nepal corresponding author: ms. bandana pokharel e-mail: anupbandana@gmail.com how to cite this article: pokharel b, pokharel a. perceived social support among mentally ill patients. journal of lumbini medical college. 2014;2(1):14-7. doi: 10.22502/jlmc.v2i1.48. ___________________________________________________________________________________ bandana pokharel,a,c anupama pokharelb,c perceived social support among mentally ill patients wellbeing under conditions of stress. social support is a multifaceted construct and a review of literature indicates that the construct of social support consists of both structural and functional component.3,4 the structural component includes informal and formal support, such as an individual’s social network, the size of the social network, frequency of contact with members of the network, reciprocal support and quality of the support.4 functional support refers to the perceived level of the support received, such as emotional support, affirmative support and tangible support.5 social support has a major role to play in the long term course and outcome of any chronic illness. social support from the key caregivers, environment and community can play a positive role by enabling a person with chronic disorder. positive functional social network can work as a buffering agent.6 this way social support can uplift the quality and subjective wellbeing of people as well as enable people to develop and use positive forms of coping and problem solving strategies.7 there is a lack of study on perceived social support of mentally ill introduction: social support is the perception that one is cared for and has assistance available from friends and significant others. it may benefit health by buffering stress influencing affective states and/or changing behavior, and also influencing the ability to adjust and to live with illness. social support has generally been found to promote psychological wellbeing.1,2 over the past twenty years, there has been great interest in the role of social support as a mechanism for the maintenance of psychological https://doi.org/10.22502/jlmc.v2i1.48 14 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 pokharel b. et al. perceived social support among mentally ill patients patients. this study was done with the objective to assess the level of perceived social support among mentally ill patients. methods: it is a cross-sectional study done from 1st january 2014 to 30th march 2014 in outpatient of psychiatric department at lumbini medical college. a purposive sampling technique was adopted for the study. patients with a history of mental illness for at least one year and age more than 18 years were included in the study. patient who had significant physical illness during the time of study, patients under addiction problems of any substances and patients not willing to participate were excluded from the study. sociodemographic profile and a valid tool of multidimensional scale of perceived social support (a 12 item with 7 point scale related to significant others, family, friends) were used as data collection instruments. each of the 3 areas had 4 subscales. items were measured on 7 point likert type scale from 1 ‘very strongly disagree’ to 7 ‘very strongly agree. scores were derived by summing the individual items and dividing by the number of items. data was collected by interview using selfdeveloped proforma and perceived social support scale. all the data was collected and entered in microsoft excel 2013 then imported to spss 21. descriptive and inferential statistics as well as regression analysis was done to find out the relationship between selected demographic variables and perceived social support. results: demographic characteristics of participants is presented in table 1. majority (60%) of the patients perceived social support from their family, 28% from significant others and the rest 12% from friends. mean score of perceived social support was 3.33 (sd=1.37). the mean score for all individuals and each sex is shown in table 2. it shows that the difference in score in male and female is not statistically significant. regression analysis was done by stepwise method to describe the relationship between the dependent variable (social support score) and the independent variables. the independent variables were sex (male, female), type of family (nuclear, joint), number of admissions (two or less, more table 1: demographic characteristics of the participants (n=90) variables n % cast brahmin/chhetri 37 41.1 janjati 23 25.6 dalit 20 22.2 madeshi 3 3.3 muslim 7 7.8 sex female 51 56.7 male 39 43.3 age ≤ 20 8 8.9 21-40 52 57.8 41-60 30 33.3 education below slc 29 32.2 plus two 13 14.4 illiterate 30 33.3 literate 18 20.0 occupation employed 58 63.7 unemployed 32 35.2 family type nuclear 50 55.6 joint 40 44.4 diagnosis depression 48 53.3 anxiety disorder 26 28.9 adsd 13 14.4 dissociative disorder 3 3.3 than two), subjective financial status (inadequate, adequate), employment (unemployed, employed) and psysical illness (absent, present). there was a significat correlation (r) of social support score with type of family, employment and physical illness. there was poor correlaton with other variables (table 3). three models of regression analysis was done stepwise by the computer automatically adding the variable with significant correlation one at a time in each step until the change statistic in the model was m sd n overall 3.33 1.37 90 male 3.45 1.56 28 t = 0.54 df = 88 p = 0.59female 3.27 1.29 62 table 2: mean of social support score se x no o f t im e a dm itt ed fa m ily ty pe fi na lc ia l st at us em pl oy ed ? ph ys ic al ill ne ss ? social support r -.058 -.045 .378 -.064 .519 -.408 p .295 .336 .000 .275 .000 .000 table 3: correlation between social support and variables 15 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 pokharel b. et al. perceived social support among mentally ill patients significat. the result is shown in table 4. it shows three models with increasing r2 until the change in r2 is significant. here, model 3 has the higest r2 indicating highest coffecient of determination of dependent variable taking into account the predictors in that model. model r r2 adjusted r2 r2 change p 1 .519a .269 .261 .269 .000 2 .696b .484 .472 .215 .000 3 .749c .561 .546 .077 .000 a. predictors: (constant), employed b. predictors: (constant), employed, type of family c. predictors: (constant), employed, type of family, physical illness dependent variable: pss_score table 4: regression model discussion: the majority (60%) of the patient perceived social support from family, 28% from significant others and the rest 12% from friends. other studies also has similar findings and states that support from family and friends is a key part for people with mental illness.8 close relations like spouse/partner or parent are better support system for mentally ill patients. social support, particularly the emotional support from a close relatives is one important protective factor for mental health problems. support from significant others included siblings and peers was also the crucial system to provide support, and their relationships should be encouraged as an important part of service delivery to families dealing with mental illness.9 this study shows that the patients who were employed had significantly better perceived social support than the unemployed. similarly, patient staying with the joint family had better support. those with physical illness had negative support. these finding are supported by other studies that if mentally ill people were unemployed or stay in a nuclear family, they got less support from other resources too.10,11 this might be due to the fact that the families of mentally ill patients comes under financial strain to support them along with financial hardship, which is indicated by lack of material resources and inability to afford essentials. there is no significant relationship of social support with gender, subjective financial status, number of times hospitalized. conclusion: perceived social support is significantly better in employed people and in those who live in joint family. support is significantly less if one has physical illness. social support is not influenced by gender, subjective financial status and number of times hospitalized. conflict of interest: none. financial declaration: none unstandardized coefficients standardized coefficients b std. error beta p (constant) 28.402 2.929 .000 employed 20.056 2.515 .577 .000 type of family 13.481 2.718 .377 .000 physical illness -9.769 2.512 -.292 .000 table 5: regression coefficients table 5 shows the regression coefficients of the predictors. social support score (sss) can be predicted as: sss = 28.4 + 20.06(employment) + 13.48(family type) 9.77(physical illness) where employment = 1 if employed and 0 if unemployed, and family type = 1 if joint and 0 if nuclear, physical illness = 1 if present and 0 if none. employment status, when adjusted for other variables, has the greatest influence on the support score as shown by the largest beta value. type of family has lesser influence and physical illness has least influence in the opposite direction, i.e. if physical illness occurs, the social support score decreases. 16 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan-june 2014 pokharel b. et al. perceived social support among mentally ill patients references: 1. attkisson c, cook j, karno m, lehman a, mcglashan th, o’connor m, et al. clinical services research. schizophrenia bulletin. 1992;18(4):561-626. 2. hoenig j, hamilton mw. the schizophrenic patient in the community and his effect on the household. international journal of social psychiatry. 1966;12(3):165–76. 3. tonsing k, zimet gd, tse s. assessing social support among south asians: the multidimensional scale of perceived social support. asian journal of psychiatry. 2012;5(2):164–8. 4. zimet gd, powell ss, farley gk, werkman s, berkoff ka. psychometric characteristics of the multidimensional scale of perceived social support. journal of personality assess. 1990;55(3-4):610-17. 5. edwards lm. measuring perceived social support in mexican american youth: psychometric properties of the multidimensional scale of perceived social support. hispanic journal of behavioral sciences. 2004;26(2):187-94. 6. association of relatives and friends of the emotionally and mentally ill. (2007). identifying carer needs for support and advocacy (arafemi carer consultation: research report 1). retrieved 25 april 2014, from http:// www.arafemi.org.au/uploads/downloads/carerconsultationfinalreport2.pdf. 7. baronet am. factors associated with caregiver burden in mental illness: a critical review of the research literature. clinical psychology review. 1999;19(7):819–41. 8. edwards b, higgins d, gray m, zmijewski n, kingston m. the nature and impact of caring for family members with a disability in australia (research report no. 16). melbourne: australian institute of family studies, 2008. 9. mccabe km, yeh m, lau a, garland a hough r. racial/ ethnic differences in caregiver strain and perceived social support among parents of youth with emotional and behavioral problems. ment health serv res. 2003;5(3):137-47. 10. guarnaccia pj, parra p. ethnicity, social status, and families’ experiences of caring for a mentally ill family member. community mental health journal. 1996;32(3):243– 60. 11. reupert a, maybery d. families affected by parental mental illness: australian programs, strategies and issues. the (missing) role of schools. international journal for schoolbased family counseling. 2010;2:1-16. 12. zimet gd, dahlem nw, walker rr. the multidimensional scale of perceived social support: a confirmation study. journal of clinical psychology. 1991;47(6):756-61. 17 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 7, no 1, jan-jun 2019 ___________________________________________________________________________________ submitted: 19 june, 2018 accepted: 04 february, 2018 published: 13 february, 2019 a associate professor and head b lecturer c associate professor d department of anesthesia and critical care e department of obstetrics and gynaecology f kathmandu university school of medical sciences, dhulikhel corresponding author: jeevan singh e-mail: drjeevan25@gmail.com orcid: https://orcid.org/0000-0003-4319-6261_______________________________________________________ —–————————————————————————————————————————————— abstract: introduction: spinal anesthesia is considered a reasonable option for cesarean section. bupivacaine and ropivacaine have been used as intrathecal drugs alone or in combination with various opioids. ropivacaine is considered a valid and safe alternative to bupivacaine for intrathecal anesthesia. this study aims to determine the median effective dose (ed50) of intrathecal bupivacaine and ropivacaine for cesarean section and defines this as the minimum local anesthetic dose (mlad). methods: forty pregnant women undergoing elective cesarean section were allocated and randomized into two groups. the initial dose was 13mg for both ropivacaine and bupivacaine groups and was increased or decreased of 0.3mg, using the up-down sequential allocation technique. efficacy was accepted if adequate sensory dermatomal anesthesia to pinprick to t6 was attained within 20 minutes after intrathecal injection and required no supplemental epidural injection for procedure until at least 50 minutes after the intrathecal injection of test drugs. the mlad for both bupivacaine and ropivacaine was calculated with 95% confidence interval using the formula of dixon and massey. comparison of different variables between the groups was done using t-test with significant p value at < 0.05. results: the two groups were comparable in terms of demographic profile and clinical characteristics. the mlad of ropivacaine and bupivacaine were 11.63 mg (95% ci, 11.5-12.92) and 10.459 mg (95% ci, 10.12-10.87) respectively. the potency ratio between spinal ropivacaine and bupivacaine was 0.89. conclusion: ropivacaine provided clinically surgical anaesthesia of shorter duration without compromising neonatal outcome and can be used as a safe alternative to bupivacaine. keywords: bupivacaine, cesarean section, ropivacaine, spinal anesthesia —————————————————————————————————————————————— original research articlehttps://doi.org/10.22502/jlmc.v7i1.250 jeevan singha,d,f ashish shresthab,d,f kalpana kharbujab,d,f alex tandukarb,d,f abha shresthac,e,f minimal local analgesic dose of intrathecal bupivacaine and ropivacaine in patients undergoing cesarean section: a comparative study introduction: spinal anesthesia is considered a reasonable option for cesarean section. intrathecal drugs like bupivacaine and ropivacaine have been used either alone or in combination with various opioids. ropivacaine, a pure s-(-) enantiomer aminoamide long acting local anesthetic agent with structural and pharmacological similarity to bupivacaine.[1] at high doses, it produces surgical anesthesia and at lower doses it produces analgesia (sensory block) with limited and non-progressive motor block. as compared to bupivacaine, the motor block is often slower in onset, shorter in duration and less potent. in-vitro, ropivacaine has shown less cardiotoxicity than the equivalent concentration of racemic bupivacaine. it has been registered for use in intrathecal spinal anesthesia. [3, 4] a number of studies have evaluated intrathecal use of ropivacaine for obstetric and non-obstetric patients.[5,6,7,8] there is, however, a lack of comparative studies and adequate information on the analgesic and anesthetic how to cite this article: singh j, shrestha a, kharbuja k, tandukar a, shrestha a. minimal local analgesic dose of intrathecal bupivacaine and ropivacaine in patients undergoing cesarean section: a comparative study. journal of lumbini medical college. 2019;7(1):5 pages. doi: 10.22502/ jlmc.v7i1.250. epub: 2019 feb 13. https://orcid.org/0000-0003-4319-6261 https://doi.org/10.22502/jlmc.v7i1.250 singh j. et al. minimal local analgesic dose of intrathecal bupivacaine and ropivacaine jlmc.edu.npj. lumbini. med. coll. vol 7, no 1, jan-jun 2019 potency of intrathecal ropivacaine and bupivacaine administration, especially in obstetric practice. this comparative study applies a model to determine the median effective dose (ed50) of intrathecal ropivacaine and bupivacaine for cesarean section and defines this as the minimum local anesthetic dose (mlad). methods: this is a comparative, up-down sequential allocation study conducted in the department of anesthesiology of a tertiary hospital over a period of six months from october, 2017 to march, 2018. the ethical approval was taken from institutional review committee (kusms/irc 93/17) kathmandu university school of medical sciences. written informed consent was obtained from all participants of the study. sample size calculation was done using the formula, n = [ (z1-α/2+z1-β) / es ]2where es = (µ1µ2) /σ. assuming estimated standard deviation (σ) = 0.55, clinically important difference (µ1µ2) = 0.5 and taking α = 0.05 with desired power (1-β) of 0.80, the minimum sample size was calculated to be 19.34, that is 20 in each group. a total of 40 women scheduled for elective cesarean delivery at more than 37 weeks of gestation and asa physical status class i or ii were enrolled into the study. indications for cesarean section included previous cesarean section, transverse lie, complete placenta previa, pregnancy with tumors in lower uterine segment and primi breech presentation. all the participants were pre-medicated with 150 mg of ranitidine two hours before surgery. they were not given opioids during the study period. they were divided randomly into two groups of twenty each, using a computer generated random numbers list. intravenous access was obtained with an 18g cannula through which all participants were pre-loaded with a balanced crystalloid solution of one liter over ten minutes before inducing combined spinal epidural (cse). the participants were not aware of the group that they were in and the observer was also kept blinded for the study drug dose injected by the independent anesthesiologists giving cse in the sitting position by two space cse technique at the l3-l4 interspace.[9,10] after confirming a free flow of cerebrospinal fluid(csf), the study drug was injected at a rate of approximately 0.2ml/second intrathecally, to the allocated group accordingly by an anesthetist not related to the study. the dose of ropivacaine or bupivacaine in all syringes was taken by the response of the previous participant to a greater or lesser dose according to the vertical sequential allocation. the starting dose was 13mg for both ropivacaine and bupivacaine group. an anesthesia nurse who had no further role in the study prepared the syringes with the solution. sensory level to pinpricks was assessed by the hollmen scale: 0= ability to appreciate a pinprick as sharp; 1= ability to appreciate a pinprick as less sharp; 2= inability to appreciate a pin prick as sharp (analgesia); 3= inability to appreciate a pin prick as pin touching (analgesia). the participants were assessed before cesarean delivery, at skin incision, uterine incision, birth, peritoneal closure and at the end of the surgery. there were three possible outcomes. a) effective: women declared a visual analogue pain scale (vaps)≤ 30mm and did not require an epidural rescue bolus; this result directed a decrease of 0.3mg in the dose of bupivacaine or ropivacaine for the next participant in the same group, b) ineffective: women reported a vaps 30mm which resulted in the administration of 10 ml epidural 2% lidocaine. a bupivacaine or ropivacaine 0.3mg increment was directed for the next patient in the same group. c) rejected: women reported a vaps 30mm which failed to rescue bolus or some problems with cse occurred. this result directed a repeat of the same dose of the same drug in the same group. the intra operative monitors used were heart rate (hr), electrocardiogram (ecg), non-invasive blood pressure (nibp) and oxygen saturation (spo2). a consultant anesthesiologist on duty on the day of study period recorded these parameters before intrathecal injection and at three minutes interval until delivery, then every five minutes through surgery. maternal hypotension was defined as a 20% reduction in systolic arterial pressure from baseline values and was treated promptly with intravenous ephedrine 10mg. during intra-operative period, the onset of action time in both the drugs was noted from incision up to closure of skin and postoperative complications like hypotension, nausea and vomiting were noted. the data collection was done mainly using the questionnaire which was filled up by the anesthesiologists regarding level of block, pain score using visual analogue scale, duration of anesthesia, hypotensive effect and post-operative nausea and singh j. et al. minimal local analgesic dose of intrathecal bupivacaine and ropivacaine jlmc.edu.npj. lumbini. med. coll. vol 7, no 1, jan-jun 2019 vomiting. patient and obstetrics data were tabulated into microsoft excel and analyzed with the statistical package for social sciences (spss™) version 21. it was presented as mean (+sd), median (iqr) and was analyzed using analysis of variance and chisquare test respectively. the significance of difference between two groups was evaluated by student's t test. the significance level for all tests was set at p<0.05. the mlad for both bupivacaine and ropivacaine was calculated with 95% confidence interval using the formula of dixon and massey. result: a total of 40 consecutive eligible participants, enrolled into the study, were randomized into two study groups. the groups were comparable in terms of patient characteristics (age, weight, duration of surgery, asa grade, apgar score and the gestational age), and baseline vital parameters. the anesthetic and surgical techniques were standardized for both groups. the new born babies had a mean apgar score (±sd) of 9.0(±0.20) and 9.5(±0.35) at five minutes in the bupivacaine and ropivacaine groups respectively (table 1). the intrathecal mlad (95% ci) of ropivacaine was 11.6mg (11.2-12.6mg) and that of bupivacaine was 11.25mg (10.0-12.5mg), using the formula of dixon and massey (figures 1 and 2). the relative potency ratio between spinal ropivacaine and bupivacaine was 0.90. anesthesia was successfully performed within the predetermined criteria in all 20 patients in both groups. the participants labelled ‘ineffective' were pain free at skin incision or at delivery, but required supplementary analgesia at peritoneal closure. all patients who required epidural top-ups obtained good pain relief. the mean map decreased significantly in both the groups compared to baseline/pre-operative values (p<0.005). the percentage of participants with hypotension was 36.5% in the ropivacaine and 60% in the bupivacaine group. the results were statistically significant both with p=0.032. bradycardia occurred during intra-operative period in two patients in each group. there were no significant differences between the two groups with respect to respiratory rate and oxygen saturation. eight participants in bupivacaine group and six in ropivacaine group required ephedrine for correction of hypotension. three participants in ropivacaine and five in bupivacaine group required ondansetron table 1. comparison of demographic profile, clinical characteristics and neonatal outcome between the study groups (n=40) variables ropivacaine group (n=20) bupivacaine group (n=20) p-value age in years, mean +sd 26.7±5.3 25.4±4.7 >0.05 weight in kg, mean + sd 58.2±7.2 60.3±8.3 >0.05 height in cm, mean + sd 153±6.5 152±5.5 >0.05 asa grade (i/ii) 16/4 17/3 >0.05 duration of surgery in minutes, mean + sd 52±7.0 56±6.0 >0.05 apgar score at 5 minutes, mean + sd 9±0.20 9.5±0.35 >0.05 gestational age in weeks, mean + sd 37.2±1.4 37.8±1.8 >0.05 figure 1. the mlad of bupivacaine for cesarean section was 10.459 mg (ci 95%: 10.12–10.87)), using the formula of dixon and massey. singh j. et al. minimal local analgesic dose of intrathecal bupivacaine and ropivacaine jlmc.edu.npj. lumbini. med. coll. vol 7, no 1, jan-jun 2019 for correction of vomiting. incidence of hypotension, consumption of ephedrine and episodes of nausea and vomiting were similar between the groups. discussion: the mlad model has been used in the investigation of analgesic requirements in labour. [11] a relatively recent concept of minimum local anesthetic concentration determines the median effective dose and potencies of local anesthetics for spinal anesthesia.[12] a study by stocks et al.[13] established the mlad of intrathecal bupivacaine in parturients to determine the minimum local analgesic concentration of epidural local anesthetic. in our study, we used the sequential allocation design for cesarean section to discover any difference in the estimation of the ed50 found in previous clinical studies with other statistical method. khaw et al.[6], in his dose response study with plain spinal ropivacaine for cesarean delivery, determined the effective doses for ed50 to be 16.5 mg ( 95% ci, 14.1 – 18.8) and ed95 to be 26.8 mg ( 95% ci, 23.6 – 34.1). in another study done by celleno et al. [14], the ed50 of plain ropivacaine for cesarean section was reported to be 14.22mg. this study showed a higher ed50 than ours. we attributed this difference to density of ropivacaine solutions administered intrathecally. the ropivacaine solution used in this study was isobaric where as that used in previous studies was hyperbaric. the feature of the neuraxial block during spinal anesthesia depends on the baricity, and the position of the patient. in parturients, while performing spinal anesthesia in lateral position the level of head is lower than the hip as the width of hips is usually larger than the shoulders in women. further more, during pregnancy the gap is even higher. during the hyperbaric solution injection, in lateral position, the drug solution moves cephalad due to gravity. unlike hyperbaric, isobaric solution is not affected by the gravity. in order to avoid the spread, this hyperbaric solution in our study was given in a sitting position. in our study, we found the mlad of bupivacaine was 11.25mg and ropivacaine was 11.6mg. this finding was similar to the study done in meerut by singh s et al. where mlad of 0.5% of hyperbaric bupivacaine was 12.5mg and for 0.75% isobaric ropivacaine, it was 24mg.[15] however in their study, they used 0.75% isobaric ropivacaine whereas, we used 0.5% isobaric ropivacaine. in a similar study done by tadeusz et al. [16] in poland and fei xiao et al. [17] in china, the mlads of intrathecal ropivacaine and bupivacaine for cesarean delivery were reported 9.45mg and 7.33 respectively. these results are consistent with the present study with only difference that they performed spinal anesthesia in l2-3 space whereas we performed in l3-4 space. in another study done in peking university by geng zhi-yu et al.,[18] the intrathecal mlad was 9.45mg (95% ci, 8.45-10.56mg) for ropivacaine and 7.53mg (95%ci, 7.00-8.10mg) for bupivacaine. this was slightly less than that found in our study. this difference can be attributed to the density of ropivacaine and bupivacaine. likewise, a similar study done in lucknow by gupta a et al.[19] had found the mlad of ropivacaine was 12.5mg in combination with 25mg of fentanyl which is consistent with our study. similar to our study, another study by whiteside et al. comparing 15 mg of 0.5 % ropivacaine or 0.5 % bupivacaine in 8% glucose, reported that ropivacaine was reliable for spinal anaesthesia for lesser duration and with lesser hypotension than bupivacaine.[20] another study by mcnamee et al.[21] reported intrathecal administration of 17.5 mg plain ropivacaine 0.5% or plain bupivacine 0.5% also had similar effective spinal anesthesia for total hip arthroplasty.[21] conclusion: figure 2. the mlad of ropivacaine for caesarean section was 11.63mg (95%ci, 11.5-12.92) using the formula of dixon and massey references: 1. collis re, davies dw, aveling w. randomised comparison of combined spinal-epidural and standard epidural analgesia in labour. lancet. 1995;345(8962):14136. pmid: 7760614 2. richardson mg, thakur r, abramowicz js, wissler rn. maternal posture influences the extent of sensory block produced by intrathecal dextrose-free bupivacaine with fentanyl for labor analgesia. anesthesia & analgesia. 1996;83(6):1229-33. pmid: 8942591 3. malinovsky jm, charles f, kick o, lepage jy, malinge m, cozian a, et al. intrathecal anesthesia: ropivacaine versus bupivacaine. anesthesia & analgesia. 2000;91(6):1457-60. pmid: 11094000 4. wille m. intrathecal use of ropivacaine: a review. acta anaesthesiologica belgica. 2004;55(3):251-9. pmid: 15515303 5. chung cj, choi sr, yeo kh, park hs, lee si, chin yj. hyperbaric spinal ropivacaine for cesarean delivery: a comparision to hyperbaric bupivacaine. anesthesia & analgesia. 2001;93(1):157-61. pmid: 11429357 6. khaw ks, ngankee wd, wong m, ng f, lee a. spinal ropivacaine for cesarean delivery: a comparison of hyperbaric and plain solutions. anesthesia & analgesia. 2002;94(3):680-5. pmid: 11867397 7. danelli g, fanelli g, berti m, cornini a, lacava l, nuzzi m, et al. spinal ropivacaine or bupivacaine for cesarean delivery: a prospective, randomized, double-blind comparison. regional anesthesia and pain medicine. 2004;29(3): 221-6. pmid: 15138906 8. kallio h, snall ev, kero mp, rosenberg ph. a comparison of intrathecal plain solution containing ropivacaine 20 or 15mg versus bupivacaine 10mg. anesthesia & analgesia. 2004;99(3):713-7. pmid: 15333400 9. vankleef jw, veering bt, burn ag. spinal anesthesia with ropivacaine: a double-blind study on the efficacy and safety of 0.5% and 0.75% solution in patients undergoing minor lower limb surgery. anesthesia and analgesia. 1994;78(6):1125-30. pmid: 8198269 10. mcdonald sb, liu ss, kopacz dj, stephenson ca. hyperbaric spinal ropivacaine: a comparison bupivacaine in volunteers. anesthesiology. 1999;90(4):971-7. pmid: 10201665 11. lacassie hj, columb mo, lacassie hp, lantadilla ra. the relative motor blocking potencies of epidural bupivacaine and ropivacaine in labor. anesthesia & analgesia. 2002;95(1);204-8. pmid: 12088969 12. copagna g, parpaglioni r, lyons g, columb m, celleno d. minimum analgesic dose of epidural sufentanil for firststage labor analgesia: a comparison between spontaneous and prostaglandin-induced labors in nulliparous women. anesthesiology.2001;94(5): 740-4. pmid: 11388522 13. stocks gm, hallworth sp, fernando r, england aj, columb mo, gordon l. minimum local analgesic dose of intrathecal bupivacaine in labor and the effect of intrathecal fentanyl. anesthesiology. 2001;94(4):593-8. pmid: 11379678. doi: 10.1097/00000542-20010400000011 14. celleno d, parpaglioni r, frigo mg, barbati g. intrathecal levobupivacaine and ropivacaine for cesarean section. new perspectives. 2005;71(9):521-5. pmid: 16166911 15. singh s, singh vp, jain m, gupta k, rastogi b, abrol s. intrathecal 0.75% isobaric ropivacaine versus 0.5% heavy bupivacaine for elective casarean delivery: a randomized controlled trial. journal of pakistan medical student. 2012;2(2):75-80. 16. kasza t, knapik p, misiolek h, knapik d. comparison of spinal anaesthesia with 0.75% ropivacaine and 0.5% bupivacaine for elective caesarean section. annales academiae medicae silesiensis. 2009;63(6):15-22. 17. xiao f, xu wp, zhang yf, liu l, liu x, wang lz. the dose-response of intrathecal ropivacaine co-administerd with sufentanyl for cesarean delivery under combined spinal-epidural anesthesia in patients with scarred uterus. 2015;128(19):2577-82. pmid: 26415793. doi:10.4103/0366-6999.166036 18. geng zy, wang dx and wu xm. minimum effective local anesthetic dose of intrathecal hyperbaric ropivacaine and bupivacaine for cesarean section. chinese medical journal 2011;124(4):509-513. pmid: 21362272 19. gupta a, bogra j, singh pk, kushwaha jk and srivastava p. randomized double-blinded dose response study of the fentanyl with hyperbaric ropivacaine in cesarean section. journal of anesthesia & clinical research. 2014;5(11):467. doi:10.4172/2155-6148.1000467 20. whiteside jb, burke d, wildsmith jaw. comparison of ropivacaine 0.5% (in glucose 5%) with bupivacaine 0.5% (in glucose 8%) for spinal anaesthesia for elective surgery. british journal of anaesthesia. 2003;90(3):304-8. pmid: 12594141. doi: https://doi.org/10.1093/bja/aeg077 21. mcnamee da, mcclelland am, scott s, milligan kr, westman l, gustafsson u. spinal anaesthetic: comparison of plain ropivacaine 5mg/ml with bupivacaine 5mg/ml for major orthopedic surgery. british journal of anaesthesia. 2012;89(5):702-6. doi: 10.1093/bja/aef259 j. lumbini. med. coll. vol 7, no 1, jan-jun 2019 jlmc.edu.np singh j. et al. minimal local analgesic dose of intrathecal bupivacaine and ropivacaine for elective cesarean delivery under spinal anesthesia, 11.6 mg of 0.5% isobaric ropivacaine is an effective and safe alternative to bupivacaine. ropivacaine provided clinically surgical anaesthesia of shorter duration without compromising neonatal outcome. conflict of interest: the authors declare that no competing interests exist. source of funds: no funds were available. lmc journal vol. 2.indd 56 original article l m coll j 2013; 1(2): 56-58 extrapulmonary tuberculosis: a retrospec ve study at a ter ary care hospital in palpa, nepal thakur ck,1 khanal lk,1 jain sk,2 lamichhane b1 and poudel a2 1department of microbiology, 2department of pathology, lumbini medical college and teaching hospital, pravas, tansen, palpa, nepal. corresponding author: chandan kumar thakur. lecturer, department of microbiology, lumbini medical college, tansen, palpa, nepal; e-mail: chandanpgi@gmail.com abstract background: extra-pulmonary tuberculosis (eptb) is a signifi cant global health problem. related studies to it in diff erent places and diff erent dura ons are indicated by many previous research fi ndings. findings of this study could be benefi cial for its preven ve and control strategies. methodology: retrospec ve analysis of clinical specimens submi ed to central laboratory of lumbini medical college and teaching hospital (lmcth) for extrapulmonary tuberculosis was performed. total 261 samples submi ed from april 2011 to february 2013 were included for analysis in this study. results: total 20.7% (54/261) prevalence of eptb was reported. based on sites involved; lymph node 87.03%, pleural eff usion7.40%, peritoneal5.55% were found. genderwise equal prevalence was seen among male and females. age-wise prevalence among pa ents between 21-40 years was reported. conclusion: our fi nding indicates great necessity for further large scale study on prevalence of eptb in this loca on for its preven on and control. keywords: extrapulmonary tuberculosis, nepal, tuberculosis introduction tuberculosis is the most common fatal infec ous disease in the world.1 it ranks as the second leading cause of death from an infec ous disease worldwide, a er the human immunodefi ciency virus (hiv). geographically, the burden of tb is highest in asia and africa.2 around 45% of total popula on of nepal is infected with tb. fourty thousand new cases arising every year, about half of these are infec ous (sputum smear posi ve tb) and 5000-7000 people die each year from tb. however number of deaths in nepal has reduced due to introduc on of directly observed treatment short course (dots).3 tuberculosis affects all age groups. it can virtually involve any organ system although pulmonary tb is the most common presenta on of disease. extrapulmonary tuberculosis (eptb) is defi ned as the occurrence of tb in any part of the body other than lungs. extrapulmonary tb is increasing all over the world. however, only limited data is available about the situa on of eptb in developing countries.4,5,6 this study was conducted to assess the frequency of eptb in various organ systems and to evaluate the role of demographic factors like age groups and gender in its causa on. materials and methods a retrospec ve study was carried out at the central laboratory of lumbini medical college & teaching hospital from april 2011 to february 2013. a total of 261 pa ents a ending hospital over 2 years duration were included in this study. all samples were collected by fine needle aspiration cytology (fnac) & paracentesis. it was stained by wright, papanicolaou (pap) and acid fast stain and examined microscopically. a er screening 261 specimens, 54 were found to be posi ve for extrapulmonary tuberculosis. informa on regarding other parameters like age, sex was retrieved from the records of the medical department. demographic variables were compared between tb of the lymph nodes and tb involving loca on other than lymph nodes. data were analyzed using sta s cal package for social sciences, version 16 (spss). results out of total 261 samples examined, 54 (20.7%) revealed presence eptb (fig.1). eptb was found to be equal among males and females (27/54 vs. 27/54) (table.1). age wise, eptb was found to be highest among young age group of 21-40 years (32.0%), whereas the lowest number of eptb cases was among age groups less than ten years as shown in table.1. findings of the study showed that, the eptb in 47(87.03) case was lymph node, while it affect pleural fluid in 4(7.40%), and peritoneal fl uid 3(5.55%) respec vely (fig.2). discussion despite gradual decline in prevalence of tb globally, many research reports indicate eptb as a signifi cant health problem par cularly in developing countries. 57 ck thakur et al shrestha et. al.2010 have reported declining trend of tb in nepal during 8 years study from 2001-2008.7 our result, 20.7% prevalence of eptb matches with results of above men oned study and which might be related to health knowledge and life style of people living in this loca on. however, this result appears dras cally diff erent (less) than prevalence of eptb compared to fi nding of study in pokhara.8 this again could be due to same reason in diff erent places. extrapulmonary tb can aff ect any body parts and mostly it involves lymph nodes, peritoneum, pleura, bone etc. ra o of involvement of these may vary according to various previous studies in nepal and other countries. our fi ndings report lymph node tb as most common eptb (87.03%), followed by pleural eff usion tb(7.40%) and peritonial tb (5.55%). this is similar to fi ndings of previous studies by diff erent authors.5,9-14 this indicates that lymphoid involvement is most common in eptb cases. our study showed the equal distribu on of eptb without gender diff erence in male and female which is contrary to fi nding of sreeramareddy et.al (2008) but similar to sreeramareddy et.al (2010).8,15 our result correlates with many reports of gender unbiasness of eptb infec on according to other previous research fi ndings.5 we found that eptb most commonly prevalent among adults (21-40 years) compared to low and high age groups which is similar to previous fi nding of piryani et.al(2008) but is contrary to that of sreeramareddy et al (2010).9,15 as we performed retrospec ve analysis, relevant socioepidemiological informa on’s could not be included for analysis. however, this fi nding has indicated the need for designing of large scale study on prevalence of eptb and tb in general in this loca on. further studies on such topics could be milestone for bringing health revolu on in this western-hilly area of nepal. references 1. sadoon a. ibraheem, yaa'rub i. salih, haider saad. extra pulmonary tuberculosis among pa ents a ended the consulta on clinic of respiratory diseases in salahiddin governorate; an epidemiological study. tikrit med j 2011; 17(1): 74-80. 2. who report 2012 global tuberculosis control. [online] available from: url: [http://www.who.int/tb/publications/ global_report/en/index.htm]. table 1: gender-wise and age-wise distribu on of eptb characteris c number (n=54) percent total female male gender 54 27 27 100.0 age(years) 010 0 0 0 0 11-20 9 5 4 16.6 21-30 14 10 4 25.9 31-40 15 8 7 27.7 41-50 5 1 4 9.2 51-60 4 1 3 7.4 61-70 4 1 3 7.4 71-80 3 1 2 5.5 fig.1 prevalence of eptb fig.2 distribu on of eptb on various sites 58 journal of lumbini medical college 3. national tuberculosis centre. government of nepal ministry of health and popula on department of health service-tb burden in nepal [online] available from: url: [www.nepalntp.gov.np] 4. chandir s, hussain h, salahuddin n, amir m, ali f, lo a i et al. extrapulmonary tuberculosis: a retrospec ve review of 194 cases at a ter ary care hospital in karachi, pakistan. j pak med assoc 2010; 60(2): 105-9. 5. makaju r, mohammad a, thakur nk. scenario of extrapulmonary tuberculosis in a ter ary care center. j nepal health res counc 2010; 8(16):48-50. 6. ullah s, shah sh, aziz-ur-rehman, kamal a, begum n, khan g. extrapulmonary tuberculosis in lady reading hospital peshawar, nwfp, pakistan: survey of biopsy results. j ayub med coll abbo abad 2008; 20(2): 43-6. 7. shrestha l, jha kk, malla p. changing tuberculosis trends in nepal. nepal med coll j 2010; 12: 165-70. 8. sreeramareddy ct, panduru kv, verma sc, joshi hs, bates mn. comparison of pulmonary and extrapulmonary tuberculosisin nepal – a hospital based retrospec ve study. bmc infect dis 2008; (doi: 10.1186/14712334 -8-8). 9. piryani rm, kohil sc, shrestha g, rawat t. tuberculosis diagnosed/ managed at ngmc-th : a joint private-public eff ort. kathmandu univ med j 2008; 6: 28-32 10. bam ts, enarson da, hinderaker sg, champan rs. high success rate of tb treatment among bhutanese refugees in nepal. int j tuberc lung dis 2007; 11: 54-8. 11. mar n a, preston c, byanjankar l, bam ts, pande sb, baral sc, newell jn. es mated number of new tb cases in patan, a city of nepal. j health organ manag 2007; 21: 546-53. 12. peto hm, pra rh, harrington ta, lobue pa, armstrong lr. epidemiology of extrapulmonary tuberculosis in the united states, 1993-2006. clin infect dis 2009; 49: 1350-7. 13. sharma sk, mohan a. extrapulmonary tuberculosis. ind j med res 2004; 120: 316-53. 14. sandgren a, hollo v, van der werf mj. extrapulmonary tuberculosis in the european union and european economic area, 2002-2011. eurosurveillance 2013 (march);18(12) 15. sreeramareddy ct, ramakrishnareddy n, shah rk, baniya r, surain pk. clinicoepidemiological profi le and diagnos c procedures of pediatric tb in a ter ary care hospital of western nepal – a case series analysis. bmc pediatric (2010). (doi: 10.1186/1471-2431-10-57). licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 6, no 2, july-dec 2018 ___________________________________________________________________________________ submitted: 05 july, 2018 accepted: 02 december, 2018 published: 30 december, 2018 a assistant professor, college of nursing b lecturer, department of psychiatry c associate professor, department of ent-hns dlumbini medical college and teaching hospital, pravas, palpa corresponding author: bandana pokharel e-mail: anupbandana@gmail.com orcid: https://orcid.org/0000-0002-2320-2786_______________________________________________________ —–————————————————————————————————————————————— abstract: introduction: insomnia is a common problem among old age population. almost half of all old age adults report difficulty in initiating and maintaining sleep. the objective of this study was to assess the prevalence of insomnia, its associated factors and effects in old age adults. methods: this was an observational analytical study where adults above 60 years of age from a ward of a village development committee were included. data were collected for a period of four months. insomnia was measured by athens insomnia scale and structured questionnaires were used to assess the effects of insomnia. descriptive statistics were presented as frequency and percentages. association between variables was assessed with chi-square test or fisher's exact test as appropriate. results: there were a total of 55 participants in the study. insomnia was prevalent in 56.4% (n=31) of the study population. among the studied socio-demographic variables, presence of medical illness was significantly associated with insomnia. insomnia was significantly associated with morning headache, irritability, unhappiness, fatigue, lack of concentration, day time sleepiness, avoiding interaction with people, and need of sedative for sleep. conclusion: majority of the old age adults suffer from insomnia with night awakenings as the most common symptom. insomnia significantly affects various aspects of life at an old age. keywords: insomnia, old age, sleep —————————————————————————————————————————————— original research articlehttps://doi.org/10.22502/jlmc.v6i2.256 bandana pokharela,d bhaskkar sharmab,d anup acharyac,d insomnia, its prevalence, associated factors and effects on old age: a cross-sectional study introduction: insomnia is a common sleep disorder consisting of an inability to fall asleep easily or remain asleep throughout the night, early morning awakening, or sleep that is poor in quality associated with daytime impairment such as fatigue, memory impairment, social or vocational dysfunction, or mood disturbance.[1] sleep disorders and sleeping difficulties are among the most pervasive and poorly addressed problems of ageing and may lead to substantially impaired health, cognitive decline, and reduced quality of life.[2] there were a total of 21,54,410 people above 60 years in nepal according to the census of 2011. the proportion of the senior citizens has increased from five percent in the census of 1952/54 to 6.5% in 2001 and 8.1% in 2011.[3] they are vulnerable to have insomnia because of their age related changes. [4] insomnia has far reaching and often subtle effects on health and quality of life. approximately 30-60% of the general population in the industrial world suffer from insomnia symptoms, of whom 10-20% have chronic insomnia.[5] published literature on this issue from our part of geography is scarce. this study, therefore, aims to identify the prevalence of insomnia, its associated factors and effect in old age adults in a nepalese community. how to cite this article: pokharel b, sharma b, acharya a. insomnia, its prevalence, associated factors and effects on old age: a cross-sectional study. journal of lumbini medical college. 2018;6(2):5 pages. doi: 10.22502/jlmc.v6i2.256. epub: 2018 dec 30. https://orcid.org/0000-0002-2320-2786 pokharel b. et al. insomnia, its prevalence, asoociated factors and effects on old age jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 methods: this was an observational, cross sectional study done over a period of four months from 1st september, 2017 to 30th december, 2017. the study was carried out in ward one of telgha village development committee (vdc) of palpa district, nepal old age adults were taken as people who had crossed 60 years from the age of their birth. insomnia was defined as difficulty initiating or maintaining sleep, or early morning awakening. participants above 60 years of age irrespective of gender and literacy status were included in the study. exclusion criteria were sick individuals who could not communicate during interview or those not available for interview throughout the study period. sample size calculation: there were a total of 60 such people in the ward. so, using slovin's formula for finite population , minimum sample size was calculated as: n= n/(1+ne2) or, n = 60 / (1+60*0.052) or, n = 52.17, ie. minimum sample size was 53. here, n = estimated minimum sample size, n = available population for study, e = margin of error at 5%, alpha error = 0.05. a total of 55 participants were included in the study. research instruments: •part one: a proforma was developed in nepali language to record the sociodemographic data of the participants. its reliability was maintained by pretesting in a non-study area of the vdc in 10% of the sample size. these individuals were not included in the study. •part two: athens insomnia scale was used to measure the prevalence of insomnia.[6] it was converted into nepali language. backward and forward translation was done to check the reliability of questionnaire with the help of english and nepali language experts. it consists of eight items. the first five items cover nighttime symptoms of insomnia while the last three items ask for daytime consequences of disturbed sleep. a score of six or more is diagnosed as insomnia. •part three: self developed questionnaire in nepali language was used to assess effects of insomnia. it was also pre-tested as part one of the instrument. effect of insomnia included morning headache, irritability, perceived unhappiness, fatigue, lack of concentration, day time sleepiness, avoiding interacting with people, and need of sedative to go to sleep. ethical approval was taken from the institutional review committee of lumbini medical college (irc-lmc). written permission for data collection was sought from the concerned authority of telgha vdc. verbal consent was obtained from all the participants before data collection. anonymity and confidentiality were maintained by keeping code number in questionnaire after data collection. information obtained was used only for the research purpose. data were collected from interview with each individual. a person was trained to conduct interview and collect data. at first, interpersonal relationship was maintained by the interviewer and a friendly environment was created. purpose of study was explained to the participants. verbal consent was taken and confidentiality assured. the participants gave answers to the questions verbally which were recorded by the interviewer in the research instruments. the collected information were numbered serially and filed. data were entered, coded, processed, and analyzed using statistical package for social sciences (spss™) software version 16. descriptive statistics were presented as frequency and percentages. inferential statistics (chi-square or fisher's exact test) was applied to show the association between categorical variables. results: there were a total of 55 participants. sociodemographic information of the participants is presented in table 1. according to nepal census 2011,[3] there were 10,89,471 (50.57%) female and 10,64,939 (49.43%) male population older than 60 years of age in western development region giving a f:m ratio of 1.023:1. with this reference, we analyzed the difference in gender in our sample where there were 32 (58.2%) male and 23 (41.8%) female with a f:m ratio of 0.72:1 using chi-square goodness of fit test and found that the difference was not statistically significant (x2=1.69, df=1, p=0.19). pokharel b. et al. insomnia, its prevalence, asoociated factors and effects on old age jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 overall literacy rate in this region during 2011 census was 65.94%.[3] the literacy rate among our sample was 47.3% (n=26, n=55). using chi-square goodness of fit test, we found that the difference was statistically significant (x2=4.28, df=1, p=0.039). thus, our sample population was less literate than the total population in this region in 2011. table 2 presents the clinical characteristics of the study population. hypertension was the most common medical illness observed while mental illness was relatively less frequent, being present in only two participants. insomnia was present in 31 (56.4%) of the participants. relationship between sociodemographic variables and insomnia is presented in table 3. among the variables analyzed, only medical illness was statistically associated with insomnia. effects of insomnia and their relationship with insomnia are presented in table 4. all the variables presented in the table were statistically significantly associated with insomnia. discussion: the study was aimed at assessing the prevalence and effects of insomnia among older age adults and analyzing association between prevalence and effects. we found that insomnia was prevalent in 56.4% of the participants and was significantly associated with effects like morning headache, irritability, unhappiness, fatigue, lack of concentration, day time sleepiness, avoiding interaction with people, and need of sedative for sleep. in our study, insomnia was present in 65.2% of total female population. this finding is similar to the findings of the study done in pashupati old age home in which more than two third (67.9%) of the female population had insomnia.[7] this finding is also similar to the study done by quan et al. in which men were less likely than women to develop table 2. clinical characteristics of the study population (n=55). table 1. sociodemographic characteristics of the study population (n=55) variables frequency percentage age in years 60-64 16 29.1 65-69 15 27.3 70-74 11 20.0 75-79 9 16.3 80-84 4 7.3 gender male 32 58.2 female 23 41.8 marital status married 30 54.6 unmarried 1 1.8 w i d o w / widower 24 43.6 type of family nuclear 21 38.2 joint 33 60.0 extended 1 1.8 literacy status literate 26 47.3 illiterate 29 52.7 variables frequency percentage medical illness hypertension 10 18.2 copd* 9 16.4 mental illness present 2 3.64 absent 53 96.36 physical disability present 8 14.55 absent 47 85.45 use of medicine yes 19 34.55 no 36 65.45 variables insomnia statisticspresent n (%) absent n (%) gender male 16 (50) 16 (50) x2=1.26, df=1, p=0.26female 15 (65.2) 8 (34.8) literacy literate 14 (53.8) 12 (46.2) x2=0.13, df=1, p=0.72 illiterate 17 (58.6) 12 (41.4) medical illness present 15 (78.9) 4 (21.1) x2=6.02, df=1, p=0.014absent 16 (44.4) 20 (55.6) psychiatric illness present 2 (100) 0 (0) p=0.5, fisher's exactabsent 29 (54.7) 24 (45.3) physical disability present 4 (50) 4 (50) p=0.72, fisher's exact absent 27 (57.44) 20 (42.56) financial support present 27 (54) 23 (46) p=0.38, fisher's exact absent 4 (80) 1 (20) daily physical work or exercise yes 29 (54.7) 24 (45.3) p=0.5, fisher's exactno 2 (100) 0 (0) table 3. relationship between socio-demographic and clinical variables and insomnia (n=55) pokharel b. et al. insomnia, its prevalence, asoociated factors and effects on old age jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 insomnia symptoms.[8] the result is consistent with that of the study by allah et al. in egypt where females developed insomnia more commonly than males (61.1% vs. 38.9%).[9] another finding was that 78.9% of the patients with medical illness had insomnia, the most common medical illness being hypertension (18.2%). this finding is similar to a study done in india by panda et al. where hypertension (42.6%) was the most common medical illness among insomniac elders.[10] in this study presence of headache and psychiatric illness were significantly associated with insomnia. this finding is supported by another study in which insomnia was associated with exacerbation of headache symptoms and psychiatric co-morbidities. [11]. presence of irritability, unhappiness and fatigue were significantly associated with insomnia. these findings agree with those of other studies [12,13] in which depression and insomnia were independent risk factors for each other. this might be due to individuals with insomnia who do not recognize their depressive symptoms. preventive education can be initiated by concerned authorities in vdc for reducing the prevalence in vulnerable groups and promoting the mental health of older adults. daytime sleeping, avoidance of interaction with other people and need of sedation were significantly associated with insomnia. katz et al. [14] have also reported similar findings in which limitations in activities of daily living, and use of benzodiazepines is strongly associated with insomnia. conclusion: this study indicates a higher prevalence of insomnia in older adults. the most common sleep problem in older sub-population was night awakenings. similarly males had slightly higher amount of insomnia. majority of insomniac elders experienced effects of insomnia like headache, sadness, feeling of tiredness, irritability and inability to concentrate in work. there was also significant association between prevalence and effect of insomnia in the study population. conflict of interest: the authors declare that no competing interests exist. source of funds: no funds were available. variables insomnia statistics present, n (%) absent, n (%) morning headache present 30 (100) 0 p<0.001 fisher's exactabsent 1 (4) 24 (96) irritability present 28 (93.3) 2 (6.7) x2=36.7, df=1, p<0.001absent 3 (12) 22 (88) unhappiness present 27 (96.4) 1 (3.6) x2=40.4, df=1, p<0.001absent 4 (14.81) 23 (85.19) fatigue present 28 (84.84) 5 (15.15) x2=27.8, df=1, p<0.001absent 3 (13.63) 19 (86.36) lack of concentration present 24 (100) 0 (0) p<0.001 fisher's exact absent 7 (22.58)0 24 (77.41) sleeps at day time yes 26 (83.87) 5 (16.12) x2=23.3, df=1, p<0.001no 5 (20.83) 19 (79.16) avoids interaction with people yes 25 (92.59) 2 (7.40) x2=27.6, df=1, p<0.001no 6 (21.42) 22 (78.57) need of sedative for sleep yes 27 (93.10) 2 (6.89) x2=34.3, df=1, p<0.001no 4 (15.38) 22 (84.61) table 4: effects of insomnia and their relationship with insomnia references: 1. international classification of sleep disorders. diagnostic and coding manual. 2 ed. westchester: american academy of sleep medicine; 2005. p. 137. 2. townsend-roccichelli j, sanford jt, vandewaa e. managing sleep disorders in the elderly. the nurse practitioner. 2010 may 1;35(5):30-7. pmid: 20395765 doi: 10.1097/01.npr.0000371296.98371.7e 3. central bureau of statistics. census info nepal 2011. national planning commission – government of nepal. 2011. available from: http://dataforall.org/dashboard/ nepalcensus/ 4. limbu a. age structure transition and senior citizens in nepal: the impending challenges. alliance for social dialogue policy research fellowship program 2012. 2012. available from: http://asd.org.np/wp-content/ uploads/2015/03/age_structure_transition_and_senior_ citizens_in_nepal0.pdf 5. hellstrom a. insomnia symptoms in elderly persons assessment, associated factors and nonpharmacological nursing interventions. division of nursing, lund university, 2013. 170 p. available from: http://portal.research.lu.se/portal/en/publications/ insomnia-symptoms-in-elderly-persons--assessmentassociated-factors-and-nonpharmacological-nursinginterventions(0ae67ac8-7a48-43d0-bcd1-ee1a9b1e683d)/ export.html#export 6. taylor dj, lichstein kl, durrence hh, reidel bw, bush aj. epidemiology of insomnia, depression, and anxiety. sleep. 2005 nov 1;28(11):1457-64. pmid: 16335332 [publisher full text] 7. shrestha s, roka t, shrestha s, shakya s. prevalence and contributing factors of insomnia among el-derly of pashupati old aged home (briddhashram). mj psyc. 2 (2): 014. citation: shrestha s, roka t, shrestha s and shakya s.(2017). prevalence and contributing factors of insomnia among elderly of pashupati old aged home (briddhashram). mathews journal of psychiatry & mental health. 2017;2(2):014. [publisher full text] 8. quan sf, enright pl, katz r, olson j, bonekat w, young t, newman a. factors associated with incidence and persistence of symptoms of disturbed sleep in an elderly cohort: the cardiovascular health study. the american journal of the medical sciences. 2005 apr 1;329(4):16372. pmid: 15832098 doi: 10.1097/00000441-20050400000001 9. allah esa, abdel-aziz hr and el-seoud ara. in somnia: prevalence, risk factors, and its effect on qual ity of life among elderly in zagazig city, egypt. journal of nursing education and practice. 2014;4(8):52-69. doi: 10.5430/ jnep.v4n8p52 [publisher full text] 10. panda s, taly ab, sinha s, gururaj g, girish n, nagaraja d. sleep-related disorders among a healthy population in south india. neurology india. 2012 jan 1;60(1):6874. pmid: 22406784 doi: 10.4103/0028-3886.93601 [publisher full text] 11. mallon l, broman je, åkerstedt t, hetta j. insomnia in sweden: a population-based survey. sleep disorders. 2014;2014:843126. epub 2014 may 12. pmid: 24955254 doi: 10.1155/2014/843126 [publisher full text] 12. budhiraja r, roth t, hudgel dw, budhiraja p, drake cl. prevalence and polysomnographic correlates of insomnia co-morbid with medical disorders. sleep. 2011jul 1;34(7):859-867. pmid: 21731135 doi: 10.5665/ sleep.1114 [publisher full text] 13. kim j, cho sj, kim wj, yang ki, yun ch, chu mk. insomnia in tension-type headache: a population-based study. the journal of headache and pain. 2017 sep 12;18(1):95. pmid: 21731135 doi: 10.1186/s10194-0170805-3 [publisher full text] 14. katz da, mchorney ca. clinical correlates of insomnia in patients with chronic illness. archives of internal medicine. 1998 may 25;158(10):1099-107. pmid: 9605781 doi: 10.1001/archinte.158.10.1099 [publisher full text] j. lumbini. med. coll. vol 6, no 2, july-dec 2018 jlmc.edu.np pokharel b. et al. insomnia, its prevalence, asoociated factors and effects on old age https://doi.org/10.1097/01.npr.0000371296.98371.7e http://dataforall.org/dashboard/nepalcensus/ http://dataforall.org/dashboard/nepalcensus/ http://asd.org.np/wp-content/uploads/2015/03/age_structure_transition_and_senior_citizens_in_nepal0.pdf http://asd.org.np/wp-content/uploads/2015/03/age_structure_transition_and_senior_citizens_in_nepal0.pdf http://asd.org.np/wp-content/uploads/2015/03/age_structure_transition_and_senior_citizens_in_nepal0.pdf http://portal.research.lu.se/portal/en/publications/insomnia-symptoms-in-elderly-persons--assessment-associated-factors-and-nonpharmacological-nursing-interventions(0ae67ac8-7a48-43d0-bcd1-ee1a9b1e683d)/export.html#export http://portal.research.lu.se/portal/en/publications/insomnia-symptoms-in-elderly-persons--assessment-associated-factors-and-nonpharmacological-nursing-interventions(0ae67ac8-7a48-43d0-bcd1-ee1a9b1e683d)/export.html#export 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https://doi.org/10.1097/00000441-200504000-00001 https://doi.org/10.1097/00000441-200504000-00001 https://dx.doi.org/10.5430/jnep.v4n8p52 https://dx.doi.org/10.5430/jnep.v4n8p52 http://www.sciedu.ca/journal/index.php/jnep/article/view/4434/2864 https://doi.org/10.4103/0028-3886.93601 http://www.neurologyindia.com/article.asp?issn=0028-3886;year=2012;volume=60;issue=1;spage=68;epage=74;aulast=panda https://doi.org/10.1155/2014/843126 http://downloads.hindawi.com/journals/sd/2014/843126.pdf https://doi.org/10.5665/sleep.1114 https://doi.org/10.5665/sleep.1114 https://watermark.silverchair.com/aasm.34.7.859.pdf?token=aqecahi208be49ooan9kkhw_ercy7dm3zl_9cf3qfkac485ysgaaakcwggjdbgkqhkig9w0bbwagggi0miicmaibadccaikgcsqgsib3dqehataebglghkgbzqmeas4weqqmkxuuavkwmbrb8ajfageqgiib-mfxgdnkwy1y1gkvc61zg5b2uiqqin7yqdpnatle6i https://doi.org/10.1186/s10194-017-0805-3 https://doi.org/10.1186/s10194-017-0805-3 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5595708/pdf/10194_2017_article_805.pdf https://dx.doi.org/10.1001/archinte.158.10.1099 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/205708 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/205708 jlmc.edu.np original research article —–————————————————————————————————————————— abstract: objective: to compare the outcome of induction of labour with titrated dose of oxytocin with or without pre induction cervical ripening using prostaglandin e2. methods: this is a prospective study. sixty women with prelabour rupture of membranes (prom) and bishops score of less than six were randomly assigned to either immediate induction with intravenous oxytocin drip or induction with intravenous oxytocin drip preceded by cervical priming with prostaglandin e2 (pge2) gel 0.5mg instilled intracervically. these two groups were compared regarding the mode of delivery, induction to delivery interval and maternal and neonatal morbidities. results: cervical priming with pge2 resulted in lesser number of caesarean section (5 vs. 12) and lower incidence of meconium stained liquor (n=6 vs. n=2). induction to vaginal delivery interval was shorter when cervical priming was done (5.4 hrs vs 7.9 hrs). the maternal morbidity was negligible (<1%) in both the groups. the number of neonates with birth asphyxia (n=2) and the need for their resuscitation (n=2) was more in the oxytocin group but the need of antibiotics for the neonates was more in pge2 group (5% vs. 3%). conclusion: induction of labor with oxytocin, with or without cervical priming with vaginal pge2 gel, are both reasonable options in cases of prom, since they result in statistically non significant rates of maternal and neonatal morbidities and caesarean section. cervical priming with prostaglandin results in higher rate of vaginal delivery and shorter induction to vaginal delivery interval and this is viewed as an advantage to the mother. keywords: induced labor • premature rupture • oxytocin • prostaglandin • cervical ripening —–————————————————————————————————————————— j. lumbini. med. coll. vol 2, no 1, jan june 2014 ___________________________________________________________________________________ a lecturer, department of obstetrics and gynaecology, lumbini medical college teaching hospital, palpa, nepal b professor, department of obstetrics and gynaecology, kathmandu medical college teaching hospital, sinamangal, kathmandu, nepal corresponding author: dr. shreyashi aryal e-mail: shreyashiaryal@gmail.com how to cite this article: aryal s, karki c. induction of labour in prelabour rupture of membranes with or without cervical ripening with prostaglandin e2: a randomized controlled trial. journal of lumbini medical college. 2014;2(1):4-9. doi: 10.22502/jlmc.v2i1.46. ___________________________________________________________________________________ shreyashi aryala, chanda karkib. induction of labour in prelabour rupture of membranes with or without cervical ripening with prostaglandin e2: a randomized controlled trial interval greater than 24 hours between prom and active phase of labour.5 fetal membranes serve as a barrier to ascending infection so once rupture of membranes occur, there is increased risk of infection, both to the mother and the fetus.6 prom is associated with significant maternal risks mainly chorioamnionitis and the postnatal risks include endometritis and pelvic infection.7 intrapartum risk factor relate to obstetric interventions mainly induction, which when done with unfavorable cervix often leads to prolonged labour and higher risk of operative delivery. the main fetal problem is also related to infection along with risk of fetal hypoxia as a consequence of cord compression, cord prolapse and placental abruption.6 the management of prom lies somewhere in between expectant management up to 48 hours or immediate induction of labour. the exact management will have to take into consideration, parental wishes, parity, cervical favorability and signs of chorioamnionitis but the best solution is introduction: rupture of membranes before the onset of labour is termed as prelabour rupture of membranes (prom) and the incidence is reported to be 8% to 10% of all pregnancy.1-3 it is also defined now as rupture of membranes at least one hour prior to the onset of labor.4 prolonged prom is defined as an https://doi.org/10.22502/jlmc.v2i1.46 4 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 aryal s. e. al. induction of labour in prelabour rupture of membranes with or without cervical ripening with prostaglandin e2. delivery. most patients of prom will go into labour spontaneously so that, in the absence of intervention, only about 2-5% remains undelivered after 48 hours.8 induction is done in the remaining cases to prevent various maternal and neonatal complications. this study is done to compare the maternal and neonatal outcome in two different management schemes of induction in cases of prom. methods: this is a hospital based randomized, interventional, prospective study conducted at the department of obstetrics and gynaecology, kathmandu medical college teaching hospital, sinamangal for the time period of one year, november 1st 2011 to october 31st 2012. the study was approved by the ethical committee of the hospital. during this time period, the total number of nulliparous ladies presenting with prom was identified. these nulliparous ladies included primigravidas as well as virtual primigravidas i.e, the patient in her second pregnancy, the first having ended in an abortion. the main inclusion criteria were nulliparous women with singleton, term pregnancy (37-42 weeks of gestation) with cephalic presentation with diagnosed prom. high vaginal swab was taken and sent for culture and sensitivity and all diagnosed cases were given prophylactic antibiotics as per the hospital protocol. the exclusion criteria were bishops score more than or equal to six, previous uterine scar, chorioamnionitis, antepartum hemorrhage, cephalopelvic disproportion, meconium stained amniotic fluid, severe oligohydramnios (afi of 4 centimeters or less), severe pre eclampsia, history of allergy to prostaglandins and those unwilling to participate. after taking informed consent, the identified cases were then allocated randomly to one of the two groups with the help of computer generated random numbers. the two groups were managed as follows. group a: induction of labour was done with intravenous oxytocin in titrating dose infused at the rate of 6.25 miu/min (10 drops/min) and gradually increasing the dose every 30 minutes in case of inadequate contractions, to a maximum dose of 37.5miu/min (60 drops/min). adequate contractions were taken as 3 contractions in 10 minutes each lasting for more than 40 seconds. group b: induction of labour was done with titrating doses of oxytocin following cervical ripening with pge2 gel. cervical ripening was done by 0.5mg pge2 gel (dinoprostone gel) inserted intracervically every six hours upto three doses until the bishops score was six or more. cervix was assessed every six hourly to find out the improvement in bishops score. in the process of cervical assessment when the bishops score was found to be more than or equal to six, induction with oxytocin was immediately started but in this process if before the scheduled time of cervical assessment, adequate uterine contractions were noted, per vaginal examination was done before the scheduled time for cervical assessment. if at this time, bishops score was more than or equal to six, further cervical priming was not done but induction was done with oxytocin after six hours from the last dose of pge2. oxytocin was then infused in the same way as in group a to maintain the adequate contractions. those patients who developed adequate contractions and delivered with cervical priming with pge2 without the use of oxytocin were noted separately. a group of clients who neither showed improvement in bishop’s scoring nor progressed into adequate uterine contractions with three doses of dinoprostone gel were also managed with oxytocin infusion with titration. failed induction was considered if the subject did not go into active phase of labour after twelve hours of induction with oxytocin. according to the hospital protocol, babies with prom for more than 18 hours were admitted for observation in the nicu for presumed sepsis. antibiotics were given to those neonates who were diagnosed to have probable or confirmed sepsis. a neonate suspected clinically to have sepsis, with c-reactive protein positive and at least one of the following rapid diagnostic tests positiveabsolute neutrophil count, thrombocytopenia, toxic granules in the peripheral smear, or a band count of greater than 500/mm3 was said to have probable sepsis. the blood culture was negative. when the blood, urine or cerebrospinal fluid culture yielded an organism, then the neonate was diagnosed as confirmed sepsis and antibiotics were started. the neonates admitted in the neonatal intensive care unit were followed up till discharge. the neonates with presumed sepsis were discharged from nicu if the blood or urine culture and sensitivity reports showed no growth. neonates with other complications were discharged as per the nicu protocols. the reports of high vaginal swab culture and sensitivity were collected from the laboratory and treatment given if required, before discharging the patient. all the clients were followed up daily till one week postpartum. after discharge they were contacted through telephone on the seventh postoperative day. all relevant data for each individual study subjects were collected and recorded in a predesigned data collection sheet. all data were analyzed using 5 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 aryal s. et al. induction of labour in prelabour rupture of membranes with or without cervical ripening with prostaglandin e2. statistical package for social sciences (spss) version 11. pearson’s or fisher exact test, chi square test were used and p value was calculated. p <0.05 was considered to be statistically significant. results: during the study period of one year, there were total 2606 antenatal obstetric admissions in this department. the incidence of prom among all antenatal admissions during this period was 5.7 %. there were 149 cases of prom who were admitted out of which, 89 cases did not meet the inclusion criteria and therefore were excluded from the study. the cases that were excluded were multigravida (36), bishops score <6 (20), cephalopelvic disproportion (11), no evident leaking (8), meconium (4), severe oligohydramnios (4), fetal heart rate abnormalities (2), breech (2), twin (1), severe pregnancy induced hypertension (1). sixty primigravida ladies meeting the inclusion criteria were randomized into each of group a and b. table 1 shows the demographic characteristics of both the groups. table 2 shows prolonged prom. fig. 1 shows the mode of delivery in the two groups and table 3 shows the delivery details of both the groups. when cervical priming was done with prostaglandins, vaginal delivery rate is shown to be higher (80%) and the induction to vaginal delivery interval is also found to be shorter. the total number of vaginal examinations done was also noted since more number of vaginal examinations are related to higher rates of maternal group a group b p age, sd 24.13, 3.93 23.70, 3.08 0.205 parity (n) 0.201 primigravida 27 26 virtually primigravida 3 4 bmi(kg/m2) 27. 03 27.25 0.208 education status illiterate 0 0 primary 3 5 secondary 8 6 higher secondary 12 8 bachelors 6 4 masters 1 7 table 1: demographic distribution the antenatal parameters which are comparable. regarding the duration of gestation, 76% of the clients were between 37 to 40 weeks of gestation and no clients were post term. the interval between prom and delivery is known as the latent period and neonatal morbidities are increased when latent period is more than 18 hours. the results of this study show seven cases (four in group a and three cases in group b) with group a group b p adequate antenatal check up (>4), n (%) 30 (100%) 29 (96.6%) 0.205 gestational age(wks) m,sd 39.35, 1.13 38.89, 1.16 0.201 preinduction bishop score 4.3 4.3 antenatal risk factors young primi (<19yrs) 3 0 rh negative pregnancy 1 1 obstetric cholestasis 1 0 mild pregnancy induced hypertension 1 1 duration of prom (hrs) 1-6 16 10 7-12 4 11 13-18 6 6 >19 4 3 high risk factors for prom noted in the study uti 3 6 anemia (hb < 11gm%) 2 6 low socioeconomic status 7 2 elderly primigravida (age >34yrs) 0 1 smoking 0 0 table 2: distribution of cases according to antenatal parameters 17 (56.7%) 24 (80%) 12 (40%) 5 (16.7%) 1 (3.3%) 1 (3.3%) g r o u p a g r o u p b normal lscs intrumental fig 1: distribution of cases according to the mode of delivery 6 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 aryal s. et al. induction of labour in prelabour rupture of membranes with or without cervical ripening with prostaglandin e2. in both the groups (table 4). one client in group b had wound infection following lower segment caesarean section for fetal distress which required a secondary suturing. the vaginal swab which was sent for culture and sensitivity in an aerobic media showed no growth for all 60 clients. absence of growth could be due to the use of a non selective media used in the laboratory. the neonatal outcome was similar in both the groups in terms of birth weight and sex (table 5). a good apgar score and the need of resuscitation are some of the indicators for a good neonatal outcome. the need of resuscitation besides tactile stimulation was recorded in this study and 3.3% babies needed resuscitation of some form besides tactile stimulation. the need of resuscitation was more in group a. the most common indication for admission was presumed sepsis in both the groups. discussion: prom is one of the common and challenging problems in perinatal medicine and its management has gone through various cycles from inactivity and expectant management to immediate intervention. incidence of prom in the present study variables group a group b p vaginal delivery, n 17 24 0.369 lscs, n 12 5 indication for lscs fetal distress fetal heart rate abnormalities: n(%) 4(33.33) 2 (40) meconium stained liquor: n(%) 3 (25) 0 failed induction 4 (33.33) 0 outlet cpd: n(%) 1 (8.33) 1 (20) instrumental delivery: vacuum delivery, n(%) 1(3.33%) 1(3.33%) forceps delivery, n(%) 0 0 average no. of vaginal examinations (n) 3.4 4.1 induction to delivery time in hrs (m, sd) 7.13, 3.84 7.23, 3.68 0.512 induction to caesarean delivery time in hrs (m,sd) 6.23, 2.74 8.23, 3.51 0.126 induction to vaginal delivery interval in hrs (m, sd) 7.95, 3.53 5.42, 2.83 0.254 meconium stained amniotic fluid (n) 6 2 0.428 table 3: distribution of cases according to delivery details maternal complications group a group b nausea 0 1 vomiting (>2episodes) 1 1 diarrhoea 0 0 fever 0 0 hyperstimulation 0 0 chorioamnionitis 0 0 perineal tear (episiotomy excluded) first degree 2 2 second degree 1 1 third and fourth degree 0 0 postpartum haemorrhage 0 0 puerperal pyrexia 0 0 wound infection (requiring secondary suturing) episiotomy wound 0 0 lscs wound 0 1 hospital stay in days (m,sd) 2.7, 1.4 2.4, 2.2 table 4: distribution of cases according to maternal morbidities and neonatal infection. the number of vaginal examinations was higher in group b as multiple doses of prostaglandins were used in this group. the maternal complications were negligible table 5: distribution according to the neonatal outcome group a group b p apgar score, 1' (m,sd) 6.9, 1.74 7.4, 0.66 0.463 apgar score, 5' (m,sd) 7.9, 1.7 8.4, 0.49 0.521 need of resuscitation (n) bag and mask 1 0 mechanical ventilation 1 0 sex 0.13 male 18 17 female 20 13 birth weight kg (m,sd) 2.93, 0.31 2.94, 0.30 0.177 <2.5kg 1 4 2.5-4kg 29 26 neonatal jaundice (n) 1 0 perinatal death (n) 1 0 admission to neonatal unit (n) 16 12 indication for neonatal admission: presumed sepsis 120 10 birth asphyxia 2 0 congenital anomaly 1 1 jaundice 1 0 rh negative mother 0 1 need of antibiotics (n) 3 5 0.212 7 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 aryal s. et al. induction of labour in prelabour rupture of membranes with or without cervical ripening with prostaglandin e2. is 5.7% among all antenatal admissions which is similar to other studies done within the country,9-11 but is lower than the incidence of 8-10% shown in different studies in the united states.2,3 one of the main objectives of this study was to compare the mode of delivery between the two groups. in these two groups with similar demographic characters, it was observed that the number of vaginal delivery was more in the group where prostaglandin was used. induction following good cervical ripening seems to reduce caesarean section which is also shown by gungorduk et al. where a single dose of sustained release dinoprostone pessary was used before oxytocin infusion and by chaudhury s. et al. where vaginal delivery rate was higher when prostaglandin was used.12,13 in a study by chiong tp. where concurrent prostaglandin pessary and oxytocin was used, the rate of fetal distress was more and thus vaginal delivery rate was only 59.6% which is significantly lower than this study.14 the results of this study show the use of prostaglandins for cervical ripening has reduced the rate of lscs for failed induction, compared to induction without cervical priming which highlights its importance. also, unfavorable bishop score at admission for induction of labour are associated with a two to three fold increased risk of caesarean delivery, whereas a score of six or more is usually associated with a probability of vaginal delivery after labour induction, similar to that after spontaneous labour.15,16 in this study the use of dinoprostone gel for induction of labour, improved the bishop score so chances of successful induction also increased. in the analysis of the presence of meconium stained amniotic fluid after cervical priming, use of prostaglandin reduced the induction to delivery interval and decreased chances of fetal hypoxia. more the latent period in prom, more are the chances of poor maternal and fetal outcome.7 this stresses the importance of cervical priming to shorten the induction to delivery interval in cases of prom. gungorduk et al. and chiong tp. showed a longer induction to delivery interval compared to this study in both the groups.12,14 regarding the maternal morbidities in the two groups, though the induction to delivery interval was short in cases where prostaglandin was used, there was no clear advantage to the mother in terms of intrapartum and postpartum morbidities. various studies have shown the incidence of tachysytole with the use of prostaglandins.12,14 since this study has no cases of uterine hyperstimulation or tachysystole, it is suggestive that pge2 use for cervical priming is a safe option in cases of prom. with no adverse effects and the benefits of ability to be mobile and not attached to an intravenous infusion makes the use of pge2 for cervical ripening in cases of prom more desirable. one of the likely complications of prom is chorioamnionitis. in an evaluative study derived from international multicentre term prelabor rupture of membranes study, incidence of chorioamnionitis was 7% and postpartum fever was 3% whereas in our study, there were no cases of either postpartum fever or chorioamnionitis.17 this difference could be due to the large difference in sample size in the two studies and probably due to early induction and the use of prophylactic antibiotics at the time of diagnosis. the mean induction to delivery interval of seven hours in both the groups suggests that the delivery of the baby was within 24 hours after prom which carries a better prognosis for the neonate. there were fewer admissions to neonatal care ward in the group where prostaglandins was used but there were more number of neonates who required antibiotics in this group. this is probably due to the increased number of vaginal examinations done for prostaglandin insertion and increased chances of sepsis. in a study by hellen ym. et al., two neonates were diagnosed with infection when prostaglandin was used, whereas no cases of infection was seen in the oxytocin group which is similar to this study where more neonates were tested positive on septic screening in group b.18 in this study, all ladies with prom were given oral amoxycillin capsules as per the department protocol whereas in the previous mentioned studies antibiotics given to the subjects is not mentioned so this could be the reason for variation seen in neonatal infection rate but the study by shrestha sr. et al. shows no difference in neonatal infection rate after the mother received iv penicillin.10-12,18 traditionally, oxytocin induction has been recommended for the induction of labour in the management of prom with an unfavorable cervix. the results of this study show that cervical priming which improves bishops score, results in a higher number of vaginal delivery and results in a decreased caesarean section rate especially for the indication 8 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 aryal s. et al. induction of labour in prelabour rupture of membranes with or without cervical ripening with prostaglandin e2. of failed induction. the recommendations from this study with a relatively small sample size may not be sufficient to come to a conclusion for all the parameters measured in this study and further larger trials would be required, probably with a third arm undergoing expectant management. conclusion: in cases of prom, if timely diagnosis and administration of prophylactic antibiotics is done, the results of labour induction with or without cervical priming are comparable. cervical priming with pge2 results in a higher rate of vaginal delivery and shorter induction to vaginal delivery interval. therefore, in terms of mode of delivery, cervical priming is recommended when the cervix is unfavourable. since no drug related complications were observed, cervical priming is a considerable option keeping in mind the lower number of caesarean sections following cervical ripening. in view of neonatal morbidities and nicu admissions, both the options of induction with or without cervical priming seem to be acceptable. we can conclude that induction of labour with intravenous oxytocin, with or without cervical priming with vaginal prostaglandin e2 gel, are both reasonable options for women and their neonates in cases of prom, since they result in similar rates of intrapartum and postpartum maternal morbidities and neonatal morbidities. 1. robinson js. prelabour rupture of membranes. in: james dk, steer pj, weiner cp, gonik b, editors. high risk pregnancy management options, 3rd ed., india: elsevier; 2006.p.1321-28. 2. american college of obstetricians and gynecologists committee on practice bulletins—obstetrics. premature rupture of membranes: clinical management guidelines for obstetrician-gynecologists. acog practice bulletin no. 80. obstet gynecol. 2007;109(4):1007–19. 3. poma pa. premature rupture of membranes. j natl med assoc. 1996 jan;88(1):27-32. 4. sullivan r. prelabour rupture of membranes at term. in: bonnar j, dunlop w, editors. recent advances in obstetrics and gynaecology 23, london: royal society of medicine press; 2005.p. 27-37. 5. kui li, yanping w, haiyan li, huixia y. a study of 579 pregnant women with premature rupture of membranes at term. international journal of gynecology and obstetrics. 2011;112:45–7. 6. d’ souza as. prelabour rupture of membranes. in: arulkumaran s, penna lk, roa kb, editors. the management of labour, 2nd ed., chennai: orient longman; 2005.p.306-18. 7. induction of labour. in: cunningham fg, leveno kj, bloom sl, hauth cj, rouse dj, spong cy, editors. williams obstetrics, 23rd ed., usa: mcgraw hill; 2010.p.500-9. 8. prelabour rupture of membranes. in: majhi ak, editor. bedside clinics in obstetrics, kokatta: academic publishers; 2011.p.6.2.1-2.2. 9. gautam j. fetal outcome of premature rupture of membranes [thesis]. kathmandu: t.u.; 1997. 10. shrestha sr, sharma p. fetal outcome of pre-labor rupture of membranes. n. j. obstet. gynaecol. 2006 nov-dec;1(2):19-24. 11. reproductive health clinical protocol for medical officers. family health division, dept. of health services, ministry of health and population. government of nepal. 2007, 5256 12. gungorduk k, asicioglu o, besimoglu b, gungorduk oc, yildirm g, ark c, et al. labor induction in term premature rupture of membranes: comparison between oxytocin and dinoprostone followed 6 hours later by oxytocin. am j obstet gynecol. 2012 jan;206(1):60-68. 13. chaudhuri s, mitra sn, biswas pk. premature rupture of membranes at term: immediate induction with pge2 gel compared with delayed induction with oxytocin. j obstet gynecol india. 2006 may/jun;56(3):224-29. 14. chiong tp. concurrent dinoprostone and oxytocin for labor induction in term premature rupture of membranes. obstet gynaecol. 2009;113(5):1059-65. 15. qualls cr, rappaport vj, rayburn wf. randomized trial of concurrent oxytocin with a sustainedrelease dinoprostone vaginal insert for labor induction at term. am j obstet gynecol. 2002;186:61-5. 16. tan pc, valiapan sd, tay py, omar sz. concurrent oxytocin with dinoprostone pessary versus dinoprostone pessary in labor induction of nulliparas with an unfavorable cervix: a randomized placebo-controlled trial. bjog. 2007;114:824-32. 17. seaward pg, hannah me, myhr tl, farine d, ohlsson a, wang ee, et al. international multicenter term prom study: evaluation of predictors of neonatal infection in infants born to patients with premature rupture of membranes at term. am j obstet gynecol.1998;179(3):635-9. 18. helen ym, andrew cb, o'brien s. a comparison of oral prostaglandin e2 tablets with intravenous oxytocin for stimulation of labor after premature rupture of membranes at term. acta obstetricia et gynecologica scandinavica. 1988;67(8):703-9. references: 9 jlmc.edu.np original research article —–————————————————————————————————————————— abstract: introduction: biological, psychosocial, cognitive, emotional and social changes begin during puberty and continue throughout adolescence. the age at which a female reaches sexual maturity is critical in determining her future reproductive health and success. the aim of the study was to assess the average age of sexual feeling and menarche among the adolescent girls and its determinants. methods: three hundred fifty five respondents were selected through simple random sampling from three secondary schools (namely sunrise boarding school, swaraswati secondary school and gyanjyoti samudayak bidhyalaya) in palpa for the cross-sectional study. structured interview schedule was used to collect information. data was tabulated in microsoft excel spreadsheet and analyzed with spss-16. results: most of the girls (44.8%) attained menarche at 12 years (m = 12.4, sd = 1.11). age at menarche was more likely before 13 years of age when the age of onset of sexual feeling was earlier than 12 years of age, in students than in domestic workers and if they are living with parents than in those not living with parents. conclusion: the average age of menarche among the adolescent girls was 12.40 years and it could be influenced by age of sexual feeling, occupation and living status of girls. keywords: adolescent • menarche • puberty —–————————————————————————————————————————— j. lumbini. med. coll. vol 2, no 1, jan june 2014 ___________________________________________________________________________________ a lecturer b school of social science, jaipur national university, jaipur, india c assistant professor d department of community medicine, lumbini medical college, palpa, nepal. corresponding author: mrs. moushami ghimire e-mail: bulbul2feb@yahoo.co.in how to cite this article: ghimire m, sharma a, ghimire m. menarche and its determinants in adolescent girls. journal of lumbini medical college. 2014;2(1):10-3. doi: 10.22502/jlmc.v2i1.47. ___________________________________________________________________________________ moushami ghimirea,d, achala sharmab, madhusudhan ghimirec,d menarche and its determinants in adolescent girls adult mental processes and adult identity, transition from total socioeconomic dependence to relative independence.1 in girls, menarche starts during this period and girls feel shy to discuss the topic openly. a number of factors related to economic and social disadvantage put youth at risk of engaging in unprotected sex and becoming pregnant or acquiring an sexually transmitted disease (std).2 menarche is the first menstrual period generally occurring in early stages of adolescent girls. it is a part of the maturation process and an important milestone of puberty for most women in adolescent girls. menarche age is an important indicator of reproductive health of a woman or a community. the first scientific record on age at menarche was 158 years ago.3 strong evidence exists of a downward secular trend in the age at menarche; which appears to be associated with improved health and nutritional conditions. the mean age at menarche varies from population to population and is known to be a sensitive indicator of various characteristics of the population including nutritional status, geographical location, environmental conditions and socio-economic status.4-6 over time, the age at introduction: the term adolescence means “to emerge” or “achieve identity” which is a relatively new concept, especially in developmental thinking. who defines adolescence both in terms of age (spanning the ages between 10 and 19 years) and in terms of a phase of life marked by special attributes which include rapid physical growth and development, physical, social and psychological maturity, but not all at the same time, sexual maturity and the onset of sexual activity, experimentation, development of https://doi.org/10.22502/jlmc.v2i1.47 10 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 ghimire m. et al. menarche and its determinants in adolescent girls. menarche has been found to show a steady decline of about two to three months per decade in developed countries,7 and about six months per decade in developing countries.8 menstrual hygiene is a vital aspect of women’s health. in many developing countries, a culture of silence surrounds the topic of menstruation and related issues; as a result many young girls lack appropriate and sufficient information regarding menstrual hygiene. this may result in incorrect and unhealthy behaviour during their menstrual period. there is paucity of literature regarding menarcheal age and the factors influencing it among adolescent girls of nepal and this has been a less discussed topic. this study aims to find the variation of age at menarche in nepalese adolescent girls and also evaluate the major factors affecting it through which reproductive health issues of women can be well addressed. methods: in this cross-sectional study, a total of 355 adolescent girls from three secondary schools (sunrise boarding school, swaraswati secondary school and gyanjyoti samudayak bidhalaya) in palpa district of nepal were enrolled. simple random sampling method was used for sample collection. a pretest procedure was applied in order to verify the reliability and validity of research tools. after getting informed consent from the respondents, data was collected through face-to-face structured interview schedule during the months of april to june 2014. all data was analyzed by spss 16. results: table 1 shows the socio-demographic profiles of adolescent girls (n=355). table 2 shows the age distribution of adolescent girls, their sexual feeling and menarche. table 3 shows age of menarche and its associated factors among the adolescent girls. it shows that the age at menarche was more likely before 13 years of age when the age of onset of sexual feeling was earlier than 12 years of age, in students than in domestic workers and if they are living with parents than in those not living with parents. discussion: menarche and associated factors were assessed among the adolescent girls from three secondary schools in palpa district of nepal. this study found that majority of the respondents experienced menarche at age of 12 years (m= 12.40, sd= 1.11). studies from different parts of india observed the variation of mean age of menarche as maharashtra (12.99 years),9 kolkata table 2: age distribution of adolescent girls, their sexual feeling and menarche (n=355). variables n % education primary 10 2.8 secondary 345 97.2 family type nuclear 249 70.1 joint 106 29.9 occupation student 337 94.9 domestic worker 18 5.1 living with parent no 8 2.3 yes 347 97.7 table 1: socio-demographic profiles of adolescent girls (n=355) variables n % m, sd age (years) 11-13 149 42.00 13.89, 1.3914-16 195 54.90 ≥17 11 3.10 age at onset of sexual feeling <12 yrs 217 61.1 12.33, 0.94≥12 yrs 138 38.9 age at menarche (years) 11 33 9.3 12.40, 1.11 12 159 44.8 13 133 37.5 14 28 7.5 15 2 0.6 variables age of menarche (in years) relation < 13 ≥13 age at onset of sexual feeling <12 yrs 164 53 x2=1.012 p <0.001 ≥12 yrs 29 109 occupation student 191 146 x2=14.300 p<0.001 **expected frequency=8 domestic worker* 2 ** 16 living with parent yes 193 154 p=0.002 fisher exactno 0 8 * domestic worker = student working in other house. table 3: age at menarche and its relation with other factors (n=355) 11 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 ghimire m. et al. menarche and its determinants in adolescent girls. (12.3 years),10 chandigarh (13.2 years)11 and delhi (13.34 years),12 which is comparable to this study. similar cross-sectional studies carried out in 1989, 2000 and 2008 in a rural gambian community of west africa revealed a median menarcheal age of 16.06 (95% ci; 15.67–16.45), 15.03 (95% ci; 14.76–15.30) and 14.90 (95% ci; 14.52–15.28) respectively.13 in nepal, median age at menarche among the tibetan speaking population living at 3250–3560 m in upper chumik was 16.2 years in 1983.14 average age at menarche in different studies in different time in nepal was found to be 12 years among the rural adolescent girls in 2007,15 12.5 years in sunsari district in 2013,16 12.94 years in five government schools of kailali district in 2014.17 our study showed that the mean age at menarche among adolescent girls was 12.4 (sd = 1.11). a study on basic level school girls in madina and accra reported that the mean age at menarche was 12.74 (sd = 1.15) years; a median age of 12.09 while most girls (90%) had first menstruation before age 13 years which is comparable to that in the present study.18 our study reported that menarcheal age was strongly associated (p < 0.001) with age at onset of sexual feeling of the girls, occupation and living status (living with parents or not). the downward trend in age at menarche to an average of 12–13 years in most developing countries has been well established as surveys show that urban, educated, middle-class girls in many countries are now starting their periods on average at 12.5 years or earlier, the same age as (or even younger than) their european and north american counterparts.19-23 there is overwhelming evidence of the declining age at which menarche occurs.24-26 the role of enhanced living situation, measured as improved access to health care, optimal nourishment and appreciating socio-economic status on the onset of menarche has been reported in both developed and developing countries.4-6 conclusion: this cross-sectional study concluded that the age at menarche was more likely before 13 years of age when the age of onset of sexual feeling was earlier than 12 years of age, in students than in domestic workers and if they are living with parents than in those not living with parents. references: 1. world health organization (searo): adolescence the critical phase, the challenges and the potential. new delhi: world health organisation;1997.34p. 2. kirby d, emerging answers: research findings on programs to reduce teen pregnancy (summary). washington, dc: national campaign to prevent teen pregnancy; 1997.p.31. 3. ong kk, ahmed ml, dunger db. lvesson from large population studies on timing and tempo of puberty (secular trend and relation to body size): the european trend. mol cell endocrinol. 2006; 254–5:8–12. 4. chumlea wc, schubert cm, roche af, kulin he, lee pa, himes jh et al. age at menarche and racial comparisons in us girls. pediatrics. 2003;111(1):110–13. 5. swenson i, havens b. menarche and menstruation: a review of the literature. j community health nurs. 1987;4(4):199–210. 6. thomas f, renard f, benefice e, de meeüs t, guegan jf. international variability of ages at menarche and menopause: patterns and main determinants. hum biol.2001;73(2):271–90. 7. wyshak g, frisch re. evidence for a secular trend in age of menarche. n engl j med. 1982; 306:1033–5. 8. bagga a, kulkarni s. age at menarche and secular trend in maharashtrian (indian) girls. acta biologica szeged. 2000;44(1-4):53–7. 9. deo ds, gattarji ch. age at menarche and associated factors. indian journal of pediatrics. 2004;71(6):565-6. 10. banerjee i, chakraborty s, bhattacharya ng, bandopadhyay s, saiyed hn, mukherjee d. a cohort study of correlation between body mass index and age at menarche in healthy bengali girls. journal of the indian medical association. 2007;105(2):75-8. 11. sharma k, talwar i, sharma n. age at menarche in relation to adult body size and physique. ann hum biol. 1988 nov-dec;15(6):431-4. 12. acharya a, reddaiah p, baridalynel. nutritional status and menarche in adolescent girls in urban resettlement colony of south delhi. american j of epidemiology. 1990;132(5):953-61. 13. prentice s, fulford aj, jarjou lma, prentice a. evidence for a downward secular trend in age of menarche in a rural gambian population. ann hum biol. 2010 sepoct;37(5):717–21. 12 jlmc.edu.npj. lumbini. med. coll. vol 1, issue 2, july-dec 2013 ghimire m. et al. menarche and its determinants in adolescent girls. 14. beall cm. ages at menopause and menarche in a high-altitude himalayan population. ann hum biol. 1983;10(4):365-70. 15. adhikari p, kadel b, dhungel sl, mandal a. knowledge and practice regarding menstrual hygiene in rural adolescent girls of nepal. kathmandu univ med j. 2007;5(3):382-6. 16. sapkota d, sharma d, budhathoki ss, khanal vk, pokharel hp. knowledge and practices regarding menstruation among school going adolescents of rural nepal. journal of kathmandu medical college. 2013;(3):122-8. 17. hamal m, kc susma. hygiene, health problems and socio-cultural practices: what school girls do during menstruation? ijhsr. 2014;4(4): 28-33. 18. aryeetey r, ashinyo a, adjuik m. age of menarche among basic level school girls in medina, accra. afr j reprod health. 2011;15(3):113-21. 19. morabia a, costanza mc. international variability in ages at menarche, first livebirth and menopause. world health organisation collaborative study of neoplasia and steroid contraceptives. am j epidemiol. 1998 dec;148(12):1195205. 20. parent as, teilmann g, juul a, skakkebaek ne, toppari j, bourguignon jp. the timing of normal puberty and the age limits of sexual precocity: variations around the world, secular trends, and changes after migration. endocr rev. 2003 oct;24(5):668–93. 21. patton gc, viner r. pubertal transitions in health. lancet. 2007 mar;369(9567):1130–9. 22. lloyd cb (ed.) (panel on transitions to adulthood in developing countries; committee on population; board on children; youth and families; division of behavioral and social sciences and education; institute of medicine; national research council). growing up global: the changing transitions to adulthood in developing countries. washington dc: the national academy press; washington dc;2005. 16p. 23. adali t, koç i. menarcheal age in turkey: secular trend and socio-demographic correlates. ann hum biol. 2011;38(3):345-53. 24. kaplowitz p: pubertal development in girls: secular trends. curr opin obstet gynecol. 2006; 18(5):487-91. 25. herman-giddens me, the decline in the age of menarche in the united states: should we be concerned? j adolesc health. 2007 mar;40(3):201-3. 26. abioye-kuteyi ea, ojofeitimi eo, aina oi, kio f, aluko y, mosuro o. the influence of socioeconomic and nutritional status on menarche in nigerian school girls. nutrition and health. 1997 jan;11(3):185-95. 13 research shows that the healthcare needs of individuals living in rural areas are different from those in urban areas, and rural areas often suffer from a lack of access to healthcare. these differences are the result of geographic, demographic, socioeconomic, workplace, and personal health factors. health care facilities, hygiene, nutrition and sanitation in nepal are of poor quality, particularly in the rural areas. despite that, it is still beyond the means of most nepalese. provision of health care services are constrained by inadequate government funding. the poor and excluded have limited access to basic health care due to its high costs and low availability. the demand for health services is further lowered by the lack of health education. reproductive health care is neglected, putting women at a disadvantage. in its 2009 human development report, un highlighted a growing social problem in nepal. individuals who lack a citizenship are marginalized and are denied access to government welfare benefits.1 traditional beliefs have also been shown to play a significant role in the spread of disease in nepal.1,2 these problems have led many governmental and nongovernmental organizations (ngos) to implement communication programs encouraging people to engage in healthy behaviour such as family planning, contraceptive use, and spousal communication, safe motherhood practices, and use of skilled birth attendants during delivery and practice of immediate breastfeeding.3 much of rural nepal is located on hilly or mountainous regions. the rugged terrain and the lack of proper infrastructure makes it highly inaccessible, limiting the availability of basic health care.4 in many villages, the only mode of transportation is by foot. this results in a delay of treatment, which can be detrimental to patients in need of immediate medical attention.5 most of nepal’s health care facilities are concentrated in urban areas. rural health facilities often lack adequate funding.6 in 2003, nepal had ten health centres, 83 hospitals, 700 health posts, and 3,158 “sub-health posts”, which serve villages. in addition, there were 1,259 physicians, one for every 18,400 persons.7 on the other hand, the last two decades have seen a tremendous boom of medical colleges in nepal. before 1993, institute of medicine, maharajgunj was the sole national institution for medical education for almost 15 years. in the year 1993, bp koirala institute of health sciences, dharan was established and this was soon followed by a rapid increase in the number of affiliated medical colleges of kathmandu university and also tribhuwan university later. meanwhile, kathmandu university also started its own medical college, kathmandu university medical school (kums) in 2001 and patan academy of health sciences was established in 2008.8 under kathmandu university affiliation some colleges like lumbini medical college, nepalgunj medical college, dhulikhel hospital as university hospital and community hospital are serving community in remote areas at their own strength as secondary and tertiary care centre in related fields. lumbini medical college per se is giving most of the services which are available in capital. the college being in such a place it has become an example that people need and will utilize good health care services in every corner of the country and health care can be given with good outcome in any corner if we have strong desire to work and serve. ironically, there are currently 19 medical colleges running their services indifferent areas of nepal. and 8 more proposals in pipe line. the government has very minimum interaction with these projects which are run by the private sectors. in spite of having very good infrastructure with regard to district hospital and above, government is not able to propagate the service of secondary care centre, in these hospitals properly. these centre in partnership with medical colleges can be centres to train the postgraduate students in different fields. there need to be a good collaboration with the education ministry, health ministry, the medical council and the planning commission. to conclude, if we work it out once again and put all these sectors and issues in the health and eduheath system infrastructure of nepal and role of medical colleges in rural medicine: is there need for collaboration? nabin pokharel associate professor and academic coordinator, lumbini medical college and teaching hospital, email: nabindai@yahoo.com editorial cation system infrastructure of the country we can do a lot. the health indicators of nepal in present context is as follows. parameters overall urban areas rural areas children under 5 years stunned 51% 37% 52% wasted 10% 8% 10% underweight 48% 33% 49% 2. beine, david. 2003. ensnared by aids: cultural contexts -of hiv/aids in nepal. kathmandu, nepal: mandala book point. 3. karki, yagya b.; agrawal, gajanand (may 2008). “effects of communication campaigns on the health behavior of women of reproductive age in nepal, further analysis of the 2006 nepal demographic and health survey”. 4. international fund for agricultural development (ifad) retrieved 20 september 2011. 5. united methodist committee on relief; retrieved on 20 september 2011. 6. shiba kumar rai, kazuko hirai, ayako abe,yoshimi ohno 2002 “infectious diseases and malnutrition status in nepal: an overview”. 7. nepal health profile world health organisation data (2010). 8. dixit h. nepal’s quest for health. educational publications, 2005. 9. unicef nepal statistics. 10. health organisation data from the global health observatory. 11. health profile world health organisation data (2010). health lndicators9,10,11 population growth 1.28 life expectancy 67 infant mortality 39 fertility 2.64 total expenditure on health per capita (intl $, 2009) 69 total expenditure on health as % of gdp (2009) 5.8 l m coll j 2013; 1(2) references 1. beine, david. 2001. “saano dumre revisited: changing models of illness in a village of central nepal.” contributions to nepalese studies 28(2): 155-185. j. lumbini. med. coll. vol 7, no 1, jan-june 2019 koju b. et al. cardio-respiratory fitness in medical students by queen’s college step test: a cross-sectional study licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ a lecturer, department of physiology b lecturer, department of anatomy c lumbini medical college and teaching hospital, palpa, nepal. d kathmandu university school of medical sciences, dhulikhel, nepal. co rresponding author: bibek koju e-mail: believebibek@gmail.com orcid: https://orcid.org/0000-0002-5882-2707 _______________________________________________________ —–————————————————————————————————————————————— abstract: introduction: cardio-respiratory fitness indicates the ability of circulatory system to supply oxygen to working muscles during continuous physical activity. maximum oxygen uptake (vo2max) is a single best measure of cardio-respiratory fitness and is considered gold standard to quantify aerobic capacity. methods: eighty students of age group 18-25 years were taken by simple random sampling. vo2max was estimated indirectly by following the protocol of queen’s college step test (qcst) method. results: mean value of vo2max for male (51.61±6.26 ml/kg/min) and female (36.02±3.71 ml/kg/min) was compared, which was found significantly higher in males than in females (p<0.001). there was negative correlation of gender (r = -0.838), body mass index (bmi) (r = -0.339), obesity category (r = -0.275), obese vs non-obese (r = -0.264) and basal pulse rate (r = -0.456) with vo2max and positive correlation of height (r = 0.592) and hours of study(r = 0.309) with vo2max. conclusion: this study showed that increased bmi is associated with decreased level of vo2max in young adults. one can improve vo2max by maintaining bmi within normal limits. keywords: aerobic capacity, circulatory system, fitness, oxygen, physical activity bibek kojua,c shaligram chaudharya,c lok raj joshia,c anupama shresthab,d cardio-respiratory fitness in medical students by queen’s college step test: a cross-sectional study how to cite this article: koju b, chaudhary s, joshi lr, shrestha a. cardio-respiratory fitness in medical students by queen’s college step test: an analytical cross-sectional study. journal of lumbini medical college. 2019;7(1):5 pages. doi: doi.org/10.22502/jlmc.v7i1.268 epub: 2019 june 28. introduction: cardio-respiratory fitness indicates the ability of circulatory system to supply oxygen to working muscles during continuous physical activity.[1] inadequate physical activity is responsible for about one third of deaths due to coronary heart disease, diabetes and colon cancer. rising level of obesity is also contributing to these diseases.[2] maximal oxygen consumption (vo2max) is the maximum amount of oxygen an individual can breathe in and utilize it to produce energy ie, atp aerobically.[3] the direct measurement of vo2max requires an extensive laboratory, specialized equipments and considerable physical effort and motivation. these considerations increase the importance of sub maximal exercise test to predict vo2max from performance during walking or running or from heart rate during or immediately after exercise.[4] to generalize, heart rate to predict vo2max is simple and valid.[5] exercise tests represent an important clinical tool to evaluate cardio respiratory fitness and to predict future adverse cardiovascular events.[6] the linear relationship of heart rate and https://doi.org/10.22502/jlmc.v7i1.268 original research article submitted: 31 october, 2018 accepted: 24 june, 2019 published: 28 june, 2019 j. lumbini. med. coll. vol 7, no 1, jan-june 2019 koju b. et al. cardio-respiratory fitness in medical students by queen’s college step test: a cross-sectional study jlmc.edu.np vo2max has been successfully employed in a number of fitness tests.[7,8,9] medical students are future physicians and a good physician must be physically fit and mentally alert.[10] they exercise less frequently and are subjected to different kinds of stress mainly due to heavy academic work load. it is important to measure and analyze their physical fitness for their own benefit and improvement to maintain healthy lifestyle. the present study is aimed to assess and compare the effect of various physical and academic parameters on cardio-respiratory fitness in terms of maximum aerobic capacity (vo2max) in adult males and females. methods: this was an analytical cross-sectional study conducted in the department of physiology, lumbini medical college (lmc), pravas, tansen, palpa. the study was carried out from september 2018 to december 2018. it included apparently healthy males and females between age group of 18-25 years willing to participate voluntarily. participants having any acute or chronic illness, cardiovascular disease, respiratory disease and joint disease were not included in the study. ethical clearance was obtained from institutional review committee of the institute (irc-lmc 12-h/018) prior to data collection. the sample size was calculated using the formula n=2(zα+z1-β) 2σ2/δ2. based on the study by nabi t et al.[10] standard deviation σ = 8.96, estimated effect size δ=7.81 zα=1.96 (at 5% level of significance) z1-β= 0.8416 (at power of 80%). simple random sampling was used to collect data and there was attrition of 25%. as sample size of 30 was desirable, final sample size was 40 participants in each group. eighty participants, who fulfilled eligibility criteria, were recruited for the study after obtaining their consent. prior explanation about the aim and purpose of the study, test procedure, method of testing and instructions on how to perform test were given. all participants were tested under similar laboratory conditions in comfortable environment. they were instructed not to indulge in any activities before the test and not to have heavy meals/tea/ coffee at least two hours prior. detailed history was taken and clinical examination was done to rule out cardio-respiratory and musculoskeletal illnesses. the anthropometric data including age, height, weight was noted and body mass index [bmi] was calculated as body weight in kilograms divided by square of height in meter, using quetelet index.[11] normal weight was defined as bmi 18.5 to 22.9 kg/m2, underweight as bmi < 18.5 kg/m2, over weight as bmi 23 to 24.9 kg/m2, obese as bmi 25 to 29.9 kg/m2 and morbidly obese as bmi ≥ 30 kg/m2.[12] participants were asked to rest at least for five minutes before commencement of test and all basal parameters like pulse rate and blood pressure were measured. vo2max was estimated indirectly by following the protocol of queen’s college step test (qcst) method. individuals stepped to a four-step cadence (“up-up-down-down”) using a tool of 16.25 inches height (height of standard gymnasium bleachers). stepping was done for a total duration of three minutes at the rate of 24 steps up per minute set by a metronome at a setting of 96 beats per minute for males and 22 steps up per minute set by a metronome at a setting of 88 beats for females. stepping was started after a brief demonstration and practice period. after completion of stepping, radial pulse was measured for 15 seconds (5-20 seconds into recovery period). the 15 seconds pulse rate was converted into beats per minute (pr x 4) and following equation was used to predict vo2max.[13] for males: vo2max = 111.33 – [0.42 × pulse rate (beats/min)] [ml/kg/min] for females: vo2max= 65.81– [0.1847 × pulse rate (beats/min)] [ml/kg/min] the data was collected, compiled and analyzed using statistical package for social sciences (spsstm) software 16.0. analysis was done using descriptive statistics like frequency, percentage, mean and standard deviation, and inferential statistics like student’s t-test and pearson correlation analysis. p value < 0.05 was considered significant. results there were 80 participants in the study of which 40 were males and 40 females. the mean age of the participants was 19.49±1.62 years. there alok typewritten text : j. lumbini. med. coll. vol 7, no 1, jan-june 2019 koju b. et al. cardio-respiratory fitness in medical students by queen’s college step test: a cross-sectional study table 1. mean values of study parameters. parameters mean±sd (male, n=40) mean±sd (female, n=40) mean±sd (n=80) p value age (years) 19.35±1.85 19.63±1.35 19.49±1.62 0.450 height (m) 1.69±0.06 1.57±0.06 1.63±0.08 <0.001 weight (kg) 61.42±7.85 58.22±12.63 59.82±10.57 0.178 bmi (kg/m2) 21.38±2.44 23.44±4.42 22.41±3.69 0.012 basal pulse rate (beats/min) 77.55±8.45 86.00±9.45 81.78±9.87 <0.001 basal systolic bp (mm hg) 118.50±9.20 111.95±9.80 115.23±10.01 0.003 basal diastolic bp (mm hg) 72.55±7.40 70.50±9.41 71.53±8.47 0.282 basal pulse pressure (mm hg) 45.95±9.16 41.45±7.62 43.70±8.67 0.019 basal mean arterial pressure (mm hg) 87.87±6.79 84.32±8.84 86.09±8.03 0.047 hours of study per day 3.48±1.47 2.70±1.14 3.09±1.36 0.012 academic percentage (%) 77.35±4.46 76.36±5.30 76.86±4.89 0.371 sleeping hours per day 7.15±1.12 6.60±1.23 6.88±1.20 0.040 was no significant difference in the age (p=0.450), weight (p=0.178), basal diastolic blood pressure (p=0.282) and academic percentage (p=0.371) of male and female students. statistically significant difference was found in height (p<0.001), bmi (p=0.012), basal pulse rate (p<0.001), basal systolic blood pressure (sbp) (p=0.003), basal pulse pressure (pp) (p=0.019), basal mean arterial pressure (map) (p=0.047), hours of study per day (p=0.010) and hours of sleep per day (p=0.040) among male and table 2. body mass index (bmi) of the participants (n=80). bmi female male total underweight (< 18.5 kg/m2) 3 4 7 normal (18.5 to 22.9 kg/m2) 18 24 42 overweight (23 to 24.9 kg/m2) 8 8 16 obese (25 to 29.9 kg/m2) 6 4 10 morbidly obese (≥ 30 kg/m2) 5 0 5 total 40 40 80 female participants (table 1). majority of males and females were in “normal” category according to bmi (table 2). mean values of vo2max for males (51.61±6.26 ml/kg/min) and females (36.02±3.71 ml/kg/min) were compared, which was found significantly higher in males than in females (p <0.001). when the study participants were categorized as per the fitness scale it was observed that more males fell under good and excellent category whereas more females were in average and good category (table 3). result of the study showed negative correlation of bmi (r = -0.339), obesity category (r = -0.275), obese vs non-obese (r = -0.264) and basal pulse rate (r = -0.456) with vo2max and positive correlation of height (r = 0.592) and hours of study (r = 0.309) with vo2max. no correlation was found between weight and vo2max, basal blood pressure and vo2max, academic percentage and vo2max and hours of sleep and vo2max. (table 4) discussion: the purpose of our study was to assess and compare the effect of various physical and academic parameters on cardio-respiratory fitness in terms of maximum aerobic capacity (vo2max) in adult males and females. the present study showed that the mean value of vo2max for males was significantly higher than for females (p < 0.001) which is similar to other studies.[10,14,15,16] according to the standard vo2max classification, among 40 male students, three students (7.5%) fell in average group, 25 students (62.5%) fell in good group and 12 students (62.5%) fell in excellent group. among 40 female students, three students (7.5%) fell in fair group, 27 students jlmc.edu.np j. lumbini. med. coll. vol 7, no 1, jan-june 2019 koju b. et al. cardio-respiratory fitness in medical students by queen’s college step test: a cross-sectional study table 4. relationship of different parameters with vo2max. parameters pearson’s correlation with vo2max p value gender -0.838** <0.001 height 0.592** <0.001 weight 0.027 0.815 bmi -0.339** 0.002 obesity category -0.275* 0.013 obese vs non-obese -0.264* 0.018 basal pulse rate -0.456** <0.001 basal sbp 0.193 0.086 basal dbp 0.020 0.859 basal pp 0.203 0.071 basal map 0.094 0.406 academic percentage 0.032 0.776 hours of sleep 0.125 0.270 hours of study 0.309** 0.005 **strong correlation, *weak correlation (67.5%) fell in average group and 10 students (25%) fell in good group. most of the male students fell under good group while most of the female students fell under average group. similar study done by rymbui db et al. showed those students doing regular exercise fall in and above “good” category and those who do not exercise fall in and below the “fair” category.[17] majority of male and female participants were in “normal” category according to bmi. aerobic capacity of male students was significantly higher compared to that of female. this has been confirmed by correlations between considered variables in male and female participants disregarding their physical activity levels. the reason for reduced vo2max in female subjects participated in our study may be due to sedentary lifestyle, decreased physical activity, unhealthy lifestyle behaviors, etc. it may also be due to lower muscle mass in females compared to males. more the muscle mass is involved in exercise, greater the contribution of muscle pump to venous return and in turn cardiac output. increase in regular physical activity or exercise may help in increasing muscle mass as well as vo2max. therefore, a suggestion to reduce body fat percentage by the help of increased physical activity or exercise would help to decrease health risks in young adults.[18] there are few limitations of this study. only adults of age group 18-25 years were taken. a study with different age groups with wide range of bmi may provide a better scenario of relation between the bmi and aerobic capacity. physical activity of participants were not assessed that may affect performance. conclusion: this study showed that non-obese participants have better cardio-respiratory fitness than obese. females were found to be more obese than males and males had better cardio-respiratory fitness than their female counterparts. males fell under good and excellent category whereas females fell under average category. thus, increased bmi was associated with decreased level of vo2max in young adults. one can therefore improve vo2max by maintaining normal bmi which would help us to maintain cardiovascular fitness and reduce risk of cardio-respiratory morbidity and mortality. jlmc.edu.np references: 1. khurana e, oommen er. determination of cardiovascular fitness in young healthy medical students. international archives of integrated medicine. 2016;3(10):74-8. availble from: http:// iaimjournal.com/ 2. karandikar ms, prasad nb, kumar a. assessment of cardiopulmonary efficiency levels in student population. international table 3. normative data for vo2max. male female vo2max category(ml/kg/ min) n (%) vo2max category (ml/kg/ min) n (%) poor (≤24.9) 0 poor (≤23.9) 0 fair (25-33.9) 0 fair (24-30.9) 3 (7.5) average (34-43.9) 3 (7.5) average (31-38.9) 27 (67.5) good (44-52.9) 25 (62.5) good (39-48.9) 10 (25) excellent (≥53) 12(30) excellent (≥49) 0 total 40 (100) total 40 (100) j. lumbini. med. coll. vol 7, no 1, jan-june 2019 koju b. et al. cardio-respiratory fitness in medical students by queen’s college step test: a cross-sectional study jlmc.edu.np journal of scientific research publications. 2014;4(5):1-3. available from: http://www.ijsrp. org/research-paper-0514.php?rp=p292624 3. plowman sa, smith dl. the cardiovascular system. in: exercise physiology for health, fitness and performance. 4th ed. philadelphia: lippincott williams and wilkins; 2014. p. 353. available from: https://www.pearson. com/us/higher-education/product/plowmanexercise-physiology-for-health-fitness-andperformance/9780205162024.html 4. mcardle wd, katch fi, katch vl. individual differences and measurement of energy capacities. in: exercise physiology: nutrition, energy and human performance. 7th ed. philadelphia: lippincott williams and wilkins; 2010. p. 238-45. available from: https://www. medicosrepublic.com /exercise -physiolog ynutrition-energy-and-human-performance-7thedition-pdf-free-download 5. nieman dc. submaximal laboratory tests. in: exercise testing and prescription a health-related approach. 7th ed. new york: mcgraw-hill; 2011.p. 52-116. 6. cooney jk, moore jp, ahmad ya, jones jg, lemmey ab, casanova f, et al. a simple step test to estimate cardio respiratory fitness levels of rheumatoid arthritis patients in a clinical setting. int j rheumatol. 2013;2013:174541. pmid: 24454385. doi: https://doi. org/10.1155/2013/174541 7. billinger sa, van swearingen e, mcclain m, lentz aa, good mb. recumbent stepper submaximal exercise test to predict peak oxygen uptake. medicine & science in sports & exercise. 2012;44(8):1539-44. available from: https://journals.lww.com/acsm-msse/ fulltext /2012/080 0 0/ recu mbent _ stepper_ submaximal_exercise_test_to.17.aspx#epublink 8. quinart s, mougin f, simsonrigaud ml, nicolet-guenat m, negre v, regnard j. evaluation of cardiorespiratory fitness using three field test in obese adolescents: validity, sensitivity and prediction of peak vo2. j sci med sport. 2014;17(5):521-5. pmid: 23948247. doi: https://doi.org/10.1016/j.jsams.2013.07.010 9. hansen d, jacobs n, thijs h, dendale p, claes n. validation of a singlr-stage fixed-rate step test for prediction of maximal oxygen uptake in healthy adults. clinical physiology functional imaging. 2016;36(5):401-6. pmid: 26046474. doi: https:// doi.org/10.1111/cpf.12243 10. nabi t, rafiq n, qayoom o. assessment of cardiovascular fitness [vo2max] among medical students by queens college step test. international journal of biomedical and advance research. 2015;6(05):418-21. doi: http://dx.doi.org/10.7439/ ijbar 11. garrow js, webster j. quetlet’s index (w/h2) as a measure of fatness. int j obes. 1985; 9(2):14753. pmid: 4030199. 12. douglas g, nicol f, robertson c. macleod’s clinical examination. 13th ed. churchill livingstone elsevier: edinburgh and aberdeen; 2013.55p. available from: https:// w w w.medicosideas.com /macleods-clinicalexamination-pdf/ 13. katch vl, mcardle wd, katch fi. essentials of exercise physiology. 4th ed. 351 west camden street baltimore, md 21201: lippincott williams and wilkins, a wolters kluwer business; 2011. 224p. available from: http://thepoint.lww.com/ book/show/3403 14. yadav n, shete an, khan st. cardiorespiratory fitness in first year mbbs students indian journal of basic applied medical research. 2015;4(3):63-8. available from: http://ijbamr. com/pdf/june%202015%2063-68.pdf.pdf 15. mondal h, mishra sp. effect of bmi, body fat percentage and fat free mass on maximal oxygen consumption in healthy young adults. j clin diagn res. 2017;11(6):cc17-cc20. pmid: 28764152. doi: https://doi.org/10.7860/ jcdr/2017/25465.10039 16. hingorjo mr, zehra s, hasan z, qureshi ma. cardiorespiratory fitness and its association with adiposity indices in young adults. pakistan journal of medical sciences. 2017;33(3):659-664. available from: https://www.thefreelibrary.com/ cardiorespiratory fitness and its association with adiposity indices...-a0498478688 17. rymbui db, devi tp, devi kg, gowda k, ao s, bhardwaj p. cardiorespiratory fitness among mbbs students of rims, imphal. journal of dental medical sciences. 2016;15(6):23-5. available from: http://iosrjournals.org/iosrjd m s /pap e r s / vol15 -issue%20 6/ ve r sion6/ g1506062325.pdf 18. shete an, bute ss, deshmukh rr. a study of vo2 max and body fat percentage in female athletes. j clin diagn res. 2014;8:1-bc01-bc03. pmid: 25653935. doi: https://doi.org/10.7860/ jcdr/2014/10896.5329 jlmc.edu.np original research article —–————————————————————————————————————————— abstract: introduction: healthcare workers are a special public icon for the community because people would like to adopt and implement their knowledge, skill, attitude and behaviour for improving quality of health. people respect them for their knowledge and health behavior. it is believed that the level of health status of health workers as well as community should go ahead parallel but many researchers have noted that high risk behaviours (smoking, tobacco use, alcoholism, irregular diet intake, lack of exercise etc.) are prevalent among health workers. the result of this will be physical, psychological, familial and social disturbance, which might have an impact on health care delivery system of the country. the study was concerned to assess health status (body mass index, smoking and depression) of healthcare workers and its impact on social adjustment in banke district of nepal. methods: a cross sectional study design was applied to conduct the research. one hundred and eight respondents were selected through random sampling from the purposive group. data wa collected through interview by using interview schedule. spss-16 windows process was used to analyze data. results: most of the respondent (81.40%) were under the age group less than 30 years (m = 27.35, sd = 9.24 years). more than 57.40% of respondents were female. most of them (68.50%) were unmarried. maximum (82.20%) responders had normal body mass index (18.5-24.99). near about forty percent (38.9%) healthcare worker had faced social problems in their working area. conclusion: age (above 20 years) and male healthcare workers were more likely to smoke cigarettes. depressed health workers were more likely to smoke cigarette. depression could be observed as a determinant for social adjustment. keywords: depression • health workers • smoking • social problems —–————————————————————————————————————————— j. lumbini. med. coll. vol 2, no 1, jan june 2014 ___________________________________________________________________________________ a assistant professor b school of social science, jaipur national university, jaipur, india c lecturer d department of community medicine, lumbini medical college, palpa, nepal. corresponding author: dr. madhusudan ghimire e-mail: madhumds@gmail.com how to cite this article: ghimire m, sharma a, ghimire m. smoking and depression among healthcare workers. journal of lumbini medical college. 2014;2(1):21-4. doi: 10.22502/jlmc.v2i1.50. ___________________________________________________________________________________ madhusudhan ghimirea,d, achala sharmab, moushami ghimirec,d smoking and depression among healthcare workers appropriate for social work, problems related to industrial hazards, occupational diseases and its safety management.1 world health assembly recognized that occupational health is closely linked to public health and the development of health systems. world health organization (who) is addressing all determinants of workers' health, including risks for disease and injury in the occupational environment, social and individual factors, and access to health services. furthermore, the workplace is being used as a setting for protecting and promoting the health of workers and their families.2 many studies state that poor treatment or inadequate service, control over health professionals, excessive workload, inadequate facilities and lack of materials are the common issues that might be sources of frustration for many health workers. these factors affect their motivation, which in turn affects their performance and social adjustment.3 therefore, occupational stress is rising due to continuing structural changes in the workplace, demands and job insecurity introduction: healthcare worker always try to understand the role of an individual in the society, social structure, stratification, issues related to caste, class and gender, socio-economic and political factors and their impact on society. they also try to understand various social problems and its impact on the society, various issues and challenges, attitudes and skills https://doi.org/10.22502/jlmc.v2i1.50 21 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 ghimire m. et al. smoking and depression among healthcare workers. imposed on employees.4 some behavioral factors like dietary pattern, alcohol intake, cigarette smoking, carelessness in family and social relationship of health workers may impact on holistic aspects of community health. tobacco smoking has numerous, well-documented, adverse health effects, both alone and in combination with hazardous workplace exposures. people who work may be active smokers.5 it has been estimated that four fifths of the estimated 1.1 million smokers live in low and middle-income countries.6 it is responsible for considerable number of morbidity and mortality in the world. it is one of the most important preventable risk factor of most non communicable diseases.7 who estimated that approximately 5 million people die each year worldwide from tobacco related illnesses. if current trend continues, this figure will rise to about 10 million per year by 2025.8 the objective of this study was to assess health status (bmi, smoking and depression) of healthcare workers and its impact on social adjustment in banke district of nepal. methods: a cross sectional study design was applied to conduct the study during the month of march 2014 in banke district of nepal. one hundred and eight respondents were selected through simple random sampling from the purposive group. a pretest procedure applied in order to verify the reliability and validity of research tools. data were collected through unstructured questionnaire. anonymity and secrecy of all participants and their wishes and expressions were maintained. after completing the data collection, spss-16 was used to analyze the information. frequency distribution, mean, standard deviation and statistical test were applied to interpret the results. results: table 1 shows the demographic profile of the participants. a chi-square test of independence was applied to examine the relation between social problem and sex. the relation between these variables was significant, x2 (1, 108) = 10.48, p < 0.001. male healthcare workers were more likely to face social problem than were females. relation between age and sex with cigarette smoking is shown in table 2. it shows male healthcare workers were more likely to smoke than females, similarly workers 20 years or older were more likely to smoke than the youngers. table 3 shows relation between depression with cigarette smoking, social problems and gemder. it shows that the depressed are more likely to smoke, have social problems and are males. table 1: demographic profile of respondents (n=108). variables n % age in years (m = 27.35, sd=9.24) ≤30 88 81.40 31-50 12 11.00 >50 8 7.60 sex male 46 42.60 female 62 57.40 marital status married 34 31.50 unmarried 74 68.50 nature of organization government 34 31.50 private 74 68.50 nature of occupation medical 38 35.20 public health 20 18.50 nursing 38 35.20 laboratory 12 11.10 body mass index below 18.5 2 2.00 18.5 to 24.99 83 82.20 above 25 16 15.80 depression yes 18 16.7 no 90 83.3 social problem yes 42 38.9 no 66 61.1 cigarette smoking yes 42 38.9 no 66 61.1 smoker non smoker age(yr) <20 0 16 p<0.001 fisher exact ≥20 42 50 sex m 30 16 x2=23.372 p<0.001 f 12 50 table 2: relation of age and sex with cigarette smoking depression yes no smoking yes 14 28 x2=13.75 p<0.001no 4 62 social problem yes 16 26 x2=22.72 p<0.001no 2 64 sex male 12 34 x2 =5.12 p=0.024female 6 56 table 3: relation of depression with smoking, social problem and sex 22 jlmc.edu.np ghimire m. et al. smoking and depression among healthcare workers. discussion: this cross-sectional study has concerned to analyze behavioural health from the 108 healthcare workers in banke district of nepal. most of the respondent (66.60%) were under the age group below 30 years (m= 27.35, sd= 9.243). more than fifty seven percent (57.40%) respondents were female. most of them (68.50%) were unmarried. regarding the nature of occupation, 35.20%, 18.50%, 35.20% and 11.10% respondents were medical, public health, nursing and laboratory workers respectively. more than two-third respondents (68.50%) were working in private sectors. in this study, 82.20% had normal body mass index (18.5-24.99) which was quite high as compared to the 57.40% of adult male population who had normal range of bmi in a study in dharan, nepal.9 overweight or obese (bmi ≥ 25 kg/m2) were 7.2% (4.8% 9.5%) in general population of nepal.10 the study explored that the prevalence of bmi ≥ 25 kg/m2 among the healthcare worker was 15.80% which was quite less as compared to the figure of employees in belgium and shiraz hospital staffs in iran where the prevalence of a bmi ≥ 25 kg/ m2 was 48.50% and 27.8% respectively.12 noteworthy tobacco use was found among undergraduate medical students. this harmful behaviour not only causes personal harm but also reduces health professionals’ ability to motivate or counsel the patients effectively.13 morrell et al. found that prevalence of smoking was 16.8% among students of health professionals which was much lower than the rates observed among their undergraduate peers.14 smoking prevalence was 40.5% (95% ci: 33.6-47.4) in males, 23.5% (95% ci: 19.2-27.8) in females (p <0.001); 43.2% in auxillaries, 26.1% in nurses, 18.9% among physicians, and 34.7% among other non-health professionals (p <0.05) in a portuguese teaching hospital.15 uprety et al. stated that the prevalence of smokers was higher in the age group after 35 years and friends and family members who smoke were found to be common reasons for early initiation of smoking.16 another study from dharan acknowledged that young people were more vulnerable to start cigarette smoking. male populations of dharan were actively involved in smoking with prevalence of 41.7% which was slightly higher than the prevalence of smoking estimated as 38.4% among male medical and dental students of b.p. koirala institute of health sciences, dharan, nepal.17,18 the study revealed that 38.90% of healthcare workers had smoked (tobacco smoking) multiple times during their life and this was higher than the prevalence of smoking (28%) reported at the national institutes of health in mexico.19 the study found that cigarette smoking was determined by age and sex of healthcare workers and the association with both age and sex was (p < 0.001). different studies remarked that the prevalence of tobacco smoking was considerably high among nepalese people. nepal also has a very high prevalence rate of chronic obstructive lung disease (cold) varying from 20-40% in persons above the age of twenty years which was found to be significantly associated with tobacco smoking.20,21 near about forty percent (38.9%) health worker had faced social problems in their working area. it is indicated that psychosocial stress at work might be a relevant risk factor for depressive symptoms among older employees across countries and continents.22 wall td. et al. found that healthcare workers generally have psychological morbidity rates higher than the general population. in a large nhs sample in the uk, the relative risk of disorder was 1.5 and was most marked in direct care staff and women.23 an analysis of the combined sample gave an overall prevalence of depressive disorders in 8.56% (95% ci 7.05-10.37) of general population in five european countries. the figures were 10.05% (95% ci 7.80-12.85) for women and 6.61% (95% ci 4.92-8.83) for men.24 the largest population-based study from india reported that the prevalence of depression among urban south indians was 15.1%. age, female gender and lower socio-economic status were associated with depression in that population.25 the prevalence of depression among the nepalese rai older adults was 29.7%.26 the prevalence of depression was 51.3% in geriatric home in kathmandu valley.27 the study revealed that 16.70% of health workers (both male and female) were depressed and sex was found to be a determinant factor for depression in working place (p <0.05) where male were supposed to be three times at a higher risk than females. it was also found that depression was significantly associated with cigarette smoking (p <0.001) and faced problem for social adjustment (p <0.001). it could be uncovered that depressed health workers were 7.75 and 19.69 times higher exposed to cigarette smoking and faced social problems compared to non smokers and healthcare worker who could not face social problem in working area respectively. j. lumbini. med. coll. vol 2, no 1, jan june 2014 23 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 ghimire m. et al. smoking and depression among healthcare workers. references: 1. world health organisation. who report on health systems financing, 2010: the path to universal coverage. world health organisation; 2010. 2. neira m. world health organisation. who global plan of action on workers health, 2008-2017. promoting a preventative safety and health culture: international instruments, national strategies and good practices. geneva: ilo international safety conference; 2011. 3. cassitto mg, fattorini e, gilioni r, rengo c, gonik v. raising awareness of psychological harassment at work: protecting workers' health series no 4. world health organisation, 2003. 4. tennant c. work-related stress and depressive disorders. j psychosom res. 2001;51(5):697–704. 5. work, smoking, and health. a niosh scientific workshop. washington dc: center for disease control and prevention; 2000. 6. jha p, chaloupka fj, moore j, gajalakshmi v, gupta pc, peck r, et al. tobacco addiction. in: jamison dt, breman j, alleyne g, claeson m, evans db, jha p, et al (eds.). disease control priorities in developing countries (2nd edition). washington dc: oxford university press; 2006.p.869-86. 7. world health organization .tobacco or health: a global status report. geneva: world health organization; 1997. 8. tobacco frees initiative (tfi): report of activities 20032004: who/ non communicable disease and mental health. geneva: world health organizatio; 2004. 9. vaidya a, pokharel pk, nagesh s, karki p, kumar s, majhi s. association of obesity and physical activity in adult males of dharan, nepal. kathmandu univ med j. 2006 apr-jun;4(2):192-7. 10. who steps surveillance: non communicable disease risk factors survey, 2007/2008, nepal. geneva: world health organisation; 2008. 11. moens g, gaal lv, muls e, viaene b, jacques p. body mass index and health among the working population: epidemiologic data from belgium. eur j public health. 1999;9(2):119-23. doi: 10.1093/eurpub/9.2.119. 12. sahebi r, seyyedi m, sahebi l, nezhad rr. epidemiology of overweight and obesity among the workers of shiraz hospitals. ind j fund appl life sci. 2014;4(2):177-84. 13. aggarwal p, varshney s, kandpal sd, gupta p. habits and beliefs pertaining to tobacco among undergraduates of a medical college in the state of uttarakhand. journal indian academy of clinical medicine. 2012;13(3):189-94. 14. morrell her, cohen lm, dempsey jp. smoking prevalence and awareness among undergraduate and health care students. am j addict, 2008;17(3):181–6. doi: 10.1080/10550490802019899. 15. ravara sb, calheiros jm, aguiar p, barata lt. smoking behaviour predicts tobacco control attitudes in a high smoking prevalence hospital: a cross-sectional study in a portuguese teaching hospital prior to the national smoking ban. bmc public health. 2011;11:720. doi: 10.1186/14712458-11-720. 16. uprety s, poudel is, bhattarai s, ghimire a, singh n, poudel m, et al. knowledge on health effects and practices of smoking among the smokers in the eastern terai region of nepal. journal of chitwan medical college. 2014;4(1):22-5. doi.org/10.3126/jcmc.v4i1.10843. 17. poudel s, gurung dk. prevalence of smoking and perceived health problems among male population of dharan municipality. journal of kathmandu medical college. 2013;2(3):129-38. 18. ghimire a, sharma b, niraula sr, devkota s, pradhan pm. smoking habit among male medical and dental students of b.p.koirala institute of health sciences, nepal. kathmandu univ med j. 2013;41(1):32-6. 19. sansores rh, caloca jv, kiengelher lh, rodriguez as, venegas ar. prevalence of cigarette smoking among employees of the mexican national institute of health. salud publica mex. 1999;41(5):381-8. 20. sreeramareddy ct, ramakrishnareddy n, kumar hnh, sathian b, arokiasamy jt. prevalence, distribution and correlates of tobacco smoking and chewing in nepal: a secondary data analysis of nepal demographic and health survey-2006. subst abuse treat prev pol. 2011;6:33. doi: 10.1186/1747-597x-6-33. 21. pandey mr, basnyat b, neupane rp. chronic bronchitis and cor pulmonale in nepal. monograph: mrigendra medical trust; 1988. 22. siegrist j, lunau t, wahrendorf m, dragano m. depressive symptoms and psychosocial stress at work among older employees in three continents. global health 2012 jul;8:27. doi: 10.1186/1744-8603-8-27. 23. wall td, bolden ri, borrell cs, carter aj, golya da, hardy ge, et al. minor psychiatric disorder in nhs trust staff: occupational and gender differences. br j psychiatry. 1997 dec;171:519– 23. 24. ayuso-mateos jl, vazquez-bargurero jl, dowrick c, lehtinen v, dalgard os, casey p, et al. depressive disorders in europe: prevalence figures from the odin study. br j psychiatry. 2001 oct;179:308-16. doi:10.1192/ bjp.179.4.308. 25. patel v, weiss ha, chowdhary n, naik s, pednekar s, chatterjee s, et al. lay health worker led intervention for depressive and anxiety disorders in india: impact on clinical and disability outcomes over 12 months. br j psychiatry. 2011 dec;199(6):459–66. doi: 10.1192/bjp. bp.111.092155. 26. chalise hn, rai sl. prevalence and correlates of depression among nepalese rai older adults. j gerontol geriat res. 2013;2:130. doi:10.4172/2167-7182.1000130. 27. choulagai ps, sharma ck, choulagai bp. prevalence and associated factors of depression among elderly population living in geriatric homes in kathmandu valley. journal of institute of medicine. 2013; 35(1):39-44. conclusion: most of the healthcare workers had normal bmi. helathworkers of age above 20 years and males were more likely to smoke cigarette. depressed healthworkers are more likely to smoke, have social problems and are males. 24 initial experience of percutaneous nephrolithotomy at lumbini medical college prakash sapkota,a,d yb tambay,b,d sunil thapa,c,d rajan shakyac,d —–————————————————————————————————————————————— abstract: introduction: renal stone disease is a challenging problem in urologic practice especially in our locality because of large stone burden and recurrence. since ,the early 1980s when percutaneous nephrolithotomy (pcnl) was established for management of renal stones, open surgical procedures have virtually been replaced. pcnl is a safe, effective and minimally invasive approach compared to open surgery for patients with large single, multiple or staghorn stones. the aim of this prospective study was to evaluate and to review our experience with pcnl in management of renal and upper ureteric stones. methods: prospective study carried out at lumbini medical college and teaching hospital during 1stjanuary 2011 to 31st october 2011. sixty patients were evaluated and subjected to pcnl. after clinical investigations like ultrasonography (usg) and intravenous urography (ivu), once patients were found to have renal or upper ureteric stones they were informed and explained about pcnl, its likely complications, probable hospital stay, the cost of treatment and data were recorded along with the operative time, estimated blood loss, stone burden, stone-free rate, length of hospitalization and complications .patients were followed up after three months to rule out recurrence of stones by plain abdominal x-ray of kidney, ureter and bladder and usg. results: out of 60 patients 35 were male and 25 were female (m: f=1.4:1) with mean age of 37 years and were subjected to pcnl monotherapy. with the average stone size of 3.26cm, the mean operative time was 78 minutes. complete stone removal achieved by pcnl alone in 60 cases, with insignificant residual small stones we achieved 97% stone clearance rate. the mean hospital stay was 3.7 days. no serious complications were encountered, 9 (15%) patients required blood transfusion and 3 (5%) patients developed transient post-operative pyrexia. conclusion: pcnl is the first line treatment option for management of large renal stones which as monotherapy has advantages in removal of renal and upper ureteric stones and achieving excellent results with minimal morbidity. keywords: experience • percutaneous nephrolithotomy (pcnl) • renal stones • upper ureteric calculi ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer b professor c medical officer d department of surgery lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. prakash sapkota e-mail: sheetal_sapkota@yahoo.com how to cite this article: sapkota p, tambay yb, thapa s, shakya r. initial experience of percutaneous nephrolithotomy at lumbini medical college. journal of lumbini medical college. 2013;1(1):35-8. doi:10.22502/jlmc.v1i1.11. ___________________________________________________________________________________ j. lumbini. med. coll. vol 1, no 1, jan-june 2013 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v1i1.11 introduction: renal stones continue to occupy a challenging and important place in everyday urological practice especially in our locality because of large stone burden and recurrence. even after the introduction of electro-shock wave lithotripsy (eswl), percutaneous nephrolithotomy (pcnl) is still the method of choice in patients with large single, multiple or stag horn stones, frequently as monotherapy.1 pcnl began to be a routine procedure in developed countries since 1980s and has become a standard, well established procedure for the treatment of renal stones.2,3 efforts have been made to decrease the procedure morbidity by improving the techniques and the equipment’s used in pcnl procedure.4 methods: sixty patients underwent pcnl for treatment of renal and upper ureteric stones at lumbini medical college from january 1st to october 31st 2011. patient’s pre-operative assessment included 35 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np sapkota p. et al. initial experience of percutaneous nephrolithotomy medical history, physical examination, urine analysis, urine culture, serum haematocrit, platelet count, coagulation profile, kidney function test, usg, plain abdominal x-ray of kidney ureter and bladder (kub) and ivu. each case had a documented negative urine culture or treated with antibiotic according to the culture and sensitivity. the procedure was performed under general anesthesia with prophylactic intravenous antibiotic, patients in dorsal lithotomy position a retrograde catheter was inserted into the proper site using 21f cystoscope, fixed to a 16f foley catheter and connected to a syringe containing contrast media. the patient was turned to prone position, a retrograde pyelogram was performed in all cases to visualize and distend the collecting system in addition to identify the site, size and number of stones. results: in our study 60 patients were treated with pcnl monotherapy for single, multiple and stag horn renal stones. the average stone diameter was 3.26 cm (range1.5-5.2cm), table 1. the mean age of these patients were 37 years (range 2064 years). right side disease was seen in 33 patients (55%) and left side disease in 27 patients (45%). of these patients 35 were males and 25 females with male to female ratio of (1.4:1). in our study most common location of the stones were 22 (36.67%) renal pelvis, 13 (21.67%) pelvic ureteric junction (puj), 11 (18.4%) lower calyx, 10 (16.67%) upper ureteric, 3 (5.0%) upper calyx, and 1 (1.67%) middle calyx respectively. 26 patients (43.34%) were grossly hydronephrotic, 15 patients (25.0%) moderately, 11 patients (18.34%) mild and eight patients (13.34%) without hydronephrosis. stones were approached through upper, middle, lower calyx and multiple sites as well in some patients with stag horn calculi table 2 and 3. average operating time was 78 minutes for 60 pcnl cases, out of which mean operating time for single stones was 52 minutes (range 45-60 minutes), multiple stones was 70 minutes (range 6090 minutes) and for staghorn 110 minutes (range 90-120 minutes). patients with large renal stones needed blood transfusions (table 4). though all cases showed 100% clearance rate under fluoroscopy intraoperative, four (6.67%) patients had clinically insignificant residual stone fragments as confirmed by post-operative usg. at three months follow up, all four patients were found to have passed the residual stone and no recurrence was seen. discussion: renal stones were usually described as more frequent in men.5 which seems to be true in our study showing 35 male (58%) slightly more than 25 female (42%). the increasing incidence of nephrolithiasis in women might be due to lifestyle associated risk factors, such as obesity. in developing countries the male-to-female ratio range from 1.15:1 in iran and 1.6:1 in thailand to 2.5:1 in iraq and 5:1 in saudi arabia.6-9 the male to female rate reported by risal et al. is 2:1.10 marshall et al have reported that it is 2 times more in males than females.11 similarly,singh et al., have also reported occurrence of renal stones is higher in males than in females.12 our findings male-to female ratio 1.4:1, are in close proximity to the reports of developing countries. in a study conducted by risal et al. demonstrated that there were decreases in stone prevalence among older age groups. strikingly, the prevalence was very high in the 20 years age group.13 similarly the interesting features of our study are the high occurrence of renal stones in the age group of 10-19 years. the major and most difficult step in pcnl procedure is the ability to create a suitable access to the renal collecting system, with better stone clearance rate and minimal risk of vascular injury and other complications.14 in our series stones were approached through upper, middle, lower calyx and as well as multiple site in some patients with staghorn calculi. traditionally, pcnl has been performed in the prone position like the approach in our cases as it considered by many urologist to be the safest approach to kidney which enable the surgeon or the radiologist to puncture the kidney through brodel’s a vascular renal plane without causing significant parenchymal bleeding or visceral injury.15 however, other investigators described supine position approach with different techniques including the use of flexible ureterorenoscope, with comparable table 1. distribution of type of stone and its range 36 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 sapkota p. et al. initial experience of percutaneous nephrolithotomy jlmc.edu.np success and complication rates.16 about prophylactic antibiotics, all our patients received a full course antibiotics in case of proved growth in urine culture, and during induction of anesthesia as most of the protocols, however, mariappan et al in their study showed that one week oral ciprofloxacin in case of large renal stone more that 20mm or in case of hydronephrosis significantly reduced the risk of urosepsis after pcnl procedures.17 fluoroscopy was done to monitor the access to the collecting system in all our steps of dilatation . nephrostomy catheter was inserted by size 20f chest tube drainage catheter at the end of our procedure, the aim is to tamponade venous bleeding, to prevent urine extravasations or allow healing of minimal pelvicalyceal system injury and allow an access for a second look pcnl through the same tract in case of significant residual stones.18 bellman et al describe the advantages of placement of nephrostomy tube after pcnl and demonstrated that the haemostatic process was easy, it provide an access if second look procedure is required and prevent urinary extravasation.19 tubeless pcnl was found by falahatkaret al on 42 renal units for staghorn stones, they found that the procedure is safe and effective even with less complications.20 the major concern in pcnl surgery involves serious postoperative complications such as blood loss, adjacent organ injuries and life threatening infection.21,22 lee et al. reported the complications of pcnl in 582 patients, they report major complications in 6.8% and minor complications in more than 50% with 11.2% requiring blood transfusion.23 in study by osman et al, the complication rate was 50.8% with the most common complication being transient pyrexia in 27.6%, however we report 8% transient post-operative pyrexia and this is explained by the restriction to the selection of patients with preoperative documentation of absence of infection or one week antibiotic treatment according to sensitivity in case of presence of urinary tract organism.24 the incidence of blood transfusion in our study was 9% and none of our patients had serious life threatening bleeding that requiring open surgery or angioembolization. regarding the stone clearance rate, falahatkar et al. in their series, they achieved 87.5% stone clearance rate, soucy et al. report 91% stone clearance rate at three months follow up for partial or complete staghorn stones using single or multiple tracts.25 our study revealed 97% stone clearance rate and 3% with clinically insignificant fragments following pcnl monotherapy compares favorably with the results ofothers.26-28 pcnl is a safe and effective method of stone removal in patients with calculi in horseshoe kidneys.29 in our table 2: patients distribution depending on location and hydronephrosis table 3. patients distribution depending on stone location and types of access table 4. duration of operation for different types of stones 37 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np sapkota p. et al. initial experience of percutaneous nephrolithotomy study a case of horse shoe kidney was also included where the stone was removed with posteriorly placed upper or middle pole puncture and successful stone removal was achieved. conclusion: pcnl as the primary treatment and monotherapy for renal calculi offers the twin advantage of minimally invasive therapy and complete stone clearance. in addition, the hypothesized decrease in renal and body wall trauma may result in less pain, reduced severity or risk of complications, and shorter hospital stays including smaller total procedural cost compared with the other techniques. the success of pcnl depends on meticulous technique and experience. as experience is gained in percutaneous stone surgery there is continuous improvement in the success rate and a decrease in operating time, complication rate and hospital stay after treatment. a general observation of clinicians suggests that the prevalence of urolithiasis is fairly high in nepal; these increases are seen across sex, race, and age. however, no systematic study has been undertaken here to explore the etiopathogenesis of disease in this region. hence, looking to the burden of stone a prospective detail study is warranted. references: 1. toth c, holman e, khan ma. nephrolithotomy monotherapy for staghorn calculi. j endourol 1992; 6: 239-43. 2. wickham je, kelle_ mj. percutaneous nephrolithotomy. br j urol 1981; 53: 297-9. 3. alken p, hutschenreiter g, gunther r, marberger m. percutaneous stone manipulation. j urol 1981; 125: 463-6. 4. feng mi, tamaddon k, mikhail a et al. prospective randomized study of various techiniques of percutaneous nephrolithotomy. urol 2001; 58: 345-50. 5. romero v, akpinar h, assimos dg. kidney stones: a global picture of prevalence, incidence, and associated risk factors. rev urol 2010; 12: e86-96. 6. safarinejad mr. adult urolithiasis in a population-based study in iran: prevalence, incidence, and associated risk factors. urol res 2007; 35: 73-82. 7. tanthanuch m, apiwatgaroon a, pripatnanont c. urinary tract calculi in southern thailand. j med assoc thai 2005; 88: 80-5. 8. qaader ds, yousif sy, mahdi lk. prevalence and e_ ology of urinary stones in hospitalized patients in baghdad. east mediterr health j 2006; 12: 853-61. 9. sandhya abbagani, sandhya devi gundimeda et al. kidney stone disease. etiology and evaluation. rev ijabpt 2010; vol1, issue-1. 10. risal s, risal p, pandeya dr et al. spectrum of stones composition: a chemical analysis of renal stones of patients visiting nmcth. nepal med coll j 2006; 8: 263-5. 11. marshall v, white rh, de saintonge mc et al. the natural history of renal and ureteric calculi. br j urol 1975; 47: 117-24. 12. singh pp, singh lbk, prasad sn et al. urolithiasis in manipur (north eastern region of india).incidence and chemical composition of stones. am j clin nutr 1978; 31: 1519-25. 13. watterson jd, soon s, jana k. access related complications during percutaneous nephrolithotomy. urology versus radiology at a single academic istitution. j urol 2006; 176:142-5. 14. ramakumar s, segura jw. rena calculi. percutaneous management. urol clin north am 2000; 27: 617-22. 15. de la rosette, peter tsakiris, michael n ferrandino et al. beyond prone position in percutaneous nephrolithotomy. a comprehensive review. eur urol 2008; 54: 1262-9. 16. deane la, clayman rv. advances in percutaneous nephrolithotomy. urol clin north am 2007; 34: 383-95. 17. mariappan p, smith g, moussa sa et al. one week ciprofloxacin before percutaneous nephrolithotomy significantly reduces upper tract infection and urosepsis; a prospective controlled study. br j urol int 2007; 99: 466. 18. matlaga br, shah od, zgoria rj et al. computerised tomography guided access for percutaneous nephrolithotomy. j urol 2003; 170: 45-7. 19. bellman gc, davidoff r, candela j et al. tubeless percutaneous renal surgery. j urol 1997; 136: 351-4. 20. falahatkar s, khosropanah i, neiroomand h et al. tubeless percutaneous nephrolithotomy for staghorn stones. endourol 2008; 22: 1447-51. 21. kukreja r, desai m, patel s et al. factors affecting blood loss during percutaneous nephrolithotomy: prospective study. j endourol 2004; 18: 715-22. 22. muslumanoglu ay, tefekli a, karadag ma et al. impact of percutaneous access point number and location on complication and success rates in percutaneous nephrolithotomy. urol int 2006; 77: 340-6. 23. lee wj, smith ad, cubelli v et al. complications of percutaneous nephrolithotomy. am j roentgenol 1987; 148: 177-80. 24. osman m, wendt-nordahl g, heger k et al. percutaneous nephrolithotomy with ultrasound guided renal access: experience from over 300 cases. br j urol int 2005;96:875 25. soucy f, ko r, duvedevani m, et al. percutaneous nephrolithotomy for staghorn calculi. a single center’s experienceover 15 years. j endourol 2009; 10: 1669-73. 26. rodrigues netto n jr, claro j de a, ferreira u. is percutaneous monotherapy for staghorn calculus still indicated in the era of extracorporeal shock wave lithotripsy? j endourol 1994; 8: 1957. 27. schulze h, hertle l, graff j et al. combined treatment of branched calculi by percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. j urol 1986; 135: 113841. 28. 28. segura jw, preminger gm, assimos dg et al. nephrolithiasis clinical guidelines panel summary report on the management of staghorn calcili. j urol 1994; 151: 1648 -51. 29. 29. khalid al-otaibi, denish. hosking. percutaneous stone removal in horseshoe kidneys. j urol 1999; 162: 674-7. 38 radha bhurtel finalised for pdf oct 22.docx https://doi.org/10.22502/jlmc.v10i1.481 original research article screen time in children of central nepal: a parent reported cross-sectional study during covid-19 pandemic radha bhurtel,a,d ram prasad pokhrel,b,d sumitra sharmac,e abstract: introduction: the insurgence of covid-19 has affected many aspects of human life and its repercussions on the life of children cannot be undermined. in addition to the serious impact on health and food insecurity, lack of recreational activities, school closure and switch to online learning have pushed children to excessive screen exposure. this study aimed to assess the duration of screen time and parental perspective towards screen viewing in children during the pandemic. methods: a community-based descriptive cross-sectional study was carried out in bharatpur metropolitan city. a total of 384 parents were included purposively. a semi-structured questionnaire was used to interview the parents during the pandemic for one month. during the data collection, appropriate universal precautions for covid-19 were taken. results: the median duration of screen exposure was two hours (30 minutes to 9 hours). most (65%) of the parents stated that their children spent more time on screen compared to pre-covid-19 times. the majority (82%) of the parents were worried about the possible consequences of excessive screen time. more than two-thirds (72%) of parents thought that screen exposure also has various benefits for children. conclusion: most of the children exceeded the duration of screen time recommended by the world health organization. most of the parents were worried about the harmful effects on the health and behavior of children. key words: child, covid-19, parents, screen time. submitted: 11 march, 2022 accepted: 29 september, 2022 published: 24 october, 2022 a: lecturer, department of nursing b: assistant professor, department of pediatrics c: fellow, trein nepal d: college of medical sciences teaching hospital, bharatpur, nepal e: kathmandu university school of medical sciences, dhulikhel, kavre, nepal corresponding author: radha bhurtel, lecturer, department of nursing, college of medical sciences teaching hospital, mob: 9801214220 email: rrbhurtel@gmail.com orcid: 0000-0002-3286-9822 introduction: screens are omnipresent in modern life in the form of mobile phones, television and video games. there is a growing concern about duration and content of screen exposure among children due to its impact on cognitive and socio-emotional development, sleep outcomes and physical health.[1,2] in high-income and middle-income countries, excess screen time is reported in 10% to 97% and 21% to 98% children respectively.[3] how to cite this article: bhurtel r, pokhrel rp, sharma s. screen time in children of central nepal: a parent reported cross-sectional study during covid-19 pandemic. journal of lumbini medical college. 2022;10(1):8 pages. doi: https://doi.org/10.22502/jlmc.v10i1. epub: 2022 october 24 j. lumbini. med. coll. vol 10, no 1, jan-june 2022 https://doi.org/10.22502/jlmc.v10i1 mailto:rrbhurtel@gmail.com https://orcid.org/0000-0002-3286-9822 bhurtel r, et al. screen time in children during covid-19 pandemic the covid-19 outbreak has made this issue even more concerning. around 1.5 billion children have been out of school and as a result, classrooms have been replaced by online learning. time on the playground is now spent playing video games and watching videos.[4,5] in nepal, only few studies are carried out and those studies have focused mainly on sedentary behavior and television viewing but very few studies have included the use of mobile devices. therefore, this study was conducted with the objective of examining duration and the perspective of screen viewing of the children by their parents during covid-19 pandemic. methods: a community-based descriptive cross-sectional study was conducted in bharatpur metropolitan city, chitwan to identify the duration of screen time and parental perspective towards screen viewing in children aged six months to 12 years who had at least one screen device at home like smartphone, television, tablet, laptop or computer. children who did not have a screen device at home were excluded from the study. the study was carried out during a one month period, october 2020. sample size was calculated using following formula n= z2pq/d2 the prevalence was taken 50%, as there was no similar study done before. at 95% confidence interval and adding 10% non-response rate, total sample size estimated was 422. however, only 384 parents met the criteria hence was taken as the sample size. ethical clearance was obtained from the institutional review committee of college of medical sciences teaching hospital (comsth-irc ref no: 2020-091). permission was obtained from the ward chairperson of ward no.12, bharatpur municipality before collecting the data. a written consent was taken from the respective parents before interviewing. a semi-structured interview schedule was used for the study that included two parts, the first part consisted of socio-demographic characteristics of the children and family and the second part was related to parental response towards the use of screen time. the parents of children aged between six months to 12 years were approached with the help of community health volunteers. parents were interviewed for 15 to 20 minutes maintaining social distance and other universal safety measures against covid-19. the responses were recorded in the predesigned pro-forma. the collected data were coded and entered in the microsoft excel version 10 and then checked for completeness. the data were then extracted to statistical package for social sciences (spss) version 20 and analyzed using descriptive statistics. results: the median duration of screen time was two hours with interquartile range of (3-1) hours. almost half (45%) of the children spent more than two hours on the digital screen every day. children below two years and two to five years spent one hour on average while those between five to 12 years spent three hours on screen. more than half (65%) of parents stated that their children spent more time on screen devices in the present days as compared to the pre-pandemic time. only 20% of the parents had set rules for duration and/or contents being watched by their children. a majority (96%) of the parents reported that they co-viewed screen content with their children. a higher number of children viewed youtube (56%) and cartoon channels (45%) on media devices compared to other applications as shown in table 1. j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np https://jlmc.edu.np/index.php/jlmc bhurtel r, et al. screen time in children during covid-19 pandemic table 1: information related to screen use during covid-19 (n=384) items frequency (%) duration upto 2 hours 213 (55) more than 2 hours 171 (45) spend more time on screen than before yes 241 (65) no 133 (35) contents watched on the screen* youtube 213 (56) cartoon 174 (45) facebook 44 (12) songs 40 (10) tiktok 28 (7) reasons parents allowed to watch* to calm the baby 129 (37) to make clever 139 (36) to make mealtime easier 69 (18) to do household chores 19 (5) to teach dance 16 (4) to make fall asleep 14 (4) *multiple responses a majority (82%) of parents were worried about their children spending more time on screen. regarding the possible health issues, almost half (46%) of the parents stated the effect on the eye as digital eye strain and refractive errors. parents were also concerned about the exposure to violence (47%) and sexual content (11%) in those media. in contrast, 72% of parents pointed out positive aspects of watching various contents in electronic media even if the duration of screen time increased. this can be seen in table 2. it was noted that mothers introduced screens to the child in the majority (92%) of cases and the most (57%) common reason was to calm the baby. a majority (96%) of the respondents had mobile phones in their j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np https://jlmc.edu.np/index.php/jlmc bhurtel r, et al. screen time in children during covid-19 pandemic table 2: parental response towards screen viewing during covid-19 (n=384) parental response frequency (%) reaction when the children watch for long time worried 315 (82) not worried 33 (9) do not know 36 (9) possible health issues due to excess screen time* digital eye strain, refractive issues 176 (46) poor school performance 94 (24) behavioral problem 62 (16) mental health problems 23 (6) worrying about violence and sexual content* exposure to violence 181 (47) sexual content 41 (11) advantage of screen time* learn various skills 275 (72) child become clever 251 (65) improve communication skill 70 (18) better school performance 44 (12) *multiple responses house followed by television (83%), laptop (23%) and videogames (3%). a mobile phone was the most commonly used device in the house by both parents and children. it was notable that only 5% of children had their own devices. this is shown in table 3. discussion: world health organization (who) has recommended no screen time for under two children and not more than one hour of sedentary screen time for older children.[6] the american academy of pediatrics (aap) and indian academy of pediatrics (iap) have also outlined similar guidelines.[7,8] in contrast to this recommendation, in the current study, almost half of the children spent more than two hours on screen time daily. similar results were also obtained by koirala s et al. in nepal.[9] shah rr et al. also found similar duration of screen exposure among pre-schoolers aged two to six years in western india.[10] j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np https://jlmc.edu.np/index.php/jlmc bhurtel r, et al. screen time in children during covid-19 pandemic table 3: information related to the child and family (n=384) items frequency (%) age of the child (median age: 6 years, iqr=9-4) ≤2 years 54 (14) <2-5 years 92 (24) 5-12 years 238 (62) family type nuclear 220 (57) joint 164 (43) screen devices used* mobile phone 369 (96) tv 317 (83) laptop 89 (23) computer 64 (17) tablet 31 (8) videogame 11 (3) reason for introducing* to calm the baby 219 (57) to make meal time easier 107 (28) to make the child clever 101 (26) to teach dance 21 (6) to do household chores 14 (4) to make fall asleep 17 (4) *multiple responses the reason for differences in prevalence of excessive screen time is multifactorial.[3] approximately two-third of the parents admitted that their children spent more time on screen devices than pre-pandemic time. this finding is consistent with the survey where 49% of survey respondents’ kids were spending more than six hours a day online compared to only 8% of kids before the pandemic.[11] the finding is also consistent with a study from turkeyand a multinational study conducted by bergmann c et al.[12,13] setting rules and parental co-viewing of screen is inversely related to the duration of screen exposure in children.[7,14] but this study showed only 20% of the parents had set rules for screen time. however, while setting restrictions on screen time in low-income countries, contextual family factors should be kept in mind which might affect the parents capacity to change the behavior.[15] in this study, a majority (96%) of the parents reported co-viewing the screen with their children. this finding is consistent with other recommendations.[7,16] in this study, the most common digital media platform watched by children was youtube (56%) similar to the findings in a study by radesky js et al.[17] a majority of the parents were worried that their children spent more time on screen. the most common health issue perceived by almost half of the parents due to excessive screen use was digital eye strain and refractive problems. moderate evidence exists for eating/obesity, mental health issues and quality of life due to excess screen viewing.[18] however, in this study no parent showed concern over the possibility of obesity. parents were also worried about the exposure to violence (47%) and sexual content (11%) of the videos being watched by their children. however, study conducted in pokhara by koirala s et al. showed that half (48.1%) of the respondents were never worried about their children’s behavior of using gadgets.[9] similar results were also noted j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np https://jlmc.edu.np/index.php/jlmc bhurtel r, et al. screen time in children during covid-19 pandemic in a study conducted in india.[19] even though attempts have been made to make bigtech companies responsible towards making the media contents safer, reducing deceptive advertisements and protecting young children from sexual predators, very few (14%) parents are convinced that enough is being done.[11] parents were also aware about the possible advantages of media devices and majority (72%) of them thought that children could learn various life skills. this is in line with studies which highlights benefits of high-quality and interactive screen time.[20,21] the study finding is congruent with finding of common sense media which concluded that parents in lower-income homes are more likely to see positive effects of screen media than parents in higher-income homes.[22] in the majority (92%) of children it was the mother who introduced screen to their child and stated for using gadget was to calm the baby. similar findings was obtained in the study conducted by susilowati et al.[23] in the current study, similar to a multi-national study, children were exposed to screen as early as first birthday.[13] mobile was the most commonly used (96%) device by the parents and the children even though other gadgets were present in their house. this finding is consistent with the study done by susilowati et al.[23] this shows the increasing popularity of smartphones over traditional fixed devices among adults and children. in the current study, only 5% of children had their own device which is lower than the study conducted by kabali in which majority (75%) of young children had their own tablet.[24] this highlights the importance of setting our own guidelines as the availability and ownership of media device directly influences the screen exposure. in this study, duration of screen viewing was a subjective response from the respective parents. the objective calculation of screen time was not feasible during the period of data collection. conclusion: children exceeded the recommended screen time during the covid-19 pandemic. most of the parents were worried about harmful effects on health and behavior of children. however, some of them thought that media exposure can benefit their children in skill development. since the digital media exposure is rising, it is imperative to educate parents and children about the best ways to handle it. acknowledgement: yanu adhikari, radhika sharma conflict of interest: none source of funding: no funds were available. references: 1. domingues-montanari s. clinical and psychological effects of excessive screen time on children. j paediatr child health. 2017;53(4):333-8. pmid: 28168778 doi:https://doi.org/10.1111/jpc.1346 2 2. hale l, guan s. screen time and sleep among school-aged children and adolescents: a systematic literature review. sleep med rev. 2015;21(0):50-8. pmid: 25193149 doi:https://doi.org/10.1016/j.smrv.2 014.07.007 3. kaur n, gupta m, malhi p, grover s. screen time in under-five children. indian pediatr. 2019;56(9):773-88. pmid: 31638012 4. aguilar-farias n, toledo-vargas m, miranda-marquez s, cortinez-o'ryan a, cristi-montero c, rodriguez-rodriguez f, et al. sociodemographic predictors of changes in physical activity, screen time, and sleep among toddlers and preschoolers in chile during the covid-19 pandemic. int j environ j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np https://pubmed.ncbi.nlm.nih.gov/28168778/ 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[accessed on 2022 jan 20]. available from: https://www.commonsensemedia.org /sites/default/files/research/report/20 20_zero_to_eight_census_final_web .pdf 23. susilowati ih, nugraha s, alimoeso s, hasiholan bp. screen time for preschool children: learning from home during the covid-19 pandemic. glob pediatr health. 2021;8(0):2333794x211017836. pmid: 34031645 doi: https://doi.org/10.1177/2333794x211 017836 24. kabali hk, irigoyen mm, nunez-davis r, budacki jg, mohanty sh, leister kp, et al. exposure and use of mobile media devices by young children. pediatrics. 2015;136(6):1044-50. pmid: 26527548 doi: https://doi.org/10.1542/peds.2015-21 51 j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np https://pubmed.ncbi.nlm.nih.gov/27267624/ https://doi.org/10.2196/ijmr.5668 https://pubmed.ncbi.nlm.nih.gov/32482771/ https://doi.org/10.1542/peds.2019-3518 https://doi.org/10.1542/peds.2019-3518 https://pubmed.ncbi.nlm.nih.gov/30606703/ https://doi.org/10.1136/bmjopen-2018-023191 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https://doi.org/10.1542/peds.2015-2151 https://doi.org/10.1542/peds.2015-2151 https://jlmc.edu.np/index.php/jlmc original research article jlmc.edu.np —–————————————————————————————————————————————— abstract: introduction: cerebrovascular accident (cva) is defined as abrupt onset of a neurological deficit that is attributable to a focal vascular cause. ct scan is a widely available, affordable, non-invasive and relatively accurate investigation in patients with stroke and is important to identify stroke pathology and exclude mimics. aim of this study is to establish the diagnostic significance of computed tomography in cerebrovascular accident and to differentiate between cerebral infarction and cerebral haemorrhage with ct for better management of cva. methods: a one year observational cross sectional study was conducted in 100 patients that presented at the department of radiodiagnosis from emergency or ward within the one year of study period with the clinical diagnosis of stroke, and had a brain ct scan done within one to fourteen days of onset. results: a total of 100 patients were studied. 66 were male and 34 were female with a male/female ratio of 1.9:1. maximum number of cases (39%) was in the age group of 61-80 yrs. among 100 patients, 55 cases were clinically diagnosed as hemorrhagic stroke and 45 cases were clinically diagnosed with an infarct. out of the 55 hemorrhagic cases, two cases were diagnosed as both hemorrhage and infarct by ct scan, one case had normal ct scan findings and one had subdural haemorrhage. these four cases were excluded while comparing the clinical diagnosis with ct scan finding. among 51 clinically diagnosed cases of hemorrhagic stroke, 32(62.7%) cases were proved by ct scan as hemorrhagic stroke and among clinically diagnosed cases of infarct, 39(86.7%) cases were proved by ct scan as infarct which is statistically significant (p <0.001). a significant agreement between clinical and ct diagnosis was observed as indicated by kappa value of 0.49. sensitivity, specificity, positive predictive value and negative predictive value of clinical findings as compared to ct in diagnosing hemorrhage were 84.2%, 67.2%, 62.8% and 86.7% respectively. the accuracy of clinical diagnosis is 74%. conclusion: this study showed that ct scan is a useful diagnostic modality to identify stroke pathology and to exclude mimics. keywords: brain hemorrhage • brain infarction • cerebrovascular disorders • computed tomography —–————————————————————————————————————————————— j. lumbini. med. coll. vol 2, no 1, jan june 2014 ___________________________________________________________________________________ a lecturer, department of radiodiagnosis lumbini medical college, palpa b professor and head, department of radiodiagnosis nepalgunj medical college, kohalpur corresponding author: dr. sumnima acharya e-mail: doctorsumnima@gmail.com how to cite this article: acharya s, chaturvedi sk. significance of computed tomography in the diagnosis of cerebrovascular accidents. journal of lumbini medical college. 2014;2(1):18-20. doi: 10.22502/jlmc.v2i1.49. ___________________________________________________________________________________ sumnima acharyaa, shyam kishore chaturvedib significance of computed tomography in the diagnosis of cerebrovascular accidents of morbidity and mortality worldwide.3 cva is also a major health issue in semi-industrialized countries like nepal.4 ct scan is a widely available, affordable, noninvasive and relatively accurate investigation in patients with stroke and is the modality of choice as an initial investigation in such patients and is important to identify stroke pathology and exclude mimics.5,6 therapeutic decisions regarding management of stroke require accurate diagnosis of stroke types and exclusion of mimics. distinction between intracerebral hemorrhage (ich) and cerebral infarction on the basis of clinical features has been shown to be unreliable. appropriately timed ct is a safe, noninvasive gold standard, and most accurate in distinguishing ich from cerebral infarction.7 this type of study is the first of its kind in western nepal so as to provide as in depth idea about the significance of computed tomography in cva and radiological profile of patients suffering introduction: cerebrovascular accident (cva) is defined by abrupt onset of a neurological deficit that is attributable to a focal vascular cause.1 the four major types of cva are cerebral infarction, intracerebral haemorrhage (ich), primary subarachnoid haemorrhage (sah) and venous occlusion.2 cva is increasingly recognized as one of the leading cause https://doi.org/10.22502/jlmc.v2i1.49 18 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 acharya s. et al. significance of computed tomography in the diagnosis of cerebrovascular accidents. from stroke in this region. methods: this is a cross-sectional study done in the department of radiodiagnosis, nepalgunj medical college, teaching hospital, kohalpur in one year duration from 11th july 2011 to 10th july 2012. all patients that presented at the department of radiodiagnosis from emergency or ward within one year of the study period with clinical diagnosis of stroke, and with brain ct scan done within 1 to 14 days of onset of stroke were included. history about potential risk factors was obtained like smoking, hypertension, diabetes mellitus, obesity and cardiovascular disease. based on history and all the clinical examination findings, clinical diagnosis was made. the patient was then subjected for noncontrast ct scan of the head performed on siemens somadom emotion in supine position by taking 10 mm axial section with 15-20 degree angulations of the gantry to make the canthomeatal line in position. wherever required, additional thinner cuts were taken. after this, the data was tabulated and statistically analyzed and the clinical features and various risk factors were correlated with the ct findings. results: a total of 100 patients were studied. sixtysix were male and 34 were female with m:f = 1.9. among 100 patients, 55 cases were clinically diagnosed as hemorrhagic stroke and 45 cases were clinically diagnosed as infarct. out of the 55 hemorrhagic cases, two cases were diagnosed as both hemorrhage and infarct, one case was normal and one had subdural haemorrhage in ct findings. all these findings are summarized in table 1. these four cases were excluded while comparing the clinical diagnosis with ct scan finding. among 51 clinically diagnosed cases of hemorrhagic stroke, 32(62.7%) cases were proved by ct scan as hemorrhagic stroke and among clinically diagnosed cases of infarct, 39(86.7%) cases were proved by ct scan as infarct which is statistically significant (p <0.001). a significant fair agreement between clinical and ct diagnosis was observed as indicated by kappa value of 0.49. sensitivity, specificity, positive predictive value and negative predictive value of clinical findings as compared to ct in diagnosing hemorrhage were 84.2%, 67.2%, 62.8% and 86.7% respectively. the accuracy of clinical diagnosis is 74%. maximum number of cases (39%) was in the age group of 61-80 yrs. in this study, most patients with intracerebral hemorrhage visited our hospital in subacute stage and only 5 patients with infarction visited in chronic stage (fig.1). this study showed that maximum number of infarction (72%) occurred in the middle cerebral artery territory, 14% were present in the anterior cerebral artery territory, 8.2% in posterior cerebral artery territory and 5.4% in basilar artery territory. in this study, out of 36 intracerebral hemorrhages, maximum number of cases (44%) was situated in basal ganglia extending to periventricular white matter. intraventricular extension occurred in 27.7% of cases as shown in table 2. discussion: asefa g. et al. found that in the eligible study population, the main clinical presentation was hemiparesis in 77.1% and coma in 20.8%, stroke mortality was 21% and 31% had persistent neurological deficit.7 in this study, the main clinical presentation was hemiplegia in 76% and coma in 22%, stroke mortality was 15% and 30% had persistent neurological deficit. these findings are comparable to those findings in other studies. ct report n % hemorrhage 36 36 infarct 51 51 both 2 2 sah 1 1 sdh 1 1 lacunar infarct 6 6 sah and sdh 1 1 large infarct and lacunar infarct 1 1 normal 1 1 total 100 100 table 1: ct scan reports in clinically suspected cva disease sites of lesions in brain n % lentiform nucleus 3 8.3 basal ganglia extension to periventricular white matter 16 44 external capsule involvement in ct 2 5.5 frontal lobe 7 19.5 temporal lobe 8 22.2 parietal lobe 10 27.7 occipital lobe 0 cerebellar hemisphere 1 2.7 thalamus 6 16.6 ventricular extension 10 27.7 table 2: intracerebral hemorrhage sites of lesions in brain 19 jlmc.edu.npj. lumbini. med. coll. vol 2, no 1, jan june 2014 acharya s. et. al. significance of computed tomography in the diagnosis of cerebrovascular accidents. this is the study done in western part of nepal. in this study, maximum number of cases was of infarction that accounts for 58% of total number of cases among which six (10% of total infarct cases) had pure lacunar infarct and one (1.7% of total infarct) had large as well as lacunar infarct. two cases (2% of total cases) had both hemorrhage and infarct. most patients with infarction visited in sub acute stage (45%) and only five patients with infarction visited in chronic stage. among 58 cases, 40 were male and 18 were female with a m:f = 2.2. maximum number of cases was in the 61-80 yrs. most of the infarct cases were in the age group of above 41 yrs. cases below 41 yrs of age accounted for 16.6%. naik m. et al. studied 150 patients with stroke in eastern part of nepal in bpkihs, dharan and found that 104 were males and 46 were females, aged 7 to 91 years in which infarction (58%) was more common than haemorrhage (42%) in both age group (< 40 years and > 40 years).5 shaik mm. did a study on burden of stroke in nepal in 2012 and found that ischemic stroke is more common (63%) than hemorrhagic stroke (37%).8 both studies are comparable to the findings of this study. sandoval j. et al. in 1999 retrospectively evaluated 200 patients of stroke. they reported hypertension as a risk factors for stroke in 13%.9 kaul s et al. in 2000 found that common risk factors in stroke were hypertension (62%) and diabetes (38%).10 findings of the above studies are comparable to this study which were 57% and 34% respectively. conclusion: this study showed that ct scan is an accurate imaging tool in visualizing infarcts, determining if they are bland or hemorrhagic and in visualizing intraparenchymal hemorrhage with associated edema and mass effect, as well as sub arachnoid hemorrhage. references: 1. smith w, english j, johnston s. cerebrovascular diseases. in: kasper dl, braunwald e, fauci as, hauser sl, longo dl, jameson jl. (eds). harrison’s principles of internal medicine (18 ed.). new york: mc grawhill professional publishing; 2008. p. 3270. 2. osborn a. diagnostic neuroradiology. new delhi(india): mosby; 1994. 3. salawu f, umar i, danburam a. comparision of two hospital stroke scores with computed tomography in ascertaining stroke type among nigerians. ann afr med. 2009;8(1):14-8. 4. bhalla d, marin b, preux pm. stroke profile in afghanistan and nepal. neurology asia. 2009;14(2):87-94. 5. naik m, rauniyar rk, sharma uk, dwivedi s, karki db, samuel j. clinico-radiological profile of stroke in eastern nepal: a computed tomography study. kathmandu university medical journal. 2006;4(2):161-6. 6. kolapo k, ogun s, danesi m, osalusi b, odusote k. validation study of siriraj stroke score in african nigerians and evaluation of the discriminant values of its parameters. a preliminary prospective ct scan study. aha journals. 2006;37:1997-2000. 7. asefa g, meseret s. ct and clinical correlation of stroke diagnosis, pattern and clinical outcome among stroke patients visting tikur anbessa hospital. ethiop med j. 2010 apr;48(2):117-22. 8. shaik mm, loo kw, gan sh. burden of stroke in nepal. int j stroke. 2012 aug;7(6):517-20. 9. sandoval j. intracerebral haemorrhage in young people. stroke. 1990;30:531-41. 10. kaul s, venketswamy p, meena a, sahay r, murthy j. frequency, clinical features and risk factors of lacunar infarction (data from a stroke registry in south india). neurology india. 2000;48(2):116-19. 11 7 0 0 0 26 45 2 3 10 5 0 0 0 0 5 10 15 20 25 30 35 40 45 50 hemorrhage infarct both sah sdh acute sub acute chronic fig 1: duration between onset of cva and doing ct scan. 20 arati final.docx https://doi.org/10.22502/jlmc.v10i1.487 original research article pap smear versus colposcopy in the absence of hpv-dna testing for the screening of pre-malignant and malignant cervical lesions arati shrestha,a,d kopila sunwar,a,d miki shah,a,d sunita thapa,a,d aruna pokharel,a,d deepak shrestha,b,d archana tiwaric,d abstract: introduction: the incidence of cervical cancer is very high in developing countries. the extensive use of cervical screening with pap smear and colposcopy has considerably increased the detection of premalignant and malignant lesions of the cervix. methods: this was a hospital-based study conducted over a period of three months. all the patients underwent gynecological examination, pap smear and colposcopy. in case of abnormal findings in colposcopy or follow-up cytology, patients were advised for cervical biopsy. with reference to the histopathological reports, the sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of pap smear and colposcopy were evaluated. results: the most common cytological result was negative for intraepithelial lesion or malignancy (nilm, 60%) followed by atypical squamous cells of undetermined significance (ascus, 10%), atypical squamous cellscannot exclude high grade lesion (asc-h, 6%), low grade squamous intraepithelial lesion (lsil,10%) and high grade squamous intraepithelial lesion (hsil, 11%). in colposcopy, 60% of the patients were normal and 40% showed atypical transition zone. histo-pathological findings among 53 patients were nilm (13.2%), cervicitis (13.2%), cervical intraepithelial neoplasia i (cin i, 28.3%), cin ii and cin iii (39.6%) and invasive carcinoma (5.66%). the sensitivity, specificity, ppv and npv of pap smear were 63.6%, 66.6%, 33.3%, and 87.5% respectively. similarly sensitivity, specificity, ppv, npv of colposcopy for abnormal cervical lesions were 87.56%, 15.38%, 76.09% and 28.57% respectively. conclusion: in the absence of hpv-dna testing, the combined use of pap smear and colposcopy to detect premalignant and malignant cervical lesions increases early detection and treatment. keywords: colposcopy, cytology, pap smear, pre-malignant, invasive carcinoma. submitted: june 20, 2022 accepted: november 29, 2022 published: december 17, 2022 alecturer, department of obstetrics and gynecology bassociate professor, department of obstetrics and gynecology cassociate professor, department of pathology dlumbini medical college and teaching hospital, tansen-7, palpa, nepal corresponding author: arati shrestha, department of gynecology and obstetrics lumbini medical college & teaching hospital, tansen-7, palpa nepal orcid: https://orcid.org/0000-0001-5214-3271 introduction: cervical cancer is one of the most common gynecological malignancies. worldwide, it ranks fourth after breast, colorectal and lung cancers with significant mortality.[1,2] it is the only preventable gynecological cancer. yet, nepal has one of the highest incidence how to cite this article: shrestha a, sunwar k, shah m, thapa s, pokharel a, shrestha d, tiwari a. pap smear versus colposcopy in the absence of hpv-dna testing for the screening of pre-malignant and malignant cervical lesions. 2022;10(1): 11 pages. doi: https://doi.org/10.22502/jlmc.v10i1.487 epub: 2022 j. lumbini med. coll. vol 10, no 1, jan-june 2022 https://doi.org/10.22502/jlmc.v10i1 shrestha a, et al. pap smear versus colposcopy in cervical lesions and mortality rates due to cervical cancer in south east asian region.[1] world health organization (who) advises screening strategy with cytology by pap smear followed by colposcopy examination, when available, to decrease the major public health problem.[2,3] pap smear is a simple, safe, non-invasive and effective method of detection of precancerous and non-cancerous changes in the cervix. colposcopy provides a unique method to study the benign and malignant lesions. it is a simple, non-invasive procedure that helps in determining the location, size and extent of abnormal cervical lesions thereby serving in detecting the sites for biopsies.[4,5] colposcopy is complementary to cytology. the final diagnosis must be made on histo-pathological examination.[6] various cervical cancer screening tools and confirmatory tests are currently available which require different levels of expertise, cost and time. they have a fair level of accuracy and have to be customized based on their prerequisites. but there is not a single screening test with 100 % sensitivity and specificity and there remains scope to identify a better method for the screening and diagnosis of this common condition.[2,7] hence, this study aimed to compare the efficacy of pap smear and colposcopy in detecting the pre-malignant and malignant lesions of cervix. methods: it was a hospital-based observational study conducted in the department of obstetrics and gynecology, lumbini medical college and teaching hospital over a period of three months from march 2022 to may 2022. all the married women aged 21 to 65 years having national health insurance presenting to gynecology out-patient department (opd) with complaints of vaginal discharge, post-coital bleeding, post-menopausal bleeding and persistent leucorrhoea were included in the study. the patients who were unmarried, pregnant and those with frank lesions and active infection were excluded. ethical approval was obtained from the institutional review committee prior to commencement of the study (irc-lmc-04/r-022). a total of 100 patients satisfying inclusion criteria were included. an informed consent was taken from all the patients. confidentiality was maintained throughout the study. the patients were interviewed using standard questionnaires regarding age, age at marriage, age at first pregnancy, parity, menstrual history, present symptoms, and smoking history. after a verbal explanation of the procedure, cervical examination was done using a cusco's speculum and findings as abnormal discharge, erosions, hypertrophic cervix, suspicious mass or ulcerative appearance at the cervix were noted. through speculum examination, the smear was taken with ayre’s spatula and cytobrush, spread thinly on the slide and fixed with 95% ethyl alcohol. the slides were stained with papanicolaou staining protocol in the pathology lab. pap smear results were reported based on 2021 bethesda system.[8] cytology was considered positive if it revealed any of the following lesionsatypical squamous cells of undetermined significance (asc-us), atypical squamous cellcannot exclude high grade lesions (asc-h), low grade squamous intraepithelial lesion (lsil), high grade squamous intraepithelial lesion (hsil) or cells suspicious for malignancy. negative smear included those with normal and inflammatory reports. j. lumbini med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np http://jlmc.edu.np shrestha a, et al. pap smear versus colposcopy in cervical lesions a colposcopic examination was done in all the patients using b’orze colposcope. if the complete transformation zone was not visualized; colposcopy was termed as “unsatisfactory" and not included in our study. inspection was done using a green filter followed by 5% acetic acid and lugol's iodine application. the margin and color of the lesion along with the appearance of blood vessels were noted. abnormal colposcopy findings like acetowhite area, punctate lesions, mosaic pattern and abnormal iodine staining were noted. cervical punch biopsy was taken from the suspicious/abnormal areas at the same setting if colposcopy finding was abnormal. the specimen was then fixed in 40% formalin, labelled and sent for histopathological examination. all the patients after pap smear were asked for follow-up with a cytology report. if any abnormal findings were noted in the cytology report, a cervical biopsy was taken in the second setting. biopsy was not taken in whom pap smear and colposcopy were normal. the histopathological terminologies used to describe the grade of the disease were: cervical intraepithelial neoplasia (cin) grades i, ii and iii, and invasive carcinoma. all the data thus collected were entered into a microsoft excel spreadsheet version 2016. it was then imported to statistical package for social sciences software version 23.0 (spss inc., chicago, il, usa). frequencies with percentages were used for descriptive statistics. the sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of cytology and colposcopy in comparison to histopathology were calculated. results: of the 100 patients enrolled in the study, 53 patients whose colposcopic findings or cytological report or both were abnormal were selected for histopathological examination. table 1 represents the socio-demographic profile of the patients. a majority (40%) belonged to the age group of 31 to 40 years. the mean age of the patients was 41.86±10.53 years, the minimum age being 21 years and the maximum, 65 years. the lowest age at marriage was 14 years. most (48%) got married at 20-30 years with the mean age at marriage being 21.24±4.33 years. majority of them were hindu (85%). the majority of the patients were brahmin (39%) followed by janjati, chhetri and dalit. whitish discharge was the most common clinical symptom (49%) among the patients followed by pain abdomen (35%), and post coital bleeding (6%) (fig.1). among all the patients examined by colposcopy, 60% of the patients findings were normal and 40% patients showed abnormal transformation zone. among 40% abnormal transformation zone 10% patients had additional atypical vessels and 3% of patients were suspected of invasive carcinoma. the majority of the patients’ cytology finding was nilm (60%) followed by hsil (11%), ascus (10%), and lsil (10%) (fig. 2). table 2 summarizes the histopathological findings of the patients who underwent cervical biopsy. table 3 describes the correlation between the cytological and histopathological findings of the study. j. lumbini med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np http://jlmc.edu.np shrestha a, et al. pap smear versus colposcopy in cervical lesions table1: socio-demographic profile of the study population (n=100) characteristics frequency ethnicity brahmin 39 chhetri 17 dalit 14 janajati 29 muslim 1 religion hindu 85 buddhist 14 muslim 1 parity nullipara 3 primipara 40 multipara 57 fig.1. distribution of symptoms in the study population (n=100). j. lumbini med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np http://jlmc.edu.np shrestha a, et al. pap smear versus colposcopy in cervical lesions fig.2. distribution of cytological (pap smear) reports of the study population (n=100) *nilmnegative for intraepithelial lesion or malignancy; ascusatypical squamous cell of undetermined significance; asc-hatypical squamous cell cannot exclude high grade lesion; lsillow grade squamous intraepithelial lesion, hsilhigh grade squamous intraepithelial lesion table 2: distribution of histopathological findings (n=53). histopathological findings frequency (%) negative for intraepithelial lesion 7 (13.2%) cervicitis 7 (13.2%) cervical intraepithelial neoplasia i (cin i) 15 (28.3%) cin ii and cin iii 21 (39.6%) invasive carcinoma 3 (5.66%) table 4 summarizes the correlation between colposcopic findings with histopathological findings of our study. the sensitivity, specificity, ppv and npv of pap smear in diagnosing various cervical pathologies are depicted in table 5. j. lumbini med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np http://jlmc.edu.np shrestha a, et al. pap smear versus colposcopy in cervical lesions table 3: correlation between cytology with histopathology (n=53). cytology/ hpe nilm cervicitis cin i cin ii and cin iii invasive ca total nilm 4 (7.55%) 4 (7.55%) 1 (1.88%) 4 (7.55%) 13 cervicitis 1 (1.88%) 1 (1.88%) 1(1.88%) 3 ascus 2 (3.77%) 2 (3.77%) 3 (5.66%) 3 (5.66%) 10 asc-h 1 (1.88%) 5 (9.43%) 6 lsil 9 (16.9%) 1 (1.88%) 10 hsil 1 (1.88%) 7 (13.2%) 3 (5.66%) 11 total 7 (13.20%) 7 (13.20%) 15 (28.30%) 21 (39.6%) 3 (5.66%) 53 *nilmnegative for intraepithelial lesion or malignancy; ascusatypical squamous cell of undetermined significance; asc-hatypical squamous cell cannot exclude high grade lesion; lsillow grade squamous intraepithelial lesion, hsilhigh grade squamous intraepithelial lesion the sensitivity, specificity, ppv and npv of colposcopy in diagnosing abnormal cervical pathologies in this study were found to be 87.5%, 15.38%, 76.09% and 28.57% respectively. j. lumbini med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np http://jlmc.edu.np shrestha a, et al. pap smear versus colposcopy in cervical lesions table 4: correlation of colposcopy with histopathology (n=53) colposcopic findings normal findings abnormal findings nilm cervicitis cin i cin ii and iii invasive ca abnormal 5(9.43%) 4 (7.55%) 11(20.7%) 17(32%) 3(5.66) normal 2(3.77%) 2(3.77%) 4 (7.55%) 5(9.43%) table 5: sensitivity, specificity, ppv and npv of pap smear in diagnosing cin i, cin ii and iii, and invasive carcinoma. parameters cin i cin ii and iii invasive ca sensitivity 90% 63.63% --specificity 86% 66.67% 94.33% ppv 60% 33.33% 0% npv 97.37% 87.5% 1% discussion: invasive cancer of cervix is considered to be a preventable condition as it has a long pre-invasive state, making it amenable to screening and treatment.[7] the incidence of cervical cancer can be reduced by as much as 80% if the quality, coverage and follow up of screening methods are of high standard.[9] the major public health problems in female of lowand middle income countries (lmic) have become rare entity in high income countries because of structured screening program by frequent pap smear examination.[2] however, in a country like nepal where there is a lack of awareness in the population about cervical cancer and the necessity and availability of frequent screening, women still present in advanced stage of cancer.[2] the necessity of frequent screening over a wide age range, requirement of skilled human resources and the low sensitivity of pap smear have led the clinicians of lmics to search for a better screening program to catch the preventable disease as early as possible and to reduce mortality and morbidity by this disease. in the present study of 100 patients, the most common age group was 31 to 40 years (40%), which was comparable to the study done by subedi k et al. (52%), and kalyankar vy et j. lumbini med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np http://jlmc.edu.np shrestha a, et al. pap smear versus colposcopy in cervical lesions al. (39.7%).[2,4] whereas natu n et al. found majority of the patients were aged 41 to 50 years (32.5%).[10] majority of our patients were hindu (85%) which might be due to the majority population of study area being hindu and also due to different study found a significantly lower incidence of cancer in muslim.[4] this finding was comparable to the studies by kalyankar vy et al. and mohanty j et al.[4,11] early age at marriage, multiple number of sexual partners and sex with high risk males whose wives died due to cervical cancer also increase the risk of developing cervical cancer.[12] mayavati et al. in her study showed association of cervical cancer with early marriage.[13] and also in the studies done by nair r et al. and dadkhah fet al. 52% and 94% patients respectively were married before 20 years.[12,14] in our study 48% patients were married at the age of 20 to 30 years and 38% before 20 years. since the study area is a hilly region where majority of the population are usually brahmins and chhetris, the most common ethnicity in our study was brahmins too (39%). the majority of our patients were multiparous (57%) comparable to findings by subedi k et al. (53%), prasad d et al. (52%), and kalyankar vy et al.(38.2%).[2,3,4] however, in the study by shaki o et al. only 16.4% were multiparous.[15] in different studies patients had various symptoms at the time of presentation. excessive vaginal discharge for long duration also be proven to be risk factor for development of cervical cancer.[12] in our study majority of patients presented with whitish discharge per vaginum (48%) followed by pain abdomen (35%) which was comparable to that reported by chaudhary rd et al. and gandavaram j et al.[6,16] however, subedi k et al. found majority had the symptom of pain abdomen (49%).[2] in the present study, 60% of cytology findings was nilm followed by hsil (11%), asc-us (10%), lsil (10%), asc-h (6%) and cervicitis (3%). these findings correlated with those of natu n et al. and gandavaram j et al.[10,16] contradictory to our findings, sachen et al. found that 48% had normal smear, 42% had inflammatory smear, 5% had lsil and only 0.48% had hsil.[17] the differences in pap smear reporting’s are due to differences in sampling, staining, fixation techniques and reporting errors. in the present study, majority (60%) of patients had normal colposcopic findings and 40% showed abnormal transformation zone. among abnormal findings, 3% were suspicious for invasive carcinoma. our findings were similar to those of joshi c et al. and oglak s c et al.[5,18] histopathological study was done in 53 cases, out of which 39.6% was cin ii and cin iii followed by cin i (28.3%), cervicitis (13.2%), nilm (13.2%) and invasive carcinoma (5.66%). the sensitivity and specificity of pap smear have been reported differently in different studies. in a meta-analysis of 62 studies, the pap smear sensitivity ranged from 11 to 99% and specificity, 14 to 97%.[18] in the present study, the sensitivity, specificity, ppv, npv of pap smear in diagnosing cin i were 90%, 86%, 60%, and 97.3% respectively and for cin ii and cin iii were 63.6%, 66.67%, 33.33% and 87.5% respectively. the sensitivity and specificity of our study are comparable to the findings of natu n et al. and cheraghi f et al.[10,19] in contrast to our findings oglak s c et al. noted the sensitivity, specificity, ppv, and npv for cin i as 28.5%, 74%, 88.1% and 13.3% respectively.[18] these differences were thought to be related to the risk group of the patient population, the number of cases, different features and deficiencies likely to j. lumbini med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np http://jlmc.edu.np shrestha a, et al. pap smear versus colposcopy in cervical lesions occur at each stage of cytological examination. in the present study, sensitivity, specificity, ppv, npv of colposcopy were noted 87.5%, 15.38%, 76.09% and 97% respectively. sensitivity was comparable to kalyankar vy et al. and natu n et al. 96% 82.57%.[4,10] specificity was comparable to cheraghi f et al. [19] ppv was comparable to natu n et al. and npv was comparable to oglak s c et al.[10,18] hpv dna testing in cervical cancer screening is not always possible. limitation and inadequacy of other screening and diagnostic methods such as pap smear and colposcopy should also be known. thus, whenever feasible, it is possible to increase the sensitivity and specificity with the sequential and combined use of these methods. limitations of the study: this study did not use a calculated sample size which limits the generalizability of the findings. additionally, evaluation of sensitivity, specificity, ppv and npv of colposcopy in terms of cin i, cin ii and iii, and invasive carcinoma was not done. conclusion: cervical cancer screening is quickly becoming an urgent public health problem which needs immediate attention from all concerned parties. one of the immediate strategies should be sustained health education and awareness creation to promote early detection of cases through appropriate screening strategies. hence, our study suggested the detection of cervical abnormalities was higher when cytology, colposcopy, colposcopic guided biopsies are used in combination in diagnosis of abnormal cervical lesions. conflict of interest: the authors declare that no competing interests exist. source of funding: none. references: 1. international agency for research on cancer, who. cancer fact sheets: cervical cancer [internet]. iarc, world health organization; 2016. available from: https://gco.iarc.fr/today/data/pdf/fact-sheet s/cancers/cancer-fact-sheets-16.pdf 2. subedi k. correlation of colposcopy with biopsy in cases of abnormal cervical cytology. nepal journal of obstetrics and gynaecology. 2019;14(1):36-9. doi: subedi, k. (2019). available from: https://www.nepjol.info/index.php/njog/ article/view/26625 3. prasad d, sinha a, mishra u, parween s, raman rb, goel n. colposcopic evaluation of cervix in symptomatic women and its correlation with pap smear. a prospective study at a tertiary care center. j family med prim care 2021;10(8):2923-2927. pmid: 34660425 doi: https://doi.org/10.4103/jfmpc.jfmpc_1208 _20 4. kalyankar vy, kalyankar bv, gadappa sn, kute s. colposcopic evaluation of unhealthy cervix and it’s correlation with papanicolau smear in cervical cancer screening. international journal of reproduction, contraception, obstetrics and gynecology. 2017;6:4959-65. doi: https://dx.doi.org/10.18203/2320-1770.ijrc og20175008 5. joshi c, kujur p, thakur n. correlation of pap smear and colposcopy in relation to histopathological findings in detection of premalignant lesions of cervix in a tertiary care centre. international journal of j. lumbini med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np https://gco.iarc.fr/today/data/pdf/fact-sheets/cancers/cancer-fact-sheets-16.pdf https://gco.iarc.fr/today/data/pdf/fact-sheets/cancers/cancer-fact-sheets-16.pdf https://www.nepjol.info/index.php/njog/article/view/26625 https://www.nepjol.info/index.php/njog/article/view/26625 https://pubmed.ncbi.nlm.nih.gov/34660425/ https://doi.org/10.4103/jfmpc.jfmpc_1208_20 https://doi.org/10.4103/jfmpc.jfmpc_1208_20 https://dx.doi.org/10.18203/2320-1770.ijrcog20175008 https://dx.doi.org/10.18203/2320-1770.ijrcog20175008 http://jlmc.edu.np shrestha a, et al. pap smear versus colposcopy in cervical lesions scientific study. 2015;3(8):55-60. available from: http://www.ijss-sn.com/uploads/2/0/1/5/20 153321/ijss_nov_oa13.pdf 6. chaudhary rd, inamdar sa, hariharan c. correlation of diagnostic efficacy of unhealthy cervix by cytology, colposcopy and histopathology in women of rural areas. international journal of reproduction, contraception, obstetrics, gynecology. 2014;3(1):213-8. available from: https://www.ijrcog.org/index.php/ijrcog/ar ticle/viewfile/821/767 7. upadhyay j, garg s. correlation of pap smear and colposcopic finding with directed biopsy in detection of cervical neoplasm. tropical journal of pathology and microbiology. 2017;3(4):396-400. available from: https://pathology.medresearch.in/index.ph p/jopm/article/view/108/215 8. kujur p, joshi c. application of the 2014 bethesda system for reporting of cervical/ vaginal cytological lesions. journal of evolution of medical and dental sciences. 2015;4(98):16366-71. doi: http://dx.doi.org/10.14260/jemds/2015/24 19 9. jyothi r, gupta p, rao r, sood pl, parasher n. correlation between colposcopy, cytology and histopathology in high-risk patients for cervical cancer in perimenopausal women in himachal pradesh, india. journal of south asian federation of menopause societies. 2013;1(1):21-3. available from: https://www.jsafoms.com/doi/jsafoms/ pdf/10.5005/jp-journals-10032-1005 10. thakur r, srivastava a, natu n. correlation of pap smear and colposcopy in relation to histopathological finding in detection of pre malignant lesion of cervix. scholars journal of applied medical sciences. 2016;4(9):3449-3453. available from: https://journals.indexcopernicus.com/searc h/article?articleid=1780420 11. mohanty j, mohanty bk. risk factors in invasive carcinoma of cervix. journal of obstetrics and gynecology of india. 1991;403-6. available from: https://jogi.co.in/storage/articles/files/fileb ase/archives/1991/feb/1991_403_406_fe b.pdf 12. nair rv, anitha r, ashok vg. comparative study of pap smear and colposcopic finding in patient with vaginal discharge attending opd in tertiary care center. indian journal of obstetrics and gynecology research. 2017;4(3):274-7. available from: https://www.ijogr.org/article-details/4667 13. mhaske m, jawadekar sj, saundale sg. study of association of some risk factors and cervical dysplasia/cancer among rural women. national journal of community medicine. 2011;2(2):209-12. available from: https://njcmindia.com/index.php/file/articl e/view/1882 14. dadkhah f, alishah n. a comparative study on colposcopy directed biopsy and pap smear tests in patient with abnormal pap smear. iranian journal of pathology. 2006;1(1):13-16. available from: https://ijp.iranpath.org/article_8894.html 15. shaki o, chakraborty bk, nagraja n. a study on cervical cancer screening in asymptomatic women using papanicolau smear in a tertiary care hospital in an urban area mumbai, india. j family med prim care. 2018;7(4):652-7. pmid: 30234033 doi: j. lumbini med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np http://www.ijss-sn.com/uploads/2/0/1/5/20153321/ijss_nov_oa13.pdf http://www.ijss-sn.com/uploads/2/0/1/5/20153321/ijss_nov_oa13.pdf https://www.ijrcog.org/index.php/ijrcog/article/viewfile/821/767 https://www.ijrcog.org/index.php/ijrcog/article/viewfile/821/767 https://pathology.medresearch.in/index.php/jopm/article/view/108/215 https://pathology.medresearch.in/index.php/jopm/article/view/108/215 http://dx.doi.org/10.14260/jemds/2015/2419 http://dx.doi.org/10.14260/jemds/2015/2419 https://www.jsafoms.com/doi/jsafoms/pdf/10.5005/jp-journals-10032-1005 https://www.jsafoms.com/doi/jsafoms/pdf/10.5005/jp-journals-10032-1005 https://journals.indexcopernicus.com/search/article?articleid=1780420 https://journals.indexcopernicus.com/search/article?articleid=1780420 https://jogi.co.in/storage/articles/files/filebase/archives/1991/feb/1991_403_406_feb.pdf https://jogi.co.in/storage/articles/files/filebase/archives/1991/feb/1991_403_406_feb.pdf https://jogi.co.in/storage/articles/files/filebase/archives/1991/feb/1991_403_406_feb.pdf https://www.ijogr.org/article-details/4667 https://njcmindia.com/index.php/file/article/view/1882 https://njcmindia.com/index.php/file/article/view/1882 https://ijp.iranpath.org/article_8894.html https://pubmed.ncbi.nlm.nih.gov/30234033/ https://pubmed.ncbi.nlm.nih.gov/30234033/ http://jlmc.edu.np shrestha a, et al. pap smear versus colposcopy in cervical lesions https://doi.org/10.4103/jfmpc.jfmpc_313_ 17 16. gandavaram j, pamulapati br. correlation of pap smear and colposcopic finding in relation to histopathological findings among women attending tertiary care hospital. a two year study. international journal of reproduction, contraception, obstetrics and gynecology. 2019;8(6):2163-8. doi: https://dx.doi.org/10.18203/2320-1770.ijrc og20192132 17. sachan pl, singh m, patel ml, sachan r. a study on cervical cancer screening using pap smear test and clinical correlation. asia pac j oncol nurs. 2018;5(3):337-41. pmid: 29963597 doi: https://doi.org/10.4103/apjon.apjon_15_18 18. oğlak sc, obut m. comparison of pap smear and colposcopy in the absence of hpv test for the diagnosis of pre malignant and malignant lesions. eastern journal of medicine. 2020;25(2):299-304. doi: https://dx.doi.org/10.5505/ejm.2020.2154 8 19. cheragji f, jolodarian p, masoumi k, forouzan a, jafari rm. comparison results of pap smear and colposcopy and histopathology in women with post coital bleeding. research journal of obstetrics and gynecology. 2015;8(1):10-15. doi: https://dx.doi.org/10.3923/rjog.2015.10.15 j. lumbini med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np https://doi.org/10.4103/jfmpc.jfmpc_313_17 https://doi.org/10.4103/jfmpc.jfmpc_313_17 https://dx.doi.org/10.18203/2320-1770.ijrcog20192132 https://dx.doi.org/10.18203/2320-1770.ijrcog20192132 https://pubmed.ncbi.nlm.nih.gov/29963597/ https://doi.org/10.4103/apjon.apjon_15_18 https://dx.doi.org/10.5505/ejm.2020.21548 https://dx.doi.org/10.5505/ejm.2020.21548 https://dx.doi.org/10.3923/rjog.2015.10.15 http://jlmc.edu.np outcome of percutaneous nephrolithotomy in horseshoe kidneys udaya man singh dongol,a,c sandeep bohorab,d —–————————————————————————————————————————————— abstract: introduction: the horseshoe kidney is extremely rare, the incidence being one in every 400 800 patients. in a recent review of more than 15000 radiographic imaging studies, the incidence was one in every 666 patients. the renal stone formation in horseshoe kidney is around 20-80%. percutaneous nephrolithotomy is the most accepted modality of treatment . this study was carried out to find the outcome of percutaneous nephrolithotomy in horseshoe kidneys. methods: between may 2013 and november 2017, 11 adult patients(12 renal units) with stones in horseshoe kidneys underwent percutaneous nephrolithotomy in the department of urosurgery, kathmandu medical college and teaching hospital and were evaluated for the operating time, stone free rate , complications and hospital stay. data analysis was done using statistical package for the social sciences (spss) version 20. categorical data were analysed by using fisher exact test. results: the mean age of the patients was 30.9 years (sd = 10.3) and the mean stone burden was 385.83 mm2 (sd = 331.3). the overall stone free rate was 83.33%. the two patients with residual stones when counselled for extracorporeal shock wave lithotripsy, refused for it and decided to be on follow up. no auxiliary procedure was done. the complications noted were of clavien-dindo grade i and ii. no pleural or bowel injury was seen. one patient needed blood transfusion. conclusions: percutaneous nephrolithotomy is safe and effective in the management of stones in horseshoe kidneys. it does not carry increased risk than reported in normal kidneys. keywords: horseshoe kidney, percutaneous nephrolithotomy, renal stones —————————————————————————————————————————————— j. lumbini. med. coll. vol 6, no 2, july-dec 2018 original articlehttps://doi.org/10.22502/jlmc.v6i2.238 ___________________________ submitted: 10 april 2018 accepted: 01 august 2018 published: 16 august 2018 a associate professor b junior resident c department of urosurgery, kathmandu medical college, nepal d department of surgery, kathmandu medical college, nepal corresponding author: udaya man singh dongol e-mail: dongoludaya@gmail.com orcid: https://orcid.org/0000-0002-8793-8717 how to cite this article: dongol ums, bohora s. outcome of percutaneous nephrolithotomy in horseshoe kidneys. journal of lumbini medical college. 2018;6(2):6 pages. doi: 10.22502/jlmc.v6i2.238. epub: 2018 august 16. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.____________________________ introduction: in genitourinary tract, the incidence of developmental anomalies is about 30 40%. [1] fusion anomalies of kidneys are common and are predisposed to various complications of nephrolithiasis, hydronephrosis, infection and possibility of renal malignancy.[2] horseshoe kidney is the most common renal fusion anomaly with the incidence of one in 400 800 cases and male to female ratio of 2:1.[3] in a recent review of radiographic imaging studies, the incidence of horseshoe kidney has been found to be one in 400 600 individuals with fusion at the lower poles in greater than 90% of the cases, with the rest showing fusion at the upper poles.[4] the fusion of the lower poles which occurs at 4th 6th week of gestation, prevents the normal ascent of kidneys when it reaches the inferior mesenteric artery. there is malrotation of the kidney with anterior displacement of the collecting system and high lateral insertion of ureters. the significant ureteropelvic obstruction due to high lateral insertion of ureters is associated with https://doi.org/10.22502/jlmc.v6i1.182 j. lumbini. med. coll. vol 6, no 2, july-dec 2018 jlmc.edu.np dongol ums. et al. outcome of percutaneous nephrolithotomy in horseshoe kidneys impaired drainage of the collecting system, urinary infection and stone formation.[5,6] the incidence of renal stones in adult patients with horseshoe kidneys is estimated to be 36%.[7] the prevalence of complex staghorn calculus in horseshoe kidney is however rare.[8] the commonest presentation is the flank pain and is seen in 83% of population with horseshoe kidneys.[9] although the treatment of nephrolithiasis in horseshoe kidneys is challenging due to anomalies in position of the kidney, the anatomy of pelvic collecting system and vascular supply, percutaneous nephrolithotomy has been accepted as the treatment of choice for stones more than 2 cm.[10,11,12] the dorsomedial orientation of posterior calyces and dorsolateral orientation of anterior calyces offer surprisingly the good percutaneous access. the stone clearance rate of percutaneous nephrolithotomy in horseshoe kidneys varies and ranges from 75% to 100% with an average stone-free rate of 84%.[13] the first report of percutaneous nephrolithotomy in horseshoe kidney was made by wickkam and kellet in 1981 and by clayman in 1983.[14] the anatomic and vascular anomalies in horseshoe kidneys increase the technical complexity and makes the management of stone in horseshoe kidneys by percutaneous nephrolithotomy challenging, despite the higher stone free rate with minimal major complications. this study was carried out to find the outcome of percutaneous nephrolithotomy in horseshoe kidneys in our set up. methods: it was an observational study and data were collected prospectively. the study was done from may 2013 up to november 2017. approval from the ethical committee was taken and informed consent was taken from all the patients. all adult patients with stone(s) in horseshoe kidneys who underwent percutaneous nephrolithotomy in the department of urosurgery in kathmandu medical college and teaching hospital during the study period were included in the study. the evaluation of all patients was done with a detailed medical history and physical examination, complete blood count, urinalysis, urine culture and sensitivity, coagulation tests, renal function tests. all the patients also underwent comprehensive radiological assessment including x-ray kub, intravenous urography, ultrasonography of abdomen and pelvis. it was only from 2015 that we started doing computed tomographic urography in our patients (six cases, seven renal units) (fig 1). patients with positive urine cultures were treated with appropriate antibiotics. the stone burden was calculated by measuring the digitized surface area (dsa) of stone on plain x-ray. for a stone of 10 mm by six mm dimensions, the dsa was 60 mm2 and for two stones of 10 mm by six mm and eight mm by five mm, it was 60 + 40 = 100 mm2. percutaneous nephrolithotomy (pcnl) was performed in all patients in prone position under general anaesthesia with dilatation of the tracts up to 24/26 fr. a dose of prophylactic antibiotics was given with the induction of general anaesthesia. after cystoscopy and ureteral catheterization with six fr ureteric catheter, the patient was kept in prone position and delineation of pelvicalyceal system was done with the contrast media. the desired calyx was punctured with 18 g angiographic needle. due to the downward and medial displacement of the calyces, c-arm at 90 degree provides a direct end on view of the posterior calyx. after puncture of the calyx, c-arm was then rotated towards the surgeon fig 1: ct urography of a patient with horseshoe kidney with bilateral renal stones j. lumbini. med. coll. vol 6, no 2, july-dec 2018 dongol ums. et al. outcome of percutaneous nephrolithotomy in horseshoe kidneys jlmc.edu.np to see the depth of penetration of needle. the site of puncture was chosen depending upon the location and number of stones as well as the orientation of the calyces. in ten renal units, upper calyceal puncture was made and in the two remaining renal units, mid calyceal puncture was made. all the upper pole calyceal punctures were made infracostal due to low lying kidneys without any pleural injury. once puncture was confirmed, a 0.035 inch thick and 150 cm long radifocus terumo nitinol hydrophilic guide wire was passed into the collecting system and well parked into the ureter. acute dilatation of the tract was done with the metallic coaxial dilators up to 24/26 fr. nephroscopy was done with 20 fr rigid nephroscope (richard wolf). once the stone was visualised, fragmentation was done with nidhi pneumatic lithotripter and all the fragments were removed. an attempt was made to remove all the fragments as far as possible. dj stenting was done and nephrostomy tube was placed in all cases at the end of the procedure. nephrostomy tube was removed on third postoperative day and dj stent in three weeks. x-ray kub (fig 2) and ultrasonography of abdomen and pelvis was done before removal of nephrostomy tube and at three weeks as well as at six weeks. patients with stone fragments less than four mm were considered stone free. results: there were 11 patients and 12 renal units, one patient having bilateral renal stones. in six renal units, there was single renal stone, four in the pelvis and two in the lower calyx. in one patient with bilateral stones, there were multiple stones in different calyces including large staghorn calculus in the pelvis in one renal unit and a pelvic calculus in the other renal unit. there were two to three stones in the remaining four renal units in lower calyces including in the isthmus in one case. in seven cases, the stones were on right side, in three cases it was on left side and in one case it was on both sides. demographic profile and perioperative variables of the patients is presented in table 1. six patients (54.5%) presented with flank pain, three (27.2%) with haematuria and two (18%) with dysuria. in almost all cases, horseshoe kidney was diagnosed in ultrasonography of abdomen. intravenous urography was also done. in six cases (seven renal units) after 2015 ad, ct urography was done. in ten renal units, percutaneous access was made through upper pole calyx and in remaining two units, through the middle calyx. the mean operating time from puncture to placement of nephrostomy drain tube was 70.3 minutes (sd = 25.3) with range of 46-138 mins. the stone free rate was 83.3%. in two patients, residual stone was seen, one in isthmus and one in lower calyx. no auxillary procedure was done because when counselled for extracorporeal lithotripsy, they refused for it and decided to be on follow up. the mean hospital stay was 4.42 days (sd = 1.0) with range of three to six days. nephrostomy table 1. demographic profile and perioperative variables of the patients total patients 11 (12 renal units) gender male 8 female 3 pelvicalyceal access (n, %) upper pole access 10 renal units (83.3%) mid calyceal access -2 renal units (17.3%) mean stone burden (mm2) 385.8 (sd = 331.8) (range 125 1325) stone clearance rate (n, %) 83.3 (10 renal units) operating time (minutes) 70.3 (sd = 25.3) (range 46 138 ) hospital stay (days) 4.4 (sd = 1) (range 3 6) fig 2: (a) x-ray plain kub showing stones in both horseshoe kidneys, (b) kub of same patient after pcnl on right side a b descriptive data analysis was done using statistical package for the social sciences (spss) version 20. descriptive results were presented as mean, standard deviation, frequency, and percentages. categorical data were analysed by using fisher exact test. p value less than 0.05 was considered significant. j. lumbini. med. coll. vol 6, no 2, july-dec 2018 jlmc.edu.np dongol ums. et al. outcome of percutaneous nephrolithotomy in horseshoe kidneys tube drain was removed on the third postoperative day. the complications noted were of claviendindo grade i and ii. fever with chills was seen in one patient. dj stent was removed and appropriate antibiotic was given. prolonged urine leak (up to 36 hours after removal of dj stent) was seen in one patient. one patient needed blood transfusion with hemoglobin dropping to 8.5 gm%. mean haemoglobin drop was 1.06 gm (sd = 0.7). there were no major complications of bowel and pleural injury. all the punctures made were infracostal. comparison of variables of patients with horseshoe kidneys undergoing pcnl is presented in table 2. it shows that none of the factors are statistically significant. one can consider laparoscopic or robotic approach in these circumstances for pyelolithotomy along with pyeloplasty.[10,15] percutaneous surgery is effective, safe and is the most commonly performed treatment modality in patients with stones in the horseshoe kidneys.[16] the atypical anatomical orientation of calyces and pelvis with high lateral insertion of the ureter makes the spontaneous passage of fragments after lithotripsy less likely. the reported stone clearance rate in horseshoe kidney in eswl is 28-78%.[17] overall the stone burden in anomalous kidneys is usually higher than in normal kidneys. [18] wickham and kellet in 1981 and clayman in 1983 first reported percutaneous extraction of stones in horseshoe kidneys. since then it has been widely accepted as the standard treatment for stones greater than two cm or when eswl has failed.[10] during percutaneous access in horseshoe kidneys, one should consider that there are two main factors different from the normal renal anatomy eg the blood supply and the orientation of the pelvicalyceal system. the blood supply to horseshoe kidneys except to the isthmus is on its ventromedial aspect but the access is made on the dorsolateral side. the blood supply to isthmus is protected by spine and are thus away from the access tract to the pelvicalyceal system. therefore the risk of bleeding during pcnl is not higher than in normal kidney.[19] in normal kidneys, the percutaneous access to the upper pole calyx often requires supracostal puncture with increased risk of pleural injury. however in horseshoe kidneys due to the inferior displacement of kidneys away from the pleura, upper pole access is relatively safe. moreover, the nephroscope lies in alignment with the long axis of the kidney making easy access to the upper calyces, renal pelvis, lower calyces, pelviureteric junction and upper proximal ureter minimising the nephroscope torque on renal tissue.[20,21] in our study, we had upper pole calyceal access in 10 renal units and mid calyceal access in two renal units without any pleural and bowel injury. though ct scan abdomen was recommended by al-otaibi in every case before surgery due to abnormal relationship with other viscera, we had done ct abdomen in only six cases (seven renal units) from 2015. there was no difficulty in getting percutaneous access to the pelvicalyceal system before 2015.[22] commonest presentation of patients in our study was flank pain (54.5%) followed by haematuria (27.2%) and dysuria (18.4%) comparable to the study table 2. comparisions of variables of patients with horseshoe kidneys undergoing pcnl variables stone free residual stone p* age (years) 21-35 5 1 1 36-52 4 1 sex male 8 renal units (7 patients) 1 0.49 female 2 1 anatomical stone location solitary in pelvis 5 0 0.09 solitary in lower calyx 2 0 staghorn with multiple stones in different calyces 1 0 multiple stones in lower calyces including one in isthmus 2 2 * fisher exact test discussion: various treatment modalities have been used for the stones in horseshoe kidneys. they include extracorporeal shockwave lithotripsy(eswl), retrograde intrarenal surgery (rirs), percutaneous nephrolithotomy (pcnl) and laparoscopic/robotic surgery. many of these treatment options have their own limitations eg. eswl has very low stone clearance especially in stones larger than two cm.[5] since horseshoe kidneys are frequently associated with ureteropelvic junction obstruction, laparoscopic or robotic surgery is an option with excellent results. j. lumbini. med. coll. vol 6, no 2, july-dec 2018 dongol ums. et al. outcome of percutaneous nephrolithotomy in horseshoe kidneys jlmc.edu.np by symons sj et al.[21] the mean stone burden was 385mm2 (sd=331.8, range 125-1325) and the mean operating time from puncture to the completion of the procedure was 70.3 minutes (sd=25.3, range 46-138 ) the stone clearance rate in our study was 83.33% at six weeks. in two patients (two renal units), when counselled for auxiliary procedure ,they chose to be on follow up later on. therefore no auxiliary procedure was done. the stone free rate regarding the age and sex of the patients was not statistically significant. the anatomical location of the stone is considered to affect the stone free rate though the statistical value was not significant in our study probably due to small sample size. the residual stone in our study was in lower calyx and in the isthmus. most of the series of pcnl in horseshoe kidneys report the stone free rate from 72%-91%. [23,24] in the study by ercan bas et al., the stone free rate was 86%.[25] though the complications are less affected by the abnormal anatomy of horseshoe kidneys, stone burden, demographic and operative parameters, the stone complexity, location and multiplicity are reported to determine the stone free status.[26] similarly the stone free rate in the series of 64 renal units (45 patients) by blackburne at et al. was 81.1% with the complications of clavien grade ii in three patients(4.68%).[27] different studies of pcnl in horseshoe kidneys and their results is shown is table 3. the complications encountered in our study were of clavien-dindo grade i and ii and were seen in three patients (27.27%). one patient got fever with chills and was managed by appropriate antibiotics and dj stent was removed. there was prolonged urine leak up to 36 hours after removal of nephrostomy tube in one patient. one patient needed blood transfusion.the mean drop of haemoglobin was 1.06 gm% (sd=0.76). all the punctures were made infracostal without pleural and bowel injury. most of the series of pcnl in horseshoe kidneys have reported the complication rate from 0-16.7%. [23,17] in the series of 21 patients by etemadian m et al. and of seven patients by ercan bas et al, the complication rate was 14% and 28.5% respectively. [24,25] similarly, salahhedin et al. reported the complication rate to be 47.5% with the clavien grade iiia being only 8.7%.[28 ] limitations: extracorporeal shockwave lithotripsy (eswl) and retrograde intrarenal surgery(rirs) could be good options for smaller single stone in patients with horseshoe kidney. we do not have these armamentarium in our institute at present. moreover, the stone free rate in horseshoe kidney is believed to increase with the flexible nephroscope especially with the stones in the isthmus and lower calyx which are sometimes inaccessible with rigid nephroscope. unfortunately flexible nephroscope is also not available in our institute. conclusion: percutaneous nephrolithotomy is safe, feasible and is an effective method in the management of stones in the horseshoe kidneys with excellent stone free rate and minimal complications. it does not carry the increased risk than reported for the normal kidneys. however it requires careful preoperative planning and the operating surgeon needs to be alert for all possible intra and postoperative complications. additional info: competing interests: none declared financial disclosure: no funds were available acknowledgement: • entire ot staff family, kmcth. • dr naresh manandhar table 3: different series of pcnl in horseshoe kidneys and their results series n upper pole access (%) complications (%) stone free rate (%) auxiliary procedure (%) stephanie et al [21] 47 48 23 88 34 lingermann je et al [26] 17 81 29 84.6 73 al-otaibi and hosking [22] 12 75 42 75 8.3 etemadian et al [24] 21 66.64 9.52 71.4 not available our study 11 (12 renal units) 83.3 27.27 83.3 0 j. lumbini. med. coll. vol 6, no 2, july-dec 2018 jlmc.edu.np dongol ums. et al. outcome of percutaneous nephrolithotomy in horseshoe kidneys references: 1. baur bs. anomalies of form and fusion, crossed renal ectopia with and without fusion. alan j, editor wein: campbell-walsh urology book 9th edition. philadelphia: wb saunders; 2007,p 3269-304. 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https://doi.org/10.1089/ end.2011.0146 pmid: 21790475 11. lanz ag, honey rjd. lumbar plexopathy as a complication of percutaneous nephrolithotomy in horseshoe kidneys. cuaj. 2015;9(1-2):78-80. https://doi.org/10.5489/ cuaj.2468. pmid: 257377674 12. turk c, knoll t, petric a, sarica k, skolarikos a, straub m et al. guidelines on urolithiasis. european association of urology. 2016. https://uroweb.org/wp-content/uploads/ eau-guidelines-urolithiasis-2016 13. gaurav p, sinha rj, jhanwar a, bansal a, singh v. outcome of percutaneous nephrolithotomy in anomalous kidneys. is it different? urol. ann.2017;9(1):23-26. https:// doi.org/10.4103/0974-7796.198836 14. yohannes p, smith ad. the endourological management of complications associated with horseshoe kidney. j urol.2002;168(1):5-8 review. pmid: 12050480 15. olcucuoglu e, camtosun a, bicer s, bayraktar am. laparoscopic pyelolithotomy in a horseshoe kidney. turk j urol. 2014;40(4):240-44. https://doi.org/10.5152/fud 2014.73604 pmid: 26328185 16. sohail n, albodour a, abderlrahman km, bhatti kh. supine percutaneous nephrolithotomy in horseshoe kidneys. journal of taibah university medical sciences. 2017;12(3):261-64. https://doi.org10.1016/j.jtumed 2016.12005 17. viola d, anagnotsu t, thompson tj, smith g, moussa sa, tolley da. sixteen years of experience with stone management in horseshoe kidneys. urol int. 2007;78(3):214-18. 18. braticevici b, salahedin y, ambert v, petca rc, diaconescu d, rascu s et al. complications of percutaneous nephrolithotomy classified by the modified clavien grading system-a single center experience over 18 months. revista romana de urologie.2014;13(1):18-22.https:// pdfs.semanticscholar.org/dfb3/b40dde697 19. janetschek g, kunzel kh. percutaneous nephrolithotomy in horseshoe kidneys. applied anatomy and clinical experience. bju int.1988;62:117-22. https://doi. org/10.1111/j.1464-410x.1988 20. miller nl, matlaga br, handa se, munch lc, lingerman je. the presence of horseshoe kidney does not affect the outcome of percutaneous nephrolithotomy. j endourol.2008;22(6)1219-25. https://doi.org/10.1089/ end.2008.0051 pmid: 18484885 21. symons sj, ramachandran a, kurien a, baiysha r, desai mr. urolithiasis in the horseshoe kidney: a single centre experience. bju int.2008;102(11)1676-80.https://doi. org/10.1111/ j.1464-410x2008.07987 pmid: 18782315 22. al-otaibi k, hosking dh. percutaneous stone removal in horseshoe kidneys. j urol. 1999;162:674-77. pmid: 10458339 23. tepelar a, sehgal pd, akman t, unsal a, ozyuvali e, armagan a et al. factors affecting outcomes of percutaneous nephrolithotomy in horseshoe kidneys. urology. 2014;84(6):1290-94. https://doi.org/10,1016/ j. urology 2014.08.008 pmid: 25304208 24. etemadian m, maghsoudi r, abdollahpour v, amjadi m.percutaneous nephrolithotomy in horseshoe kidneys. our five year experience. endourology and stone disease. 2013; 10(2):856-60. https://pdfs,semantics scholar. org/1d32/83c pmid: 23801467 25. bas e, altok m, umul m, gunes m. percutaneous nephrolithotomy in horseshoe kidneys: our first experience. journal of urological surgery.2015;1:17-21. https://doi.org/10.4274/ jus.236 26. lingerman je, saw kc. percutaneous operative procedures in horseshoe kidneys. the journal of urology.1999; 161:371. https://doi.org/10.4274/ jus.236 27. blackburne at, rivera me, gettman mt, patterson de, krambeck ae. endoscopic management of urolithiasis in horseshoe kidney. urology. 2016; 90:45-49. https://doi. org/10.1016/j.urology 2015.12.042 pmid: 26772644 28. salahhedin y, petca rc, predoiu g, danau ra,petca a, mastalier b, badiu dc et al. percutaneous nephrolithotomy for the treatment of urolithiasis in horseshoe kidneys. proc.rom. acad. series b.2017;19(2):87-92. www.acad.ro/ sectii2002/proceedingschemistry/doc2017-2/art04.pdf lmc journal vol. 2.indd 62 original article l m coll j 2013; 1(2): 62-65 prevalence of low calorie intake by rural families in palpa district of nepal ghimire m and ghimire m department of community medicine,lubmini medical college, palpa corresponding author: dr. madhusudan grimire, asistant professor, department of community medicine, lubmini medical college, palpa, nepal; e-mail: madhumds@gmail.com abstract background: healthy popula on is indispensable for na onal development. adequate food intake by people is the key determinant to keep up their health. malnutri on nevertheless remains pervasive in developing countries, undermining people’s health, produc vity, and o en their survival. food insecurity and hunger remain persistent in nepal. prevalence of low calories intake by rural family is widespread throughout the country popula on. mainly marginalized communi es, ethnic group with poor economic status, tradi onal socie es and lower cast people are exposed to food defi cit. objec ve: to inves gate the prevalence of low calories intake by rural families and its associated determinants in palpa district. materials and methods: the cross-sec onal study was designed to achieve objec ve of the research. a random sample of 339 families was selected from rural areas (dumre, damkada, gorkhekot and telgha villages) of this district. data were analyzed by using the spss so ware for windows (version 16.0). results: the existence of inadequate food calorie intake among rural families was most common. most of them were fall under the malnutri on. conclusion: low calorie intake by ethnic group was considerably higher than other groups in community. key words: demographic variables, low food calories intake, malnutri on and palpa district introduction freedom to work and the right to enjoy a healthy life are enshrined in the cons tu ons of most of the countries as fundamental rights of its ci zens. however this freedom does not always guarantee enjoyment of good health for the poor ci zens of many developing countries. most of the developing na ons are plagued by problems of under nutri on and a host of infec ons.1 nutri on is an input to and founda on for health and development. be er nutri on is a prime entry point to ending poverty and a milestone to achieving be er quality of life.2 adequate nutri on is essen al in early childhood to ensure healthy growth, proper organ forma on and func on, a strong immune system and neurological and cogni ve development.3,4 undernutrition leads to increased mortality and morbidity which lead to loss of economic output and increased spending on health, individuals are less productive (both due to physical and mental impairment),and that children benefit less from educa on.5 inadequate nutri on is perhaps the most important problem facing the poor people in the world today. in spite of the progress made in improving nutrient availability in the last decade, a large propor on of poor households in developing countries s ll have inadequate access to suffi cient food.6 although per capita daily calorie intake in developing countries has increased substan ally in the last decade, the number of undernourished people is s ll around 923 million and the recent food price increases has also triggered an increase in hunger worldwide.7 malnutri on is a complex condi on that can involve mul ple, overlapping defi ciencies of protein, energy and micronutrients. the underlying causes are illnesses, poor dietary intake, lack of sanita on and hygiene, lack of mothers’ educa on, lack of awareness, lack of appropriate educa on, cultural prac ces and taboos, women’s low social status, poor transport linkages and low levels of agricultural technology, lack of poli cal will to improve the situa on and inadequate complementary feeding.8,9 protein energy malnutri on (pem) remains a major public health problem in nepal to such extent that it is the most common cause of childhood morbidity and mortality. nepal has a very high rate of child malnutri on: half (49%) of children under fi ve are stunted and one third (39%) are underweight. maternal undernutri on is also a signifi cant problem in nepal. the economic costs of malnutri on are very high – an es mated 2-3 % of gdp.10 since 1990, at na onal level, overall food produc on is defi cit and nepal has been a net cereal importer for most years during the last two decades.11 poverty and malnutri on in nepal are characterized by considerable regional and ethnic varia on.12 materials and methods the cross-sectional study was designed to investigate the prevalence of low calories intake by rural 63 m ghimire et al families in palpa district of nepal. sample size of 339 was calculated assuming margin of error 5%, non-response rate 10% with 95% confidence interval (ci). a random sample of 339 families was selected from rural areas (dumre, damkada, gorkhekot and telgha villages) of this district. after getting the consent form concern authorities, local people and respondents, a structured questionnaire and checklist of food items (rice/wheat, potato, pulses, meat, fish, milk, eggs, vegetables, and fruits) were used to collect information (amount of continue three-day food consumed by family) from head of household (data collection period was december 2012 to june 2013). actual intake of calories by families was compared with the multiplication result of expected calories consumption and consumption unit. data were analyzed by using the spss software for windows (version 16.0). chi-square test was used to find out association of ordinal variables as: family type, house type, occupation and cast, with nutritional outcome. anonymity of the respondents and their views were maintained in the study. results the study stated that sixty nine percent of respondents were connected to the nuclear family system. most of them (41.9 %) were magar. unemployment rate was 9.4% and most of them (52.2%) had their own pucca house table-1. table 1: socio-demographic characteris cs of the respondents 1. family type nuclear 234(69.0) joint 105(31.0) 2. caste brahmin 60(17.7) kshetri 66(19.5) magar 142(41.9) schedule cast 53(15.6) janaja (except magar) 18(5.3) 3. house type kaccha 162(47.8) pucca 177(52.2) 4. occupa on unemployed 32( 9.4) teacher 32( 9.4) farmer 82( 24.2) business 117( 34.5) others 76( 22.4) results from the study found that 66.96% families were suffering from malnutrition in study areas (fig. 1.). table 2: shows that family type, cast, occupa on and house type were strongly associated (p=0.000) with calories intake by families. fig 1: prevalence of malnutri on discussion dietary assessment is a process designed to determine what kinds of foods a person is consuming and in what amounts. the present study was conducted to fi nd out whether families are mee ng their dietary needs and to iden fy associa on between demographic veriables and nutri onal outcome. united na ons universal declara on of human rights 1948 ar cle 25 stated that “everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, and housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”13 but the food and nutri on security remain most fundamental challenge for human welfare and for economic growth. in many countries, suffi cient food to meet the needs of all ci zens is not even available at a na onal level.14 nepal is a food defi cit, land locked and table 2: impact of demographic variables on nutri onal status of the families n =339 1. family type calories intake less than 2400kcl 2400kcl total nuclear 122 112 234 joint 105 0 105 pearson chi-square value (75.053), df (1 ), (p=0.000) 2. cast brahmin chhetri magar only schedule cast indigenous pearson chi-square value (1.149) df(4), (p=0.000) 3. occupa on unemployed 32 0 32 teacher 11 21 32 farmer 82 0 82 business 71 46 117 others 31 45 76 pearson chi-square value (97.222), df(4), (p=0.000) 4. house type kaccha 127 35 162 pacca 100 77 177 pearson chi-square value(18.334), df(1), (p =0.000) 64 journal of lumbini medical college least developed country. around forty nine percent of under-fi ve children are chronically malnourished.15 about eighty per cent of nepal's people live in rural areas and depend on subsistence farming for their livelihoods. poor rural people in nepal generally have large families, very small landholdings or none at all, and high rates of illiteracy, concentrated in specifi c ethnic, caste and marginalized groups, par cularly those of the lowest caste (dalits), indigenous peoples (janaja s) and women. household food insecurity and poor nutri on are major concerns in these areas.16 the fi rst health survey of nepal which was done in 1965/66 among the 6,321 people from 957 households from nineteen diff erent sites of country found that the diet as a whole was lacking in protein, calcium, vitamin a, riboflavin and ascorbic acid.17 a randomsampled nutri on survey conducted in mugu and humla districts also showed a precarious nutri on situa on.18 na onal nutri on council of bangladesh es mated that about 45-51% of the total popula on in bangladesh were poor based on their calorie consump on. the prevalence of poverty and resul ng low calorie consump on was higher in rural than in urban areas.19 the calorie intake by people of sub-saharan africa found 2098kcal/capita/day only.20 similar situa on has observed in other developing countries as: na onal sample survey organiza on of india conducted a study during 2004 2005 found that average daily intake of calories by rural popula on had 2047 kcal.21 above situa ons have indicated the food calories intake by rural people in developing countries was found to be low, so it could be key determinant to decline the level of public health in such countries. results of the study revealed that, low calories intake among the families was widespread and persistent in rural palpa. the prevalence of low calories intake by families was to be 66.96%. a study conducted by national nutrition monitoring bureau (nnmb) at diff erent me in india also showed that prevalence of under nutri on in adults was higher in rural areas as compared to urban areas but majority of the urban popula on who could work in white or blue collar jobs, their energy expenditure for these ac vi es was low, where average intake of calories by men was 2000 kcal energy/capita/day only.22 another survey carried out by nnmb in the rural communi es of nine states viz. kerala, karnataka, tamil nadu, andhra pradesh, maharashtra, madhya pradesh, gujarat, orissa and west bengal found that the propor on of preschool children underweight was about 55%, while that of severe underweight was 18%. 33% males and 36% females had chronic energy deficiency. food and nutrient intake levels were rela vely lower in kerala compared to other states, but the prevalence of under nutri on among young children was low.23 welfare of a household depends on nature of occupa on, socio economic condi on house type and family type or size, which in turn is based on the nature of the work of the main household earner. all of these veriables are most important to determine level of calorie consump on.24 present study indicated that the demographic variables as: family type, occupa on of head of the household and type of house were strongly associated (p<0.000) with low calories intake by families as compared to the result from a study conducted by masuma khatun, sm ziauddin hyder, abbas bhuiya and mushtaque chowdhury in bangladesh, where the associa on between occupa on of the household head and family size with prevalence of low calorie consump on among the rural families was signifi cantly (p<0.001) observable.25 conclusion most of the indigenous families could spend their life with low calories intake. nature of occupa on, socio economic condi on house type and family type or size found to be strong predictors to nutri onal outcome in rural communi es of palpa district. references 1. thomas v. health care in developing countriesneed for fi nance, educa on or both? calicut med j 2009; 7(1): 1. 2. briend a, prinzo zw. dietary management of moderate malnutri on: time for a change. food nutri on bull 2009; 30(3): 265-6. 3. liu l et al. global, regional, and na onal causes of child mortality: an updated systema c analysis for 2010 with me trends since 2000. who/unicef. 2012; 379:2151– 61. 4. black re et al. maternal and child undernutri on: global and regional exposures and health consequences. lancet. 2008; 371: 243-60. 5. behrman j h, alderman, hoddinott j. “hunger and malnutri on”. in b.lomborg (ed.) global crises, global solu ons. cambridge (uk): cambridge university press. 2004. 6. abdulai a, aubert d. nonparametric and parametric analysis of calorie consump on in tanzania. food policy 2004; 29(2): 113-29. 7. fao. an introduction to the basic concepts of food security: food security informa on for ac on prac cal guides. fao food security programme. 2008. 8. unicef. facts sheet: the state of the world’s children. 1998. 9. food and agriculture organiza on. assessment of food security and nutrition situation in nepal. food and agriculture organiza on of the united na ons. 2010; 14. 10. world bank. nutri on in nepal: a na onal development priority 2012. retrived from www-wds.worldbank.org/.../ pdf/683780wp0p1235000 nutri on0in0ne 68378. 11. fao. nepal food security and nutri on monitoring/early system assessment of current system, project design and proposal. 2008. 65 m ghimire et al 12. central bureau of sta s cs/ nepal,united na ons world food programme nepal / the world bank. small area es ma on of poverty, caloric intake and malnutri on in nepal. cbs nepal. 2006; 1. 13. united na ons. united na ons universal declara on of human rights 1948. ar cle 25. 1949; 5. 14. naiken l. fao methodology for es ma ng the prevalence of undernourishment. in measurement and assessment of food depriva on and undernutri on. proceedings of an interna onal scien fi c symposium convened by the agriculture and economic development analysis division, food and agriculture organiza on of the united na ons. fao. 2002; 6: 26–28. 15. undp. human development report 2009. overcoming barriers: human ability and development. oxford university press, new york. 2009. 16.united na ons development programme. rural poverty in nepal. human development report 2013. undp. 2013.17. brown ml, worth rm, shah nk. health survey of nepal. am j clin nutr 1968; 21(8): 875-81. 18. united na ons system standing commi ee on nutri on. nutri on informa on in crisis situa ons report no. 9 summary results of a nutri on and mortality survey in humla and mugu districts, karnali province, nepal. 2006; 5:7. 19. na onal nutri on council. state of nutri on in bangladesh. bnnc, dhaka. 1995. 20. cornelia fa et al. estimation of undernutrition and mean calorie intake in africa: methodology, fi ndings and implica ons. interna onal journal of health geographics 2009; 8: 37. 21. ministry of sta s cs and programme implementa on of india. na onal sample survey organiza on. nutri onal intake in india 2004-05. nss 61st round july 2004 – june 2005. nsso, new delhi.2007; 500. 22. ramachandran, p. dietary intake, physical activity and nutri onal status of indian adults. nfi bulle n. 2008; 29:3. 23. brahmam gn et al. diet and nutritional status of popula on and prevalence of hypertension among adults in rural areas. na onal ins tute of nutri on hyderabad. 2006: 143. 24. mizoguchi t. socioeconomic characteris cs of poverty. asian development review (studies on asian and pacifi c economic issues). asian development bank, philippines. 1990; 8 (1): 18-43. 25. khatun m, ziauddin hyder sm, bhuiya a, chowdhury m. eff ect of brac's rural development programme on calorie consump on: evidence from matlab. working paper no. 26. brac-icddrb joint research project. bangladesh.1998: 18. hemodynamic changes during laproscopic cholecystectomy at lumbini medical college nil raj sharma,a,d pradeep timalsena,b,d sundip dc,c,d sarad pantheec,d —–————————————————————————————————————————————— abstract: introduction: laparoscopic cholecystectomy is preferred to open cholecystectomy for several reasons. patients can be discharged home earlier. they have less pain in comparision to open cholecystectomy. this study aims to investigate the pneumoperitoneum-induced haemodynamic and ventilatory changes in patients undergoing laparoscopic cholecystectomy (lc). methods: it was a prospective study comprising 400 patients of the age 15 years to 75 years of both sex (males n=80 and females n=320). the study was conducted in lumbini medical college palpa over the two year period in jan 2010 and dec 2012. the variables recorded were: mean arterial pressure (map), end-tidal co2, peak and plateau airway pressures and heart rate. data were collected immediately after induction of anesthesia at five minutes after peritoneal insufflations and tilting the table into 30° head-up position at 10 min and finally at 10 min after exsufflation. results: there was decrease in map after head up position but there was little change after pneumoperitoneum. more the weight of the patients, more is the increased airway pressure. the end tidal co2 remained increased after pneumoperitoneum. conclusion: peritoneal insufflation of co2 to create the pneumoperitoneum and tilting the patient to the head-up position necessary for laparoscopy induces intraoperative ventilatory and hemodynamic changes that complicate anesthetic management of laparoscopy. keywords: capnography • haemodynamic changes • laproscopic cholecystectomy • pneumoperitoneum ——————————————————————————————————————————————— ___________________________________________________________________________________ a associate professor b lecturer c medical officer d department of anesthesiology and critical care lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. nil raj sharma e-mail: nilrajnp@gmail.com how to cite this article: sharma nr, timalsena r, dc sundip, panthee s. hemodynamic changes during laproscopic cholecystectomy at lumbini medical college. journal of lumbini medical college. 2013;1(1):43-5. doi:10.22502/jlmc.v1i1.13. ___________________________________________________________________________________ j. lumbini. med. coll. vol 1, no 1, jan-june 2013 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v1i1.13 introduction: laparoscopic cholecystectomy (lc) is preferred to open cholecystectomy (oc) for several reasons.1 patients are characterized by physiological alterations in circulatory and respiratory functions during lc.2 old patients are more prone to haemodynamic changes than are younger patients.3 several investigators have studied on the haemodynamic consequences of a lc in asa i-ii young and healthy patients.4-6 there is alterations in the ventricular loading conditions resulting from the increased intra abdominal pressure.7 all these studies indicated that haemodynamic alterations are potentially deleterious in patients such as elderly patients with limited cardiac reserve. also, the pneumoperitoneum in a head-up position is responsible for ventilatory changes.8 the respiratory behaviour in the elderly during this type of surgery is unknown.9 methods: all 400 patients between 15 to 75 years of age with asa grade i-ii who underwent lc were included in this study. informed consent and weight of all the patients were taken before surgery. all patients were premedicated with 0.15 mg/kg diazepam the day before surgery. general anesthesia (ga) was induced with 0.8mg/kg pethidine, 5 mg/ kg of thiopentone sodium. injection vecuronium 43 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np sharma nr. et al. hemodynamic changes during laproscopic cholecystectomy 0.1 mg/kg was given to facilitate tracheal intubation and maintenance of anaesthesia. after tracheal intubation, ga was maintained with nitrous oxide (60%) in oxygen and halothane. non invasive arterial blood pressure, electrocardiogram (ecg), heart rate, capnography, and pulse oximetry were monitored during surgery. the expired end-tidal co2 was monitored continuously by a mainstream or side stream analyzer. during laparoscopy, intraabdominal pressure was maintained at 12 to 14 mm hg by a co2 insufflator. the variables recorded were: mean arterial pressure, end-tidal co2, peak and plateau airway pressures and heart rate. data were collected immediately after induction of anesthesia at 5 min, after peritoneal insufflations and tilting the table into 30° head-up position at 10 min (routine procedure during lc) and finally at 15 min after exsufflation. results: the maximum number of cases were between the age 26-35 (24%) in females and 46-55 (4.75%) in males. there were total of 320 (80%) females and 80 males (20%). the male: female ratio is 1:4. table 1 shows that higher the weight of the patients more the change in airway pressure. the change in airway pressure after co2 insufflation was seen maximum in patients > 80 kg (average change of 8 cm of h2o). this finding was statistically significant p<0.05. table 2 shows that the heart rate and the mean arterial pressure were increased after induction of anaesthesia in all patients. this increase was statistically not significant, p>0.05. table 1:average change in airway pressure according to weight of the patients weight (kgs) airway pressure before insufflation airway pressure after insufflation mean change >80 22 30 8 (36.4%) 71-80 20 25 5 (25%) 61-70 19 23 4 (21%) 50-60 17 19 2 (11.7%) <50 16 17 1.3 (8.1%) table 2: hemodynamic changes before pneumoperitoneum (mean value) hemodynamics before induction after induction mean arterial pressure 82 89 (8.5% increased) heart rate 73 84 (15.07% increased) table 3: hemodynamic changes after pneumoperitoneum (mean value) hemodynamics before induction at 5 minutes at 10 minutes end of surgery mean arterial pressure (mm hg) 82 88 (increased by 7.31%) 93 (increased by 13.41%) 108 (increased by 31.70%) heart rate (per minute) 73 79 (increased by 8.22%) 76 (increased by 4.11%) 94 (increased by 28.76%) table 4: ventilatory changes (mean of 400) airway pressure (cm h2o) after induction head up position pneumoperitoneum at 5 minutes pneumoperitoneum at 10 minutes peak 17 14 (decreased by 17.64%) 23 (increased by 35.3%) 24 (increased by 41.18%) plateau 11 10 (decreased by 9.1%) 19 (increased by 72.73%) 19 (increased by 72.73%) table 5: end tidal co2 (mean of 400 patients) before pneumoperitoneum after pneumoperitoneum percent change 22 mm hg 27.6 mm hg 25.45% table 3 shows that haemodynamic changes with respect to mean arterial pressure and heart rate are increased by 31.70% and 28.76 % respectively at the end of surgery but there is minimal change at 5 and 10 minutes. these changes were statistically significant p<0.05. ventilatory changes in table 4 shows that peak and plateau both airway pressure were decreased during head up position and both were increased at 5 and 10 minutes (41.18% and 72.73% at 10 minutes) of pneumoperitoneum which was statistically significant, p<0.05. end tidal co2 was increased by 25.45% after pneumoperitoneum was created (table 5). this finding was statistically significant, p<0.05. discussion: this study shows that a co2 pneumoperitoneum and head-up tilt is well tolerated 44 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 sharma nr. et al. hemodynamic changes during laproscopic cholecystectomy jlmc.edu.np by all patients with regard to haemodynamic patterns and gas exchange. similar studies have revealed that creation of co2 pneumoperitonium at 12–14 mmhg has not induced major haemodynamic changes.10 our study also reveals that some haemodynamic changes were observed during co2 pneumoperitoneum and head-up tilt .there was significant change (p<0.05) in mean arterial pressure and heart rate after pneumoperitoneum at the end of surgery. more is the weight of the patient, greater is the change in the air way pressure which was statistically significant (p<0.05) in our study. but lesser the weight minimum change in airway pressure was observed. in case of elderly patients they do have some physiological cardiac and circulatory alterations that resulted in a decrease in myocardial performance which alters the haemodynamic changes.11 cardiac preload could have compromised myocardial function.12 lc procedures induce haemodynamic disturbances in asa iii-iv patients.10,13 these occur even in healthy asa i-ii patients mainly because of decreased preload and increased afterload.5,13-14 in our study there was increased level of end tidal co2. it was increased by 25.45 % (p<0.05). that is why the monitoring of et.co2 has been shown to be useful. like in our study majority of other studies concerning gas exchanges during lc have reported an increase in etco2. it is generally considered to be moderate in asa i or ii patients.15 however, high levels of end tidal carbon dioxide have been described during lc, especially in patients with previous copd or in asa iii-iv patients.16 this is the reason that the end tidal co2 monitoring is essential during lc. conclusion: creation of pneumoperitoneum during lc can alter the haemodynamic and ventilatory parameters. the changes in end tidal co2, map, heart rate and ventilatory parameters are the main indicators used for hemodynamic stability of patients undergoing lc. references: 1. joris j, cigarini i, legrand m, jacquet n, de groote d, franchimont p et.al. metabolic and respiratory changes after cholecystectomy performed via laparotomy or laparoscopy. br j anaesth. 1992;69(4):341-5. 2. schauer pr, luna j, ghiatas aa, glen me, warren jm, sirinek kr. pulmonary function after laparoscopic cholecystectomy. surg. 1993;114:389-99. 3. critchley la, critchley ja, gin t. haemodynamic changes in patients undergoing laparoscopic cholecystectomy: measurements by transthoracic electrical bio-impedance. br j anaesth. 1993;70:681-3. 4. cunningham aj, turner j, rosenbaum s, rafferty t. transoesophageal echocardiographic assessment of haemodynamic function during laparoscopic cholecystectomy. br j anaesth. 1993;70(6):621-5. 5. joris j, honore p, lamy m. changes in oxygen transport and ventilation during laparoscopic cholecystectomy. anesthesiol. 1992;77(3a):a149. 6. joris jl, noirot dp, legrand mj, jacquet nj, lamy ml. hemodynamic changes during laparoscopic cholecystectomy. anesth analg. 1993;76(5):1067-71. 7. mc laughlin jg, bonnell bw, scheeres de, dean rj. the adverse hemodynamic effects related to laparoscopic cholecystectomy. anesthesiol. 1992;77:a70. 8. joris j, ledoux d, honore p, lamy m. ventilatory effects of co2 insufflation during laparoscopic cholecystectomy. anesthesiol. 1991;75:a121. 9. fox lg, hein hat, gawey bj, hellman cl, ramsay mae. physiologic alterations during laparoscopic cholecystectomy in asa iii and iv patients. anesthesiol. 1993;79:a55. 10. wahba rwm, mamazza j. ventilatory requirements during laparoscopic cholecystectomy. can j anaesth. 1993;40:206-10. 11. feig bw, berger dh, dougherty tb, dupuis jf, hsi b, hickey rc et al. hemodynamic effects of co2 abdominal insufflation (cai) during laparoscopy in high-risk patients. anesth analg 1994;78:s109. 12. gunnarsson l, tokics l, gustavsson h, hedenstierna g. influence of age on atelectasis formation and gas exchange impairment during general anaesthesia. br j anaesth. 1991;66:423-32. 13. wittgen cm, andrus ch, fitzgerald sd, baudendistel lj, dahms te, kaminski dl. analysis of the hemodynamic and ventilatory effects of laparoscopic cholecystectomy. arch surg. 1991;126:997-1001. 14. fitzgerald sd, andrus ch, baudendistel lj, dahms te, kaminski dl. hypercarbia during carbon dioxide pneumoperitoneum. am j surg. 1992;163:186-90. 15. feig bw, berger dh, dougherty tb, dupuis jf, hsi b, hickey rc et al. pulmonary effects of co2 abdominal insufflation (cai) during laparoscopy in high-risk patients. anesth analg. 1994;78:s108. 16. wittgen cm, naunheim ks, andrus ch, kaminski dl. preoperative pulmonary function evaluation for laparoscopic cholecystectomy. arch surg. 1993;128:880-6. 45 https://doi.org/10.22502/jlmc.v10i1.466 original research article self-assessed time span of focused attention during a breath focus test task as a measure of mindfulness: a preliminary evaluation lok raj joshi, a,d shaligram chaudhary, a,d bibek koju, b,d saurav dani, c,d anuska khadka c,d abstract: introduction: an easy task-based measure of mindfulness that can be self-administered in a daily life setting is still not available. we aimed to perform a preliminary evaluation of the breath focus test task to measure mindfulness. methods: a quantitative observational study was performed among medical students. each study participant was instructed to focus attention to the participant’s own breath and count each breath with awareness until the participant noticed mind wandering. the last breath count attended before losing awareness of the task (breath count with awareness) was recalled and self-reported by each participant. three such breath focus sessions were planned for each participant. mean ‘breath count with awareness’ of each participant was then converted to time span of focused attention using the rate of breathing. this time span of focused attention was reported as the proposed measure of mindfulness. each participant also completed the 'mindful attention awareness scale questionnaire'. results: out of 101 participants, 76 completed at least one breath focus session satisfactorily. median time span of focused attention was three minutes (first quartile = 1.9 minutes and third quartile = 4.5 minutes). the mindful attention awareness score was 3.9 (sd = 0.6). the results did not show a significant correlation between the time span of focused attention and the mindful attention awareness score (r s = 0.04, p = 0.74). conclusion: this study shows the feasibility of the proposed test task. however, the measure obtained from the current form of the test did not correlate with mindful attention awareness score. keywords: focused attention, measurement, meditation, mindfulness. introduction: mindfulness is most commonly defined as “the state of being attentive to and aware of what is taking place in the present”.[1] mindfulness practice and submitted: 31 october, 2021 accepted: 07 june, 2022 published: 03 july, 2022 a lecturer, department of physiology b assistant professor, department of physiology c final year medical student d lumbini medical college and teaching hospital, palpa, nepal corresponding author: lok raj joshi e-mail: lokraaj.joshi@gmail.com orcid: https://orcid.org/0000-0002-0734-9876 interventions have been found to play an important role in prevention and management of mental health issues like stress, anxiety, depression, etc.[1,2] it also plays a supportive role in the management of chronic physical illnesses like cancer, diabetes and obesity as well as in the promotion of occupational health.[3,4,5] besides this, a meta-analysis has suggested that mindfulness brings positive changes in the brain networks involved in attentional control how to cite this article: joshi lr, chaudhary s, koju b, dani s, khadka a. self-assessed time span of focused attention during a breath focus test task as a measure of mindfulness: a preliminary evaluation. journal of lumbini medical college. 2022;10(1):9 pages. doi: https://doi.org/10.22502/jlmc.v10i1.466 epub: 2022 july 03 j. lumbini. med. coll. vol 10, no 1, jan-june 2022 joshi lr. et al. self-assessed time span of focused attention during a breath focus test task which is beneficial for a wide range of cognitive functions.[6] self-reporting questionnaires are the most common tools currently in use to measure mindfulness whereas, some objective behavioral task-based measurements are also emerging.[7,8] meditation breath attention scores task, breath counting task and mindful awareness task are some proposed behavioral task-based measures to assess mindfulness. however, further improvements are required to capture the complex construct of mindfulness.[8] though the objective measures are generally more suitable than the self-reporting questionnaire-based scales for research purpose, such measures tend to be more complex and difficult-to-use for self-assessment and monitoring in daily life situations due to the need for sophisticated technology. therefore, we proposed a technique that we have named breath focus test task (bftt) as an easy to use, task-based, on-the-spot measure of mindfulness that could be self-administered without using advanced technology. we also expected that this proposed task-based measure of mindfulness could overcome some of the shortcomings of questionnaire-based measures like differences in the interpretations of the questions and the need to recall daily life experiences over time. breath focus meditation is a commonly practiced form of mindfulness meditation. published literatures suggest that increase in mindfulness is associated with better control of attention and non-reactive awareness.[6,7,9] based on this understanding, we expected that self-reported time span of focused attention (tsfa) defined as the duration of uninterrupted attention to breath during the bftt would reflect the mindfulness of the person. hence, this study aimed to perform the preliminary assessment of the bftt and to assess the correlation of tsfa with the score obtained from self-reporting questionnaire-based mindful attention awareness scale (maas). methods: the present study was a quantitative observational study conducted in the department of physiology, lumbini medical college and teaching hospital (lmcth), prabhas, palpa, nepal. the data was collected in a period of one month (26th august to 27th september, 2021) after the approval from the institutional review committee of lmcth (irc lmc 03-d/021). informed consent was obtained from each participant. basic measures for prevention and control of transmission of infection were adopted as follows: only the participants not having covid-19 diagnosis or related symptoms were included in the study. use of face masks, physical distancing of at least six feet, hand sanitization, non-sharing of pens or papers, daily disinfection of the frequently touched surfaces and proper natural ventilation of the room were also ensured. our inclusion criteria was the age range from 18-28 years and the exclusion criteria were presence of acute illness at the time of study, major psychiatric or sleep disorder and use of psychotropic drugs at the time of data collection. sample size and sampling technique: medical students volunteered for the study. the sample size was calculated as 95 expecting correlation coefficient of at least 0.3 (at least moderate monotonic correlation) between tsfa and maas setting the level of significance at 5%, power at 80% and accounting for an attrition rate of 10%.[10] a convenience sampling technique was used to obtain the required sample. pretesting : the breath focus test task (bftt) protocol and bftt-related pro-forma were conceptualized and developed by the authors themselves after a necessary literature review. bftt-related pro-forma and maas questionnaire were pretested before data collection among nine individuals divided into two groups: one consisting of four females and the other of five males. these individuals were not included in the main study. pretesting was carried out to make sure that the test task and the questions were comprehensible to the participants. j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np joshi lr. et al. self-assessed time span of focused attention during a breath focus test task breath focus test task (bftt) procedure: the breath focus test task was performed by the participants on an empty stomach having refrained from coffee or tea in the morning; refrained from alcohol in the last 24 hours and having a good night sleep. the test was conducted between 7:00 – 8:30 am in a normally lit well ventilated quiet room. the number of participants performing the breath focus test task per day varied from a single person to a small group of six (five on average). the participants were introduced to the bftt and the pro-forma by the principal researcher beforehand. for the test, each of the participants was instructed to sit with his/her eyes gently closed, comfortably on a cushion on the floor or a chair as per the participant’s preference. after a brief period of relaxation, the participant focused his/her attention to breathing sensation at the nostrils.[11] the participant attended to quiet breathing focusing on the nostrils for each inspiration and expiration followed by (i.e. not overlapping) respective count for the breath silently (within the mind). in other words, the sequence to be attended was breathing in, breathing out, count ‘one’, breathing in, breathing out, count ‘two’ and so on. hence, there were three elements to be attended to during each breath cycle namely breathing in, breathing out (both at the nostrils) and its mental count while still maintaining the focus at the nostrils. the participant terminated the bftt session when he/she noticed that he/she had missed any one of the three elements from his/her continuous awareness. the participant then recalled and immediately recorded, in the pro-forma, the last attended breath count up to which he/she had been continuously aware of all of the three elements (will be called just ‘breath count with awareness’ or bca henceforth). however, peripheral awareness of other sensations with the main focus still maintained on breath would not lead to termination of the breath focus session. the participants were instructed to note the mode of termination of a breath focus session i.e. whether the participant (a) forgot to continue counting or (b) did it automatically without awareness or (c) had low confidence in the continuity of awareness of the task or (d) experienced unforeseen major distractions or discomfort. if the case was (b) or (c), the participants also noted the breath count at the time of termination of the session called ‘breath count on termination’. whenever permitted by the time constraints (total duration of one hour and 30 minutes for a participant for all activities, namely signing the consent form, instructions, practice, breath focus sessions, rest sessions and completing the pro-forma), each of the participants performed a total of three such breath focus sessions in a row in the same sitting and the participant was given a rest period between two test sessions as desired by the participant. the rationale of obtaining data from multiple sessions was to average out the possible variation across the sessions. if a participant was not able to complete all three sessions, reports from the completed sessions were included in the analysis. each of the participants’ rates of breathing was recorded over one minute by the researcher during the test task by inspecting chest/shoulder movement with each breath. time span of focused attention (tsfa): the proposed measure of mindfulness: tsfa was defined as the duration of uninterrupted attention to breath during the bftt. tsfa (in minutes) of a participant was calculated by dividing breath count with awareness (bca) by rate of breathing (br per minute) i.e. tsfa = bca/br. for the participants' meeting criteria for satisfactory completion of two or three breath focus sessions, mean of the bcas was used in the above calculation. if only a single session met the criteria, bca from that session alone was used. tsfa had no predefined maximum possible score. pro-forma: the bftt-related structured pro-forma included questions in english language about: (1) the breath count with awareness, (2) the level of confidence (on a scale from 1-5) in that the participant reached that breath count (neither an earlier one nor a later one) during a breath focus session, (3) the level of confidence in the j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np joshi lr. et al. self-assessed time span of focused attention during a breath focus test task continuity of the awareness of the task before that count, (4) the level of relaxation during the session and (5) the mode of termination of the test i.e. whether the participant forgot to continue counting or did it automatically without awareness or had low confidence in the continuity of awareness of the task or experienced unforeseen major distractions and (6) the breath count the participant reached when he/she terminated the task i.e.‘breath count on termination’ (if applicable according to the mode of termination). the pro-forma contained three separate equivalent sections and a section was to be filled after each of the three breath focus sessions. the pro-forma also included information about the age, sex, prior experience with meditation and breathing rate during the task. the pro-forma was filled up by the participants themselves except for the space for breathing rate which was filled up by the researcher. criteria for satisfactory completion of a breath focus session: a breath focus session meeting all of the following criteria was considered to have been satisfactorily completed for the purpose of calculation of tsfa. 1. not terminated by unforeseen major distractions 2. having an acceptable level of relaxation (at least 3/5) 3. having an acceptable confidence level (at least 3/5) in the bca 4. having an acceptable confidence level (at least 3/5) in the continuity of awareness before the reported bca 5. not having incompatible reports of termination mode and breath count on termination. for example, if a participant reported that he counted up to 20 breaths with awareness, was for certain counting automatically at the time of termination of the session but reported that the breath count on termination was also 20. such incompatible reports might occur due to lack of understanding of the task. mindful attention awareness scale (maas): mindful attention awareness scale (maas) is an already validated probably most commonly used self-report measure of mindfulness.[1,12] english version of maas questionnaire was used for data collection after pretesting. maximum possible score for a participant is 6. reliability of the scale in our study as measured with cronbach’s alpha was found to be good (0.75; 95% ci, 0.67 0.82). data analysis: data analysis was carried out with microsoft excel and r (version r-4.1.1) using r packages ‘readr’ (version 2.0.2), ‘dplyr’ (version 1.0.7), ‘magrittr’ (version 2.0.1), ‘ggplot2’ (version 3.3.5) and ‘psych’ (version 2.1.9). the measures of central tendency were expressed as mean ± sd or median (first quartile third quartile). spearman correlation was used to assess the relationship between tsfa and maas. results: a total of 101 participants (53 females) participated in the present study. the age of the participants ranged from 19-28 years (21.5 ± 1.7 years). regarding their prior experience of meditation, the majority (65.3%) of the participants had not practiced it regularly though they had some experience of meditation while 23.8% had no prior experience of meditation (table 1). in total, 76 (75.2%) of all participants (n = 101) had at least one breath focus session meeting criteria for satisfactory completion (table 1). thirteen participants did not perform the third session of the bftt due to time constraints. out of the 290 sessions performed by all participants in total, unforeseen distraction or discomfort was reported as the mode of termination of the task in 101 (34.8%) breath focus sessions (table 2). table 3 summarizes breath focus test task-related findings. the average breath count with awareness (bca) of the study participants was 42.5 (27.3 -67.2). intersession breath count difference was defined as the difference between the maximum and the minimum bcas of a participant who had two or j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np joshi lr. et al. self-assessed time span of focused attention during a breath focus test task three satisfactorily completed sessions. corrected intersession difference was computed by dividing intersession breath count difference by his/her mean bca. the average intersession breath count difference was 20 (13 – 35) and average corrected intersession difference was 0.46 (0.28 0.73). table 1: baseline characteristics of the participants (n=101) variable n (%) prior meditation experience every day 4 (4.0) three or more days per week 3 (3.0) less than three days per week 4 (4.0) not regular but has some experience 66 (65.3) never practiced 24 (23.8) participants meeting criteria for satisfactory completion of the following number of breath focus sessions: nil 25 (24.8) one 31 (30.7) two 25 (24.8) three 20 (19.8) visual inspection of the histogram revealed that the time span of the focused attention (tsfa) did not follow the normal distribution (fig 1). table 2: frequency distribution of breath focus sessions with certain features (n = 290) breath focus session features n (% )* meeting the criteria for satisfactory completion 141 (48.6) terminated due to unforeseen distraction or discomfort 101 (34.8) without reports of reason for termination 4 (1.4) with relaxation level less than 3/5 or not reported 13 (4.5) with confidence in bca** less than 3/5 or not reported 5 (1.7) with confidence ‘in continuity of awareness of breath focus task before reaching the reported bca’ less than 3/5 or not reported 8 (2.8) with incompatibility among the reports of bca, mode of termination and breath count on termination 38 (13.1) total 290 (100) * the sum of the percentage values is greater than 100 as some of the breath focus sessions had multiple features in common. **bca: breath count with awareness j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np joshi lr. et al. self-assessed time span of focused attention during a breath focus test task the average tsfa (n = 76) was 3 (1.9 4.5) minutes. mean breath count on termination and mean time on termination for a participant were also calculated from the available data and the sample averages were also determined (table 3). fig. 1: histogram showing the frequency distribution of tsfa (time span of focused attention in minutes) fig.2 scatterplot showing relationship between tsfa (time span of focused attention in minutes) and maas (mindful attention awarenesss score) (r s = 0.04; 95% ci, -0.19 to +0.26; p = 0.74) the average maas score was 3.9 ± 0.6, (n = 101). there was negligible correlation between tsfa and maas (r s = 0.04; 95% ci, -0.19 to +0.26; p = 0.74). fig. 2 is the scatter plot showing the relationship between tsfa and maas score. table3: major findings (n = 76 unless specified otherwise) variable observation rate of breathing (breath cycles per minute) 14.6 ± 3.6 breath count with awareness 42.5 (27.3 67.2) intersession breath count difference 20 (13 35) corrected intersession breath count difference 0.46 (0.28 0.73) time span of focused attention (minutes) 3.0 (1.9 4.5) breath count on termination* (n = 57) 51 (33 80) time on termination (n = 57) 3.9 (2.3 6.4) maas** 3.9 ± 0.6 correlation between tsfa*** and maas r s = 0.04; 95% ci = [-0.19 to +0.26]; p = 0.74 *not applicable for the sessions in which a participant reported that he/she had forgotten to continue counting. **mindful attention awareness score, ***time span of focused attention j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np joshi lr. et al. self-assessed time span of focused attention during a breath focus test task discussion: the present study aimed to perform a preliminary evaluation of the breath focus test task (bftt) as a task-based technique to measure mindfulness. we determined the time span of focused attention (tsfa) during bftt and assessed its correlation with a self-reporting questionnaire-based measure of mindfulness namely the mindful attention awareness scale (maas). maas score of the participants in the present study was 3.9 ± 0.6. normative data based on previous 14 independent samples showed maas score of 3.83 ± 0.7 in college students.[13] in the present study, tsfa of the participants (n = 76) was three minutes (1.9 4.5 minutes). ziegler da et al., though using somewhat different paradigm, found that their participants had sustained attention to breath for about 20 seconds on the first day and for six minutes on average after 25 day-meditation-training.[9] differences in test paradigms and the levels of experience of the participants may account for the observed results. the preliminary evaluation showed that almost three fourth of the participants met the criteria for completion of at least one breath focus session. unforeseen distraction or discomfort was the major reason for not meeting the criteria. this might be overcome by adopting more rigorous attempts to minimize noise (e.g. with sound-proof laboratory setting, testing individually instead of testing in a group at a time). the core test-related factors namely incompatible answers to different questions, low confidence in the breath count or low confidence in the continuity of awareness before the count, low level of relaxation during the task were relatively uncommon. this indicates the feasibility of the technique. adopting more practice sessions or test sessions for each participant might further reduce the rate of incompatible answers or low confidence. contrary to our expectation, our results showed negligible correlation between tsfa and maas (r s = 0.04; 95% ci, -0.19 to +0.26; p = 0.74) which was not statistically significant. however, expected results would show a monotonic positive non-linear relationship between tsfa and maas. other behavioral measures of mindfulness have shown weak to moderate positive correlation with questionnaire-based trait mindfulness.[14,15,16] for example, mindfulness score as measured with breath counting task was found to correlate with maas (r = 0.20, p = 0.05).[15] there might be various explanations, mainly the limitations of the study setting, for not observing the significant correlation between maas and tsfa in our study. a possible limitation of the study method was that the reports of tsfa from our participants might not have been very reliable as many of them were not familiar with meditation. the basic understanding of the course of events during a bftt as described below is helpful in this regard. the format of a bftt session considerably matches with the real-life mindfulness practice (breath focus meditation) and is in line with the theoretical construct of mindfulness. in a typical breath focus meditation; there is an alternating sequence of attentional focus on breath followed by automatic attentional lapse or mind wandering, detection of mind wandering and willful refocusing on breath. the cycle repeats itself over and over throughout the typical meditation.[17] a bftt session differs only in that, to offer the report from a single cycle, the participant terminates the bftt session at the end of the first cycle i.e. on detection of mind wandering instead of going to the next cycle. as many of the research participants (23.8%) were not familiar with meditation, they could not have understood the phenomenon of mindfulness or mind wandering properly and hence not reported breath count reliably. if this was the case, the proposed measure would not be suitable to measure mindfulness of the individuals who have no basic understanding or experience of mindfulness meditation. however, after having the basic understanding, its utility in self-monitoring of the j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np joshi lr. et al. self-assessed time span of focused attention during a breath focus test task improvement in mindfulness is a potential advantage. further, there was considerable within-subject variation of tsfa across different sessions. if all subjects had performed three valid sessions of bftt, their average tsfa might have reflected their mindfulness better. besides this, social desirability bias might have obscured the real scores. testing in groups (though small) and ambient noise (though minimal) might have influenced the results. other factors like background mental or emotional state at the time of the test task might also have affected the results. the level of understanding of bftt and maas by the participants of various levels of mindfulness might also have influenced their reports.[11] a major limitation intrinsic to tsfa during bftt as a measure of mindfulness is that as it relies on self-report of the person to measure mindfulness, the score is not available to any objective instrument. however, the task-based nature of the proposed test reduces subjectivity on the part of the subject. also, as bftt is substantially similar to a references: 1. brown kw, ryan rm. the benefits of being present: mindfulness and its role in psychological well-being. j pers soc psychol. 2003;84(4):822-48. pmid: 12703651 doi: https://doi.org/ 10.1037/0022-3514.84.4.822 2. tickell a, ball s, bernard p, kuyken w, marx r, pack s, et al. the effectiveness of mindfulness-based cognitive therapy (mbct) in real-world healthcare services. mindfulness (ny). 2020;11(2):279-90. pmid: 32064009 doi: https://doi.org/ 10.1007/s12671-018-1087-9 3. ruffault a, cernichow s, hagger ms, ferrand m, erichot n, carette c, et al. the effects of mindfulness training on weight-loss and health-related behaviours in common form of mindfulness meditation, the measurement process is less likely to interfere with the parameter being measured. conclusion: this preliminary study suggests the feasibility of the breath focus test task which we have proposed as an easy task-based potential measure of mindfulness that can be self-administered in a daily life setting. however, the measure obtained from the present technique did not correlate with a commonly used self-reporting questionnaire-based mindfulness scale. further study is required to explore the various aspects of validity and reliability of the breath focus test task. major shortcomings of this study protocol and potential solutions have been identified and may guide future studies. conflict of interest: the authors declare that the principal author was not involved in the editorial workflow of the article. financial disclosure: no funds were available adults with overweight and obesity: a systematic review and meta-analysis. obes res clin pract. 2017;11(5suppl 1):90-111. pmid: 27658995 doi: https://doi.org/ 10.1016/j.orcp.2016.09.002 4. mehta r, sharma k, potters l, wernicke ag, parashar b. evidence for the role of mindfulness in cancer: benefits and techniques. cureus. 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[cited 2021 aug 8]. available from: https://rdrr.io/cran/pwr/man/pwr.f2.test.html 11. yates j, immergut m, graves j. the mind illuminated: a complete meditation guide integrating buddhist wisdom and brain science for greater mindfulness. new delhi: atria books; 2017. 12. sauer s, walach h, schmidt s, hinterberger t, lynch s, büssing a, et al. assessment of mindfulness: review on state of the art. mindfulness. 2012;4:3-17. doi: http://dx.doi.org/10.1007/s12671-012-0122 5 13. brown kw. mindful attention awareness scale (maas), trait version. available from https://www.drugsandalcohol.ie/26792/2/m aas%20trait%20research-ready.pdf . 14. frewen p, hargraves h, depierro j, d’andrea w, flodrowski l. meditation breath attention scores (mbas): development and investigation of an internet-based assessment of focused attention during meditation practice. psychological assessment. 2016;28(7):830-40. doi: http://dx.doi.org/10.1037/pas0000283 15. levinson db, stoll el, kindy sd, merry hl, davidson rj. a mind you can count on: validating breath counting as a behavioral measure of mindfulness. front psychol. 2014;5:1202. pmid: 25386148 doi: https://doi.org/ 10.3389/fpsyg.2014.01202 16. f wong k, massar saa, chee mwl, lim j. towards an objective measure of mindfulness: replicating and extending the features of the breath-counting task. mindfulness 2018;9(5):1402-1410. pmid: 30294387 doi: https://doi.org/ 10.1007/s12671-017-0880-1 17. hasenkamp w. catching the wandering mind: meditation as a window into spontaneous thought. in: christoff k, fox kcr. the oxford handbook of spontaneous thought: mind-wandering, creativity, and dreaming. new york: oxford university press; 2018. p. 539-52. doi: https://doi.org/ 10.1093/oxfordhb/978019046 4745.013.12 j. lumbini. med. coll. vol 10, no 1, jan-june 2022 jlmc.edu.np https://doi.org/10.1007/s12671-021-01593-w https://doi.org/10.1007/s12671-021-01593-w https://doi.org/10.1007/s12671-021-01593-w https://pubmed.ncbi.nlm.nih.gov/30423507/ https://doi.org/10.1016/j.copsyc.2018.10.015 https://doi.org/10.1016/j.copsyc.2018.10.015 https://pubmed.ncbi.nlm.nih.gov/30959378/ https://doi.org/10.1016/j.copsyc.2019.01.008 https://pubmed.ncbi.nlm.nih.gov/31160812/ https://pubmed.ncbi.nlm.nih.gov/31160812/ https://doi.org/10.1038/s41562-019-0611-9 https://rdrr.io/cran/pwr/man/pwr.f2.test.html https://rdrr.io/cran/pwr/man/pwr.f2.test.html http://dx.doi.org/10.1007/s12671-012-0122-5 http://dx.doi.org/10.1007/s12671-012-0122-5 http://dx.doi.org/10.1007/s12671-012-0122-5 https://www.drugsandalcohol.ie/26792/2/maas%20trait%20research-ready.pdf https://www.drugsandalcohol.ie/26792/2/maas%20trait%20research-ready.pdf https://www.drugsandalcohol.ie/26792/2/maas%20trait%20research-ready.pdf http://dx.doi.org/10.1037/pas0000283 http://dx.doi.org/10.1037/pas0000283 https://europepmc.org/article/pmc/4208398 https://doi.org/10.3389/fpsyg.2014.01202 https://pubmed.ncbi.nlm.nih.gov/30294387/ https://pubmed.ncbi.nlm.nih.gov/30294387/ https://doi.org/10.1007/s12671-017-0880-1 https://doi.org/10.1093/oxfordhb/9780190464745.013.12 https://doi.org/10.1093/oxfordhb/9780190464745.013.12 https://doi.org/10.1093/oxfordhb/9780190464745.013.12 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 atreya a. ‘publish or perish’ trend: fueling the predatory journals. atreya a. ‘publish or perish’ trend: fueling the predatory journals. 183 jlmc.edu.np ___________________________________________________________________________________ submitted: 10 november, 2020 accepted: 9 december, 2020 published: 16 december, 2020 a editor, b journal of lumbini medical college, nepal. corresponding author: alok atreya e-mail: alokraj67@hotmail.com orcid: https://orcid.org/0000-0001-6657-7871_______________________________________________________ editorialhttps://doi.org/10.22502/jlmc.v8i2.409 alok atreya a,b ‘publish or perish’ trend: fueling the predatory journals how to cite this article:how to cite this article: atreya a. ‘publish or perish’ trend: fueling the predatory journals. atreya a. ‘publish or perish’ trend: fueling the predatory journals. journal of lumbini medical college. 2020;8(2):183-184. doi: journal of lumbini medical college. 2020;8(2):183-184. doi: https://doi.org/10.22502/jlmc.v8i2.409. epub: 2020 december 16.. epub: 2020 december 16. in the past, journals were published only in the print, and the only way to access them was through the library. however, today we can easily access journals and articles with a click. there are more online journals which have made it possible and feasible for authors to submit their work. as an editor of a journal, i am often approached by younger aspiring authors for accelerated publication of their manuscripts. the journal is biannual and undergoes double-blind peer review process which in itself is time consuming. the authors also fear the reviewer’s comment about major corrections or even rejection of their article. the criteria of mandatory publication for academic promotion has compelled medical professionals to write and publish research articles. to get their articles published quick and easy, they sometimes fall prey to predatory journals. the ‘publish or perish’ trend should be discouraged and young researchers should be mentored and encouraged to publish in good impact journals. many predatory journals boast of being indexed in good databases and of high impact factor. they collect the email addresses of the corresponding authors who have already published in good journals and send them spam emails. the emails usually start with a praise of the recent publication. the emails are then continued to ask for a contribution where the journal state they are short of one article for the current issue and offer one of the following benefits in the form of fast track publication, discounted article processing and publication charges, free publication of book based upon the article published, inclusion in the editorial board, reviewer etc. to mention a few. the only motive of predatory journals is to earn money. sometimes authors receive invitation too as a guest speaker for upcoming conferences. the authors are lured of special discounts and made to deposit certain amount as nominal fees. the words like ‘international’, ‘global’, ‘recent’, ‘advanced’ etc. are used to make the journal good and authentic. sometimes, similar names of the journal are used to confuse the authors. [1] the authors need to be cautious before submitting to such journals. there are some simple ways of identifying if the journal is authentic and not predatory. a. submission system: most of the predatory journals ask to submit the manuscript as an email attachment. majority of the good journals today have an online submission repository system rather than the traditional email or postal submission. if the authors are asked to submit the manuscript via email, the authors need to be cautious and check the journal home page. b. contact address: the contact details of the editorial board members are usually not provided in the journal homepage. the journal or the editors do not have institutional email address. c. archive: the authors can check the archive section of the journal and see how many issues have been previously published. they can choose any random article from the past issue and search the title to see if the search results match the journal and authors. d. indexing: many journals boast of being indexed into major databases like pubmed, scopus, copernicus, google scholar and so on. authentic journals deposit their published articles into the database in which they are indexed. if the titles of previously published articles are searched in licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 atreya a. ‘publish or perish’ trend: fueling the predatory journals. atreya a. ‘publish or perish’ trend: fueling the predatory journals. 184 jlmc.edu.np the database in which the journal is indexed, we can distinguish the predatory journal as their articles will not be shown in such databases. journals claiming to be open access are indexed in directory of open access journal (doaj). journals published from south east asian region (sear) countries are hosted on insap’s online platform. e. fee and charges: authentic journals are transparent about their publication charges and fees. the article processing charge or publication charge is mentioned in the journal homepage. this might differ as per the article type, length of the article, publication of color images etc. some journals operate in hybrid nature where there are no publication or submission charges, the author needs to pay if they wish their article to be open access. many journals provide waiver to authors from low income countries, however predatory journals usually provide no waivers. some predatory journals have a very low article processing charge (apc) or publication charges to lure the authors. these journals are not transparent on how the fees or charges would be used. f. citation: authors usually cite articles published in good journals. articles published in good journals are cited by authors doing the study in the similar subject. articles published in predatory journals are rarely cited. g. peer review process: authentic journals use peer review process to maintain the quality of the published work. the peer review process is either open or blinded. the authentic journals clearly mention the process of peer review in their webpage. h. acceptance rate: predatory journals usually have very high acceptance rate. they sometimes attract the authors stating they do not reject the manuscript instead get the manuscript instantly edited and ready to be published with or without extra charges. conducting a research is a tedious process which starts from submitting a proposal to the institutional review board (irb). after the irb approval the author is allowed to collect data. the data then need to be analyzed, manuscript drafted, edited and reviewed. a substantial amount of time and energy is already spent when the final manuscript is ready. such hard word should not fall prey to the predatory journals. references: 1. kanchan t. selecting a journal for one’s scholarly work – what is in the name? j indian acad forensic med. 2019;41(2):85. doi: 10.5958/0974-0848.2019.00023.x metabolic syndrome and benign prostatic hyperplasia: a nepalese perspective raj kumar chhetri,a,d suman baral,b,d neeraj thapac,d —–————————————————————————————————————————————— abstract: introduction: metabolic syndrome is defined as the presence of at least 3 of the following parameters: (1) waist circumference ≥ 90 cm, (2) triglycerides > 150 mg/dl or treatment for hypertriglyceridemia, (3) hdl-cholesterol < 40 mg/dl or treatment for reduced hdl-cholesterol, (4) blood pressure ≥ 130/85 mmhg or current use of antihypertensive medications, (5) fasting blood glucose ≥ 110 mg/dl or previous diagnosis of type-2 diabetes mellitus. it is closely associated with many diseases and recent studies have also shown its association with benign prostatic hyperplasia and lower urinary tract symptoms. our study aimed to investigate association between metabolic syndrombe and its components with benign prostatic hyperplasia among patients managed surgically in a tertiary centre in western nepal. methods: one hundred and four patients above 50 years with benign prostatic hyperplasia managed in the department of surgery over one year were included in the study. results: twenty-seven patients had metabolic syndrome (25.96%). there was association between metabolic syndrome and mean prostate size and among components of metabolic syndrome, high serum triglyceride and low hdl cholesterol were found to be associated. there was increase in mean prostate size with increase in number of metabolic syndrome components which was statistically significant. conclusion: metabolic syndrome along with its two components, serum triglyceride and hdl cholesterol were associated with increase in mean prostate size. keyword: benign prostatic hyperplasia, lower urinary tract symptoms, metabolic syndrome, triglycerides —————————————————————————————————————————————— j. lumbini. med. coll. vol 6, no 2, july-dec 2018 original articlehttps://doi.org/10.22502/jlmc.v6i2.207 ___________________________ submitted: 26 january 2018 accepted: 24 june 2018 published: 18 july 2018 a associate professor b lecturer c assistant professor d department of surgery, lumbini medical college, palpa, nepal corresponding author: raj kumar chhetri e-mail: chhetrirkcdr@gmail.com orcid: https://orcid.org/0000-0002-3123-2053 how to cite this article: chhetri rk, baral s, thapa n. metabolic syndrome and benign prostatic hyperplasia: a nepalese perspective. journal of lumbini medical college. 2018;6(2):4 pages. doi: 10.22502/jlmc.v6i2.207. epub: 2018 july 18. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.____________________________ introduction: metabolic syndrome (mets) is a clinical terminology which was proposed by the american endocrinologist gerald reaven in 1988.[1] it is a cluster of biological factors characterized by atherogenic dyslipidemia, hypertension, disrupted glucose metabolism and obesity. these all contribute to an increased risk of cardiovascular disease and type 2 diabetes mellitus.[2] mets was defined by the national cholesterol education program-third adult treatment panel (ncep-atpiii) united states as presence of at least three of the following parameters:[3] 1. waist circumference ≥ 90 cm 2. triglycerides > 150 mg/dl or treatment for hypertriglyceridemia 3. high density lipoprotein-cholesterol (hdl-c) < 40 mg/dl or treatment for reduced hdl-c 4. blood pressure ≥ 130/85 mmhg or current use of antihypertensive medications 5. fasting blood glucose ≥ 110 mg/dl or previous diagnosis of type 2 diabetes mellitus https://doi.org/10.22502/jlmc.v6i1.182 j. lumbini. med. coll. vol 6, no 2, july-dec 2018 jlmc.edu.np chhetri rk. et al. metabolic syndrome and benign prostatic hyperplasia as per the international diabetic federation 2005 criteria for detection of mets among indian subcontinent population, waist circumference in males ≥90 cm was considered as central obesity.(4) various epidemiological studies have shown that about 25% of middle-aged people in high-income countries have the symptoms of mets. benign prostatic hyperplasia (bph) has now assumed the status of global epidemic owing to its socio-economic implications and the increasing incidence.[4] the incidence of bph increases with the age of patients which is now the most common disease in the elderly. prostatic hyperplasia is seen in around 20% of men in the fourth decade of life, which increases to approximately 80% after 80 years of age.[5] ever since the study done by hammarsten j. in 1998 about the components of mets and the risk for the development of bph there are many studies trying to establish their relationship with varying results.[4,6,7,8] though the relationship between benign prostatic hyperplasia/lower urinary tract symptoms (bph/luts) and mets is not well understood, studies have suggested that men with mets have more rapid growth of prostate as compared to those without mets.[9] according to the census of lumbini medical college and teaching hospital (lmcth), luts and bph are the most common causes for elderly men to visit the surgical outpatient department (opd) second only to urinary stone disease. it is also seen that many a times operations are postponed or cancelled either due to raised blood pressure (bp), hyperglycaemia or other cardiovascular comorbidities. we, therefore, conducted this study to analyze the relationship between bph and mets and its components. methods: this is an observational, cross-sectional, analytical study conducted in the department of surgery of lmcth, palpa, nepal. the study protocol was approved by institutional review committee of the institute. the study was done from 1st january 2017 to 31st december 2017 over one year. a proforma was designed and it was filled up with the help of surgical residents. all the male patients above 50 years of age operated in surgery department with bph diagnosed clinically by digital rectal examination, prostate specific antigen estimation and by ultrasound evaluation were included in the study. the criteria for metabolic syndrome comprised of at least three of the components as defined by the ncep-atpiii.[4] the study population was divided into two groups: mets group and the non-mets group. patients below 50 years of age were managed medically, so were not included in this study. patients with prostatic or urinary bladder malignancy diagnosed with usg, psa and cystoscopy were excluded from the study. the grading of the prostate gland enlargement was done on the basis of clinical assessment and ultrasound findings as:[10] 1. grade i: prostate size of 21-30 cc 2. grade ii: prostate size of 31-50 cc 3. grade iii: prostate size of 51-80 cc 4. grade iv: prostate size of > 80 cc body mass index (bmi) is calculated as weight in kilograms divided by the square of the height in meters (kg/m2) and is categorized into four groups according to the national heart, lung, and blood institute (nhlbi), with the asian-pacific cutoff points as:[11] 1. underweight: less than 18.5 kg/m2 2. normal weight: 18.5 – 22.9 kg/m2 3. overweight: 23 – 24.9 kg/m2 4. obese: ≥ 25 kg/m2 international prostate symptom score (ipss) was determined in every patient and classified as mild, moderate and severe with the scores of 0 to 7, 8 to 19 and 20 to 35 respectively.[4] all statistical analyses were performed using spss version 20 (spss inc., chicago, ill., usa). descriptive data are presented as mean and standard deviation (sd) for continuous data. age was divided into four categories : 51-60, 61-70, 71-80 and more than 80 years. the chi-square, studentt test and one way anova tests were used as applicable to compare differences between the variables between the subjects with and without mets. in all comparisons, p values < 0.05 were considered to be statistically significant. results: there were total 110 patients who were operated with diagnosis of bph, however the histopathology report of six patients came as prostatic carcinoma and were excluded from the study. so, 104 patients were included in the study who met the inclusion criteria. among these patients 56.7% (n = 59) had grade three prostatomegaly and 90.4% (n = 94) had severe ipss score. amongst 104 patients, 25.96% (n = 27) had mets. ninety seven patients j. lumbini. med. coll. vol 6, no 2, july-dec 2018 chhetri rk. et al. metabolic syndrome and benign prostatic hyperplasia jlmc.edu.np had bmi < 25 (93.2%) and none of the patients were obese. table 1 shows that there is an increase in mean prostate size as the age of the patient increases. however this finding was not statistically significant (f = 0.388, df = 3 , p = 0.762). among the components of mets, serum triglyceride (p = 0.005) and hdl cholesterol (p = 0.002) were found to be associated with increase in mean prostate size in the comparative analysis of individual components of mets with the mean prostate size (table 2). it was found that as the number of components of mets increased from zero to two, there was no increase in mean prostate size (table 3). however from two onwards, there was increase in mean prostate size which was statistically highly significant (f=7.65, df=4, p<0.001) . it was also seen from table 4 that the mean prostate size was higher in patients with mets which was statistically significant. (t= -5.437, df= 102, p= 0.0001) table 5 shows that mean prostate grade was higher in patients with mets which was statistically significant (t=-2.983, df=102, p=0.004) discussion: the incidence of bph increases with the age of patients which is now the most common disease in the elderly. prostatic hyperplasia is seen in around 20% of men in the fourth decade of life, which increases to approximately 80% after 80 years of age. [5] various literatures have shown the relationship between the components of mets with bph, and the patients with the syndrome show increase in the mean size of prostate with the increase in the age of the patient.[13] the objective of our study was to find whether there was association between the mets and its components with bph. in our study, out of 104 patients with bph, 90.4% (n = 94) had severe ips score and 97 of them had bmi < 25 (93.2%) but none were obese. a study conducted by nandy pr. and saha s. in india found all patients had moderate to severe ips score while 34% were overweight and 7.8% were obese.[4] twenty seven (26%) patients in our study had mets and mean prostate size increased as the age increased though not statistically significant. a study conducted by yeon won park from korea noted mets in 29% of patients.[14] similarly, table 1: mean prostate size according to age group (n = 104) age group (years) n % mean (sd) cc p 51 60 22 21.2 56.55 (11.31) 0.76 61 70 26 25 59.77 (16.9) 71 80 46 44.2 59.52 (14.19) > 80 10 9.6 62.3 (20.47) table 2: prostate size and its association with metabolic syndrome components (n=104) metabolic syndrome components n mean±sd p serum triglyceride (mg/dl) >150 34 65.09±15.22 0.005 <150 70 56.37±14.05 hdl cholesterol (mg/dl) <40 37 65.27±13.53 0.002 >40 67 55.94±14.70 fasting blood sugar (mg/dl) >110 33 62.82±14.40 0.094 <110 71 57.55±14.96 blood pressure (mmhg) >130/85 32 59.94±17.15 0.75 <130/85 72 58.90±17.15 waist circumference (cm) <90 58 58.97±15.26 0.85 >90 46 59.54±14.64 table 3: association between components of metabolic syndrome and mean prostate size (n=104) metabolic syndrome components n mean±sd cc p 0 17 56.59±16.21 <0.001 1 26 56.38±12.35 2 34 53.26±13.13 3 21 70.29±13.15 4 6 74±8.39 table 4: association of metabolic syndrome with mean prostate size (n=104) metabolic syndrome n mean±sd in cc p present 27 71.11±12.21 <0.001 absent 77 55.05±13.52 table 5: association of metabolic syndrome with mean prostate grade (n=104) metabolic syndrome n prostate grade (mean± sd) p present 27 3.04±0.52 0.004 absent 77 2.64±0.63 j. lumbini. med. coll. vol 6, no 2, july-dec 2018 jlmc.edu.np chhetri rk. et al. metabolic syndrome and benign prostatic hyperplasia studies from china showed mets was associated with higher prostatic volume and higher annual growth rate.[7] our study showed association between the mets and mean prostate size. high serum triglyceride and low hdl cholesterol were found to be associated with the mean prostate size which was statistically significant. dibello jr. et al. in a uk based cross-sectional epidemiological study found that 26.5% of patients with bph had mets and significantly larger prostate was found in patients who had mets.[8] as the number of components of mets increased there was increase in mean prostate size which was statistically highly significant. hammarsten j. in his paper, which was the first of its kind, also found that the prostate gland was larger in men with components of mets.[6] other studies also found similar results.[3,15,16] nandy pr. in his study found that the mets and its components except the waist circumference had association with prostate volume.[4] similarly, studies from china found that mets, bmi, low hdl-c were considered risk factors for prostatic enlargement.[7,17] other meta-analysis and multicentre studies showed higher mets among bph patients (36 to 60%) and mets and its components were associated with prostate volume.[2,5,9,15,18] however, yeon won park did not find any association between bph/luts and metabolic syndrome.[14] conclusion: mean prostate size and grade were significantly larger in patients with metabolic syndrome. among the components of metabolic syndrome, high serum triglyceride and low hdl cholesterol were associated with bph. therefore, there is an association between metabolic syndrome and some of its components with bph. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study references: 1. reaven gm. banting lecture 1988. role of insulin resistance in human disease. diabetes. 1988;37(12):1595-607. doi: https://doi.org/10.2337/diab.37.12.1595 2. ryl a, rotter i, slojewski m, jedrzychowska a, marcinowska z, grabowska m, et al. can metabolic disorders in aging men contribute to prostatic hyperplasia eligible for transurethral resection of the prostate (turp)? int j environ res public health. 2015;12(3):3327-42. doi: https://doi.org/10.3390/ijerph120303327 3. zhang x, zeng x, liu y, dong l, zhao x, qu x. impact of metabolic syndrome on benign prostatic hyperplasia in elderly chinese men. urol int. 2014;93(2):214-9. doi: https://doi.org/10.1159/000357760 4. nandy pr, saha s. association between components of metabolic syndrome and prostatic enlargement: an indian perspective. med j armed forces india. 2016;72(4):350-5. doi: https://doi.org/10.1016/j.mjafi.2016.07.005 5. ryl a, rotter i, miazgowski t, slojewski m, dolegowska b, lubkowska a, et al. metabolic syndrome and benign prostatic hyperplasia: association or coincidence? diabetol metab syndr. 2015;7:94. doi: https://doi.org/10.1186/ s13098-015-0089-1 6. hammarsten j, hogstedt b, holthuis n, mellstrom d. components of the metabolic syndrome-risk factors for the development of benign prostatic hyperplasia. prostate cancer prostatic dis. 1998;1(3):157-62. doi: https://doi. org/10.1038/sj.pcan.4500221 7. pan jg, jiang c, luo r, zhou x. association of metabolic syndrome and benign prostatic hyperplasia in chinese patients of different age decades. urol int. 2014;93(1):10-6. doi: https://doi.org/10.1159/000354026 8. dibello jr, ioannou c, rees j, challacombe b, maskell j, choudhury n, et al. prevalence of metabolic syndrome and its components among men with and without clinical benign prostatic hyperplasia: a large, cross-sectional, uk epidemiological study. bju int. 2016;117(5):801-8. doi: https://doi.org/10.1111/bju.13334 9. gacci m, sebastianelli a, salvi m, de nunzio c, vignozzi l, corona g, et al. benign prostatic enlargement can be influenced by metabolic profile: results of a multicenter prospective study. bmc urol. 2017;17(1):22. doi: https:// doi.org/10.1186/s12894-017-0211-9 10. basawaraj n g adt, ashok kumar, srinath mg. can sonographic prostate volume predicts prostate specific antigen(psa)levels inblood among non prostatic carcinoma patients? international journal of biological & medical research. 2012;3(3):1895-8. 11. lim ju, lee jh, kim js, hwang yi, kim th, lim sy, et al. comparison of world health organization and asiapacific body mass index classifications in copd patients. int j chron obstruct pulmon dis. 2017;12:2465-75. doi: https://doi.org/10.2147/copd.s141295 12. berges r, oelke m. age-stratified normal values for prostate volume, psa, maximum urinary flow rate, ipss, and other luts/bph indicators in the german male communitydwelling population aged 50 years or older. world j urol. 2011;29(2):171-8. doi: https://doi.org/10.1007/s00345010-0638-z 13. berry sj, coffey ds, walsh pc, ewing ll. the development of human benign prostatic hyperplasia with age. j urol. 1984;132(3):474-9. 14. park yw, min sk, lee jh. relationship between lower urinary tract symptoms/benign prostatic hyperplasia and metabolic syndrome in korean men. world j mens health. 2012;30(3):183-8. doi.org/10.1016/j.urology.2013.03.047 15. zou c, gong d, fang n, fan y. meta-analysis of metabolic syndrome and benign prostatic hyperplasia in chinese patients. world j urol. 2016;34(2):281-9. 16. zhao s, chen c, chen z, xia m, tang j, shao s, et al. relationship between metabolic syndrome and predictors for clinical benign prostatic hyperplasia progression and international prostate symptom score in patients with moderate to severe lower urinary tract symptoms. urol j. 2016;13(3):2717-26. doi: https://doi.org/10.22037/ uj.v13i3.3225 17. yin z, yang jr, rao jm, song w, zhou kq. association between benign prostatic hyperplasia, body mass index, and metabolic syndrome in chinese men. asian j androl. 2015;17(5):826-30. doi: https://doi.org/10.4103/1008682x.148081 18. wang jy, fu yy, kang dy. the association between metabolic syndrome and characteristics of benign prostatic hyperplasia: a systematic review and metaanalysis. medicine (baltimore). 2016;95(19):e3243. doi: https://doi.org/10.1097/md.0000000000003243 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 6, no 2, july-dec 2018 ___________________________________________________________________________________ submitted: 04 october, 2018 accepted: 12 december, 2018 published: 31 december, 2018 a lecturer, department of surgery b assistant professor, department of surgery c associate professor and head, department of surgery d lecturer, department of radiodiagnosis e lumbini medical college and teaching hospital, pravas, palpa corresponding author: suman baral e-mail: brylsuman.sur@gmail.com orcid: http://orcid.org/0000-0003-0906-138x_______________________________________________________ —–————————————————————————————————————————————— abstract: introduction: various diagnostic criteria have been described for acute appendicitis. for decades the most commonly used one has been alvarado score. ripasa scoring system has also been developed for asian population which has shown highest sensitivity and diagnostic accuracy. this study aimed to compare these two diagnostic criteria in nepalese population attending a tertiary center. methods: patients with clinically suspected acute appendicitis were classified according to both alvarado and ripasa scoring systems before undergoing surgery. histopathological examination was taken as the gold standard for diagnosis. statistical analysis was done using mcnemar's test as applicable. results: ninety nine (90 %) patients had histologically confirmed appendicitis. with the cut-off value greater than 7.5 for ripasa score; sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy and negative appendectomy rates were 94.5%, 27.27 %, 92.16 %, 37.5 %, 88.18% and 7.84% respectively. with the cut-off value greater than 7 for alvarado score, sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy and negative appendectomy rates were 71.72%, 72.73 %, 95.95 %, 22.22%, 71.82 %, and 4.05 % respectively. 94.5% of patients were correctly stratified by ripasa under higher probability group while only 71.8 % were classified by alvarado (p value= 0.0001). conclusion: ripasa scoring system showed high sensitivity and diagnostic accuracy in comparison to alvarado scoring system. so, this method can be applied in nepalese setting for the diagnosis of acute appendicitis. keywords: acute appendicitis, alvarado score, ripasa —————————————————————————————————————————————— original research articlehttps://doi.org/10.22502/jlmc.v6i2.264 suman barala,e neeraj thapab,e raj kumar chhetric,e rupesh sharmad,e a comparative analysis between ripasa and alvarado scoring systems for the diagnosis of acute appendicitisa nepalese perspective introduction: with lifetime prevalence of one in seven, acute appendicitis has been one of the most common surgical emergencies worldwide.[1] it is a clinical diagnosis involving clinical history, examination and some laboratory parameters along with radiological examinations whenever required. of various scoring systems, the most commonly used one for the diagnosis has been alvarado score for the last two decades. recently ripasa (raja isteripengirananaksaleha appendicitis) scoring system has also been employed for asian population and this has shown the highest sensitivity and diagnostic accuracy in comparison to alvarado score.[2] age of the patient, gender and duration of symptoms have not been attributed by alvarado system which definitely confound the diagnosis of acute appendicitis. ripasa scoring system, however, incorporates these parameters in the clinical criteria as well. we prospectively compared these two diagnostic criteria in 110 patients with right iliac fossa (rif) pain and clinically suspected appendicitis. methods: this was a prospective analytical study conducted at department of surgery, lumbini how to cite this article: baral s, thapa n, chhetri rk, sharma r. a comparative analysis between ripasa and alvarado scoring systems for the diagnosis of acute appendicitisa nepalese perspective. journal of lumbini medical college. 2018;6(2):5 pages. doi: 10.22502/jlmc.v6i2.264. epub: 2018 dec 31. http://orcid.org/0000-0003-0906-138x baral s. et al. a comparative analysis between ripasa and alvarado scoring systems jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 medical college and teaching hospital, tansen, nepal from june 2017 to may 2018. ethical approval was taken from institutional review committee (irc-lmc 05-e/018). a total of 110 patients presenting with rif pain and clinically suspected appendicitis were classified according to alvarado and ripasa scoring systems. the required laboratory investigations like complete blood count (cbc), renal function test (rft), routine urine examinations were sent and reports retrieved as mentioned in table 1. ultrasound (usg) examination was done in every patient by a radiologist and contrast enhanced computed tomography (cect) abdomen whenever deemed necessary. the patients were then taken to operation theatre. a proforma was designed and filled up by the surgical residents which included all the variables required. the gold standard for the diagnosis was positive histopathology findings. statistical package for social sciences (spsstm) software version 16 was used for statistical analysis. mcnemar's test was applied wherever feasible. cut-off values for the analysis were 7.5 and 7 for ripasa and alvarado scoring systems respectively. ripasa scoring system comprises 18 variables and all total score of 17.5. a cut-off value of 7.5 was used which demonstrates the high probability of acute appendicitis. alvarado scoring system contains eight variables and a score of more than seven demonstrates high probability of acute appendicitis. [3, 4] the descriptive data were presented as mean ±sd and p value less than 0.05 was considered significant. receiver operating curve (roc) was formulated and area under the curve (auc) was calculated. result: a total of 110 patients who underwent surgery were included in the study. the demographics and clinical characteristics of the study population is shown in table 2. the mean age±sd of the patients was 26.84 ± 15.14 years. ninety percent of the specimens turned out to be appendicitis. twenty six patients had perforated appendicitis. the mean post-operative hospital stay±sd was 3.97±2.06 days. thirteen patients developed post-operative complications of which two patients underwent reexploration for post-operative intestinal obstruction. table 3 presents the distribution of 110 patients in four groups according to ripasa and alvarado scores with optimum cut-off values of 7.5 and 7 respectively. seventy one (71.72 %) patients were correctly placed into higher probability group according to alvarado score however this number increased to 94 (94.95%) while applying ripasa score for the clinical diagnosis of acute appendicitis (p=0.0001). twenty eight patients were missed by alvarado score and was classified into false negative score patient score gender male 1 female 0.5 age <40 years 1 >40 years 0.5 symptoms rif pain 0.5 pain migration to rif 0.5 anorexia 1.0 nausea and vomiting 1.0 duration of symptoms <48 hours 1.0 >48 hours 0.5 signs rif tenderness 1.0 guarding 2.0 rebound tenderness 1.0 rovsing’s sign 2.0 fever >37 <39 ˚c 1.0 investigations raised wbc 1.0 negative urinalysis 1.0 foreign nationality 1.0 total 17.5 table 1. ripasa scoring system *rif: right iliac fossa, wbc: white blood cell baral s. et al. a comparative analysis between ripasa and alvarado scoring systems jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 group while ripasa classified only five patients in this group. mean ripasa score for true positive cases was 10.17±1.5 while true negative cases was 3 ±0.0. mean ripasa score for perforated appendicitis was 10.26±1.15. mean total hospital stay (days) was higher in true positive cases in comparison to true negatives (4.11±2.12 vs 3±0.001). table 4 summarizes different variables at optimal cut-off level of >7.5 for ripasa score and >7 for alvarado score. the sensitivity for ripasa was 94.5 % (95 % ci: 88.61%-98.34%) while it was % (95% ci: 39.03% 93.98%) respectively (mc nemarχ2=39.32, df=1, p value 0.062). diagnostic accuracies were 88.18% (95% ci: 80.64% 93.55%) and 71.82% (95% ci:62.4% 79.98 %) respectively. however, negative appendectomy rate was higher in case of ripasa scoring system. roc analysis and optimum cut-off value the roc curves for ripasa and alvarado score have been shown in figure 1. this demonstrates the plot of sensitivity versus specificity for these two table 3. patient distribution according to ripasa and alvarado scores variables frequency (%) gender male 59 (53.64%) female 51 (46.36%) age in years, mean +sd 26.84 ± 15.14 usg findings positive 99 (90%) negative 11 (10%) positive histology for appendicitis 99 (90%) negative histology for appendicitis 11 (10%) post-operative hospital stay ( days), mean +sd 3.97 ± 2.06 mean total hospital stay ( days), mean +sd 4.62± 2.05 perforated appendicitis 26 (23.63 %) table 2. demographic and clinical characteristics of the patients (n = 110) parameters true positive false positive true negative false negative ripasa>7.5 alvarado>7 ripasa>7.5 alvarado>7 ripasa<7.5 alvarado<7 ripasa<7.5 alvarado<7 sample size 94 71 8 3 3 8 5 28 m:f 54:40 40:31 0:8 0:3 0:3 0:8 5:0 19:9 mean age± sd (years) 26.8±15.4 28.06±16.4 28.88±18.6 44±1.73 18.67±0.57 19.38±1.68 29.2±19.3 24.04±12.8 total score± sd 10.17±1.5 8.31±1.05 10.62±1.4 8±0.001 5±0.001 5±0.926 4.5±1.36 4.83±1.4 mean hospital stay± sd (days) 4.11±2.12 4.1±2.3 3.75±1.90 6.0±0.001 3 ±0.001 2.62±0.51 2.4±0.54 3.8±1.3 variable ripasa>7.5 (95% ci) alvarado >7 (95 % ci) p value sensitivity 94.5 % (88.61-98.34) 71.72% (61.78-80.31) 0.0001 * specificity 27.27 % (6.0760.97) 72.73% (39.03-93.98) 0.062 * positive predictive value 92.16% (89.0894.42) 95.95% (89.95-98.43) negative predictive value 37.5% (14.19-68.52) 22.22% (15.04-31.56) diagnostic accuracy 88.18% (80.64-93.55) 71.82% (62.479.98) negative appendectomy rate 7.84% 4.05 % table 4. comparison between ripasa and alvarado scoring systems. 71.72 % (95% ci:61.78% 80.31%) for alvarado score which was statistically significant (mc nemarχ2= 34.08, df= 1, p value 0.0001). similarly, the specificity for ripasa and alvarado scores were 27.27 % (95% ci: 6.07% 60.97%) and 72.73 diagnostic scoring systems. as evident by the figure, auc for ripasa score is 0.93 (p value= 0.0001) which is higher than that of alvarado scoring system which is 0.74 (p value= 0.011). coordinates of the curve demonstrate the cut off value of 7.75 *mc nemar's test baral s. et al. a comparative analysis between ripasa and alvarado scoring systems jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 for ripasa score which nearly corresponds to 7.5 which is the standard cut off value as given for the asian population. discussion: acute appendicitis is one of the most common surgical emergencies for all age groups with a life time prevalence of 7-8 %.[1, 5] the diagnosis of acute appendicitis is primarily based on clinical findings and laboratory examinations. radiological examinations like usg and cect have been used as adjuncts for the diagnosis and to look for the differentials. however use of these modalities have cost implications and requirement of experts for prompt diagnosis.[6] various scoring systems have been proposed for early diagnosis of acute appendicitis and alvarado scoring system is the widely used.[7] however, owing to lack of high sensitivity and specificity which is as low as 59% and 23% respectively in asian population, ripasa scoring system has been developed which has been shown to achieve better sensitivity (88%) and specificity(67%).[3] so, we intended to apply ripasa scoring system in the diagnosis of acute appendicitis at one of the tertiary centres in western nepal and look for the sensitivity, specificity and diagnostic accuracy comparing with alvarado scoring system. a study by singh a et al.[8] conducted on indian population showed sensitivity of 95.89% and diagnostic accuracy of 90.5% for ripasa which is comparable to our study (sensitivity 94.5% and diagnostic accuracy 88.18%). this could be due to similar geography, shared lifestyles and exposure to similar risk factors for developing acute appendicitis. another study by singla a et al.[9] showed sensitivity of 95.6% and diagnostic accuracy of 81%. diagnostic accuracy for ripasa was 80.50 % in a study by chong cf et al.[3] but study by klabtawee w et al.[10] showed low accuracy of ripasa in comparison to alvarado. however, specificity or true negative rate for ripasa was quite low in our context (27.27 %) which did not corroborate to any other findings or studies. a study by arroyo-rangel c et al.[11]on mexican population showed specificity as low as 71.4 % while karami my et al.[12] showed as high as 91.67 % in iranian population. in indian population, specificity for ripasa was 80%.[9]the reason behind low specificity in our study could be due to less number of cohorts who fall under this category. alvarado score showed sensitivity of 71.72 % which is comparable to a study by jalil a et al.[4] which showed it to be 66%. similarly, true positive rate was 92.7% in a study by xingye w et al.[13]in china. eleven patients who fell under true negative groups were operated either owing to usg / cect findings despite clinical suspicion while some of these group of population underwent diagnostic laparoscopy and appendix was removed as benefit of doubt in absence of other findings. there are some limitations in our study. the sample size might be small for validation of the scoring system. it definitely requires a larger cohort to carry out the comparative analysis of two scoring systems. a single institution based study might not include the aspects of the whole population of the country. conclusion: ripasa scoring system at a cut-off value of 7.5 is a better diagnostic tool for the diagnosis of acute appendicitis where other radiological diagnostic modalities are not feasible, especially in peripheral settings of the country. higher sensitivity and diagnostic accuracy in comparison to alvarado scoring system make ripasa scoring system a better alternative for the diagnosis of acute appendicitis. conflict of interest: the authors declare that no competing interests exist. source of funds: no funds were available. figure 1. roc plots for ripasa and alvarado scoring systems. references: 1. stephens pl, mazzucco jj. comparison of ultrasound and the alvarado score for the diagnosis of acute appendicitis. connecticut medicine. 1999 mar;63(3):137-40. pmid: 10218289 2. chong cf, thien a, mackie aj, tin as, tripathi s, ahmad ma, tan lt, ang sh, telisinghe pu. comparison of ripasa and alvarado scores for the diagnosis of acute appendicitis. singapore medical journal. 2011 may 1;52(5):340-5. pmid : 21633767 [publisher full text] 3. chong cf, adi mi, thien a, suyoi a, mackie aj, tin as, tripathi s, jaman nh, tan kk, kok ky, mathew vv. development of the ripasa score: a new appendicitis scoring system for the diagnosis of acute appendicitis. singapore medical journal. 2010 mar 1;51(3):220-5. pmid : 20428744 [publisher full text] 4. jalil a, shah sa, saaiq m, zubair m, riaz u, habib y. alvarado scoring system in prediction of acute appendicitis. journal of college of physicians and surgeons pakistan. 2011 dec 1;21(12):753-55. pmid: 22166697 doi: 12.2011/ jcpsp.753755 [publisher full text] 5. al-hashemy am, seleem mi. appraisal of the modified alvarado score for acute appendicits in adults. saudi medical journal. 2004;25(9):1229-31. pmid : 15448772 [publisher full text] 6. malik mu, connelly tm, awan f, pretorius f, fiuzacastineira c, el faedy o, balfe p. the ripasa score is sensitive and specific for the diagnosis of acute appendicitis in a western population. international journal of colorectal disease. 2017 apr 1;32(4):491-7. pmid: 27981378 doi: 10.1007/s00384-016-2713-4 7. alvarado a. a practical score for the early diagnosis of acute appendicitis. annals of emergency medicine. 1986 may 1;15(5):557-64. pmid: 3963537 doi: 10.1016/s01960644(86)80993-3 8. singh a, parihar us, kumawat g, samota r, choudhary r. to determine validation of ripasa score in diagnosis of suspected acute appendicitis and histopathological correlation with applicability to indian population: a single institute study. indian journal of surgery. 2018 apr 1;80(2):113-7. epub 2018 feb 2. pmid: 29915475 doi: 10.1007/s12262-018-1731-6 9. singla a, singla s, singh m, singla d. a comparison between modified alvarado score and ripasa score in the diagnosis of acute appendicitis. updates in surgery. 2016 dec 1;68(4):351-5. pmid: 27338243 doi: 10.1007/ s13304-016-0381-0 10. klabtawee w, saensak w, khetsoongnern a, piriyasupong t. accuracy of ripasa and modified ripasa score comparing with alvarado score for diagnosis of acute appendicitis and complication of acute appendicitis. khon kaen medical journal. 2011;35(1):38-47. [publisher full text] 11. arroyo-rangel c, limón io, vera ág, guardiola pm, sánchez-valdivieso ea. sensitivity, specificity and reliability of the ripasa score for diagnosis of acute appendicitis in relation to the alvarado score. cirugía española. 2018 mar 1;96(3):149-54. pmid: 29486897 doi: 10.1016/j.ciresp.2017.11.013 12. karami my, niakan h, zadebagheri n, mardani p, shayan z, deilami i. which one is better? comparison of the acute inflammatory response, raja isteri pengiran anak saleha appendicitis and alvarado scoring systems. annals of coloproctology. 2017 dec 1;33(6):227-31. pmid: 29354605 doi: 10.3393/ac.2017.33.6.227 [publisher full text] 13. xingye w, yuqiang l, rong w, hongyu z. evaluation of diagnostic scores for acute appendicitis. journal of the college of physicians and surgeons pakistan. 2018 feb 1;28(2):110-4. pmid: 29394968 doi: 10.29271/ jcpsp.2018.02.110 j. lumbini. med. coll. vol 6, no 2, july-dec 2018 jlmc.edu.np baral s. et al. a comparative analysis between 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___________________________________________________________________________________ submitted: 13 october, 2020 accepted: 11 june, 2021 published: 29 june, 2021 aassistant professor , department of psychiatry blecturer, department of psychiatry clumbini medical college teaching hospital, palpa, nepal. corresponding author: bhaskkar sharma e-mail: vasker63@yahoo.com orcid: https://orcid.org/0000-0001-8031-6926_______________________________________________________ abstract: introduction: the electroencephalography (eeg) is the recording of brain’s spontaneous electrical activity over a period of time (20-40 minutes) recorded from multiple electrodes placed on the scalp. it is used in seizure disorder, organicity, and psychiatric conditions. there is a paucity of literature with regard to the application of eeg in various conditions in our setting. methods: this was a cross-sectional study, where data of the patients who visited the eeg section of psychiatric clinic from september 15, 2019 to july 14, 2020 were collected retrospectively. the demographic details, eeg details, and the clinical details were recorded and analyzed. results: a total of 110 patients underwent eeg during the study period. of them, 61 (55.45%) had normal eeg. among the patients with normal eeg, 60 (98.36%) had clinical history suggestive of seizure disorder. of the rest 49 (44.55%) patients with abnormal eeg, 48 (97.96%) had history of seizure. majority patients referred for eeg fell in the prime of their life (1-30yrs). almost all (98.2%) patients with the history of seizure were taking anti-epileptic drugs. conclusion: eeg is a common investigation done in psychiatric clinic. nearly half of the patients with seizure disorders will have an abnormal eeg. keywords: antiepileptic drug; electroencephalogram; inter-ictal epileptiform discharges; seizure original research articlehttps://doi.org/10.22502/jlmc.v9i1.406 bhaskkar sharma,a,c rajesh shrestha,a,c ram prasad lamichhane b,c a study on electroencephalography findings of patients visiting the psychiatric clinic: an experience at a tertiary care center in western nepal how to cite this article:how to cite this article: sharma b, shrestha r, lamichhane rp. a study on electroencephalography findings of patients visiting the psychiatric clinic: an experience at a tertiary care center in western nepal. journal of lumbini medical college. 2021;9(1):3 pages. doi: https:// doi.org/10.22502/jlmc.v9i1.406. epub: june 29, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: electroencephalography (eeg) is the recording of electrical activity produced by the firing of neurons within the brain which is recorded for about 20 to 40 minutes from multiple electrodes placed on the scalp. it is one of the tools to assess cerebral function which is based on the work by hans berger in the 1930s.[1] it is a neurological test that uses an electronic monitoring device to measure and record the electrical activity in the brain.[2] the main use of this non-invasive test is in epilepsy to detect seizure activity, a common problem with estimated worldwide prevalence of 5–30 persons per 1000.[3] the other applications are in the diagnosis of coma, encephalopathy, and brain death.[4] the use of this neuro-physiological tool has been minimum in psychiatry despite the known relationship between epilepsy and psychosis and other psychiatric manifestations, especially with the temporal lobe abnormalities.[5,6] there is a paucity of reported literature on eeg findings although many institutes conduct eeg in nepal now. this study aimed to explore the eeg findings among different cases requested for eeg. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 sharma b et al. a study on electroencephalography findings of patients visiting the psychiatric clinic: an experience at a tertiary care center in western nepal jlmc.edu.np methods: this was a cross-sectional study conducted in psychiatric clinic of lumbini medical college and teaching hospital, palpa during period of september 15, 2019 to july 14, 2020. ethical clearance for the study was obtained from institutional review committee (irc) of the college(irc-lmc 11g/020). all the patients referred to the eeg section of psychiatric clinic throughout the study period were included. incomplete data were excluded. eeg was done with same eeg machine (16 channels rms digital) in standard way and the eeg waves were recorded into the computer. the report was then printed out on paper. the primary data was stored in the register of the eeg section. secondary data was collected by the researchers in a structured proforma and included demographic details, eeg findings, and clinical history of the patients. eeg results were categorized as normal and abnormal. the accuracy of the secondary data was double checked. this data was then entered into microsoft excel 2007 and coding was done. then the data was imported into statistical package for social sciences (spss) software version 16 for analysis. quantitative data was presented in mean with standard deviation while qualitative data were expressed in frequency and percentages. results: a total of 110 patients were enrolled into this study. of them, 60 (54.55%) were male. the rest 50 (45.45%) were female. thus, males slightly outnumbered females. the mean age of males was 26 years (sd=18.11) and that of females was 24 years (sd =16.67). further breakdown of age and gender was as shown in table 1 which showed that the majority of cases (67.27%) sent for eeg fell between 1-30 years verifying that majority was in the prime of life. there were only 4.5% of the patients above 60 years of age and 0.9% under one year. history of the patients about seizure disorder and its medication are presented in table 2 which shows all the patients with seizure disorder were under anti-epileptic drug (aed). a comparison of history of seizure and abnormal eeg is presented in table 3. it shows that patients without history of seizure may have abnormal eeg or vice versa. table 1. age and sex distribution of the study population. age group (years) males females <1 0 1 1-10 13 14 11-20 16 9 21-30 9 13 31-40 10 6 41-50 5 3 51-60 4 2 61-70 2 2 71-80 1 0 table 2. history of seizure and use of anti-epileptic drug. history of seizure history of aed intake yes no yes 108 0 no 0 2 table 3. eeg findings and history of seizure. eeg history of seizure yes no normal 60 1 abnormal 48 1 discussion: we carried out this study to analyze the eeg findings of patients referred to eeg section of psychiatric department. it was interesting to note that out of 108 cases with history of seizure, 60 of them had normal eeg. this is natural because it is a known fact that patients with history of seizure may have normal eeg as eeg is only a snapshot of the brain activity.[7,8] also interesting to note that out of two patients with no history of seizure, one had still abnormal eeg. actually inter-ictal epileptiform discharges (ied) are supportive of an underlying seizure disorder but never diagnostic. without clinical ictal behaviour, eeg with ied is not diagnostic of epilepsy. eeg reported abnormality in 44.54% in our study,17.6% in the study by o sullivan, 11.3 % in j. lumbini. med. coll. vol 9, no 1, jan-june 2021 sharma b et al. a study on electroencephalography findings of patients visiting the psychiatric clinic: an experience at a tertiary care center in western nepal jlmc.edu.np the study by lam but only 8.2% in the african study. [1,9,10,]this disparity could be due to variation in sample size, sample type as well as interpreter variability. eeg as an important investigative tool and is more helpful in classifying the type of seizure disorder and also helpful to decide whether to stop the aed. and also selection of appropriate aed, monitoring the therapeutic response especially in absence seizure.[4] it may suggest a possible cause for the seizure disorder and explain why some people have deteriorated. in conjunction with video monitoring, long term eeg recording is critical in evaluation of patients with refractory seizures and for epilepsy surgery. we still need to determine the type of abnormalities or the type of seizure disorder for optimum management. eeg may also be able to indicate the underlying organic or inorganic cause of seizure disorders such as cerebrovascular disease (cvd) in 15%, tumors in 6%, alcohol induced in 6%, and post traumatic and infective in the rest 2% of cases. even with eeg and other imaging investigations, the cause of seizure is unknown in 60-70%.[1] there are a few weaknesses of our study. it was a single-center study with small sample size. further, the patients with positive eeg findings were not studied further for other pathologies. conclusion: eeg is a common investigation done in psychiatric clinic. the majority of patients referred for eeg fell in the prime of their life. seizure disorder is a common condition referred for eeg. eeg with positive findings in patients without history of seizure and conversely eeg with negative findings in patients with definitive history of seizure are possible. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available for the study. references: 1. o’sullivan ss, mullins gm, cassidy em, mcnamara b. the role of the standard eeg in clinical psychiatry. hum psychopharmacol. 2006;21(4):265-271. pmid: 16783810 doi: https://doi.org/10.1002/hup.767 2. david d, fleminger s, kopelman m, lovestone s, mellers j. lishman’s organic psychiatry: a textbook of neuropsychiatry. 4th ed. oxford: wiley-blackwell; 2012. 3. lowenstein dh. seizures and epilepsy. in: kasper dl, fauci as, hauser s, longo d, jameson jl, loscalzo j, editors. harrison’s principles of internal medicine. 19th ed. new york,: mcgraw-hill education; 2015. 4. hughes jr, john er. conventional and quantitative electroencephalography in psychiatry. j neuropsychiatry clin neurosci. 1999;11(2):190-208. pmid: 10333991 doi: https://doi.org/10.1176/jnp.11.2.190 5. marsden cd, fowler tj. clinical neurology. 2nd ed. uk: hodder education publishers; 1998. 6. braunwald e, isselbacher kj, wilson jd, martin jb, kasper d, hauser sl, et al. harrison’s principles of internal medicine. 14th ed. newyork: mcgraw-hill; 1997. 7. towle vl, bolaños j, suarez d, tan k, grzeszczuk r, levin dn, et al. the spatial location of eeg electrodes: locating the bestfitting sphere relative to cortical anatomy. electroencephalogr clin neurophysiol. 1993;86(1):1-6. pmid: 7678386 doi: https:// doi.org/10.1016/0013-4694(93)90061-y 8. bradley wg, daroff rb, marsden cd, fenichel gm. neurology in clinical practice. 3rd ed. oxford: butterworth-heinemann; 1999. 9. lam rw, hurwitz ta, wada ja. the clinical use of eeg in a general psychiatric setting. hosp community psychiatry. 1988;39(5):533-6. pmid: 3378750 doi: https://doi.org/10.1176/ ps.39.5.533 10. molokomme m, subramaney u. assessing the usefulness of electroencephalography in psychiatry: outcome of referrals at a psychiatric hospital. south afr j psychiatry. 2016;22(1):702. pmid: 30263151 doi: https://doi.org/10.4102/ sajpsychiatry.v22i1.702 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 6, no 2, july-dec 2018 —–————————————————————————————————————————————— abstract: introduction: neonatal seizure is the most common manifestation and an important determinant of outcome of neurological disorders in newborn period. this study aims to delineate the etiological profile and neurodevelopmental outcome of neonatal seizures and also to identify predictors for adverse outcome. methods: one hundred and seventeen neonates with clinically proven seizures admitted in dhulikhel hospital from february 2014 to february 2016 were recruited. all of them underwent necessary neurological diagnostic tests. the survivors were followed up for at least three times within the first 18 months of life. prognostic value of factors for adverse outcomes were analyzed with chi square test and binary logistic regression analysis. results: among a total of 954 neonates admitted, 117 (12.26%) developed clinical seizures. the most common cause of neonatal seizure was hypoxic ischemic encephalopathy (n=69, 59%), followed by infection (n=20, 17.09%), and metabolic disturbances (n=16, 13.7%). the outcomes were mortality (n=16, 13.7%), post neonatal seizure (n=18, 15.4%), developmental delay (n=31, 26.5%), vision impairment (n=19, 16.2%) and hearing impairment (n=26, 22.2%). low apgar scores at one minute (p=0.03) and five minutes (p=0.001), early onset seizure (p<0.001), and more than one drug used for seizure control (p=0.001) were early prognostic factors for adverse outcome. conclusion: birth asphyxia followed by infection and transient metabolic disturbance were common etiologies for neonatal seizures. low apgar scores at one and five minutes, early onset seizure, multiple episodes of seizures and requirement of multiple anti-epileptics to control seizures were found to be significant predictors for adverse neurodevelopmental outcome. keywords: apgar score, developmental delay, hypoxic ischemic encephalopathy, neonatal seizure ——————————————————————————————————————————————— original research articlehttps://doi.org/10.22502/jlmc.v6i2.212 srijana dongol singha,d ranendra prakash bahadur shresthab,d asim shresthac,d etiological profile of neonatal seizures and prognostic factors for adverse outcome: a single center prospective study introduction: neonatal seizures are usually an acute manifestation of disturbance of the developing brain and common in the early weeks of life. the incidence of seizure varies widely in different countries ranging from 1.8 to 5 per 1000 live births in the united states of america to 39.5 per 1000 live births in kenya.[1,2] the predominant causes of neonatal seizures are hypoxic ischemic encephalopathy (hie), followed by metabolic abnormalities, infection, intracranial hemorrhage and developmental abnormalities.[3,4] several prognostic factors for adverse outcome of seizure are well known, namely brain immaturity, abnormal cranial ultrasonography (usg) findings, low apgar score, early onset of seizure or prolonged duration of seizure.[5] neonates with seizures are at an increased risk of mortality, and the survivors are at risk of neurological sequelae as developmental delay, epilepsy and cognitive impairment. we therefore need to initiate an early diagnostic work up to establish etiology, depending on the available facilities.[6] establishing risk factors that might predict outcome of newborn with seizure would be helpful in planning long term follow up and health assistance to these children. many studies have been published on risk factors, etiology and outcome of newborns with seizure from different countries. however, there is submitted: may 04, 2018 accepted: nov 25, 2018 published: nov 30, 2018 a associate professor, department of paediatrics b professor, department of paediatrics c lecturer, department of paediatrics d dhulikhel hospital, kathmandu university school of medical sciences, dhulikhel corresponding author: srijana dongol singh e-mail: docsrijana@yahoo.com orcid: https://orcid.org/0000-0001-6054-0197 how to cite this article: singh sd, shrestha rbp, shrestha a. etiological profile of neonatal seizures and prognostic factors for adverse outcome: a single center prospective study. journal of lumbini medical college. 2018;6(2):8 pages. doi: 10.22502/jlmc.v6i2.212. epub: 2018 nov 27. singh sd. et al. etiological profile of neonatal seizures jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 a paucity of literature from our country that have examined the causes, risk factors and outcomes of neonatal seizures. the aims of the current study are to describe the etiologic profile, neurodevelopmental outcome and reliable prognostic indicators of outcome of infants surviving neonatal seizures. methods: this was an observational prospective study in a cohort of newborns with clinically proven seizures. the survivors were followed up in our high risk outpatient clinic for at least 18 months. newborns included in the study were neonates with seizures admitted in the neonatal intensive care units (nicu) of dhulikhel hospital from february 2014 to february 2016. ethical approval for the study was obtained from institutional review committee of kathmandu university school of medical sciences. seizures were defined as reported or observed repeated involuntary muscle contractions, abnormal tonic extensions or jerky movements of any part of the limb, face or mouth that was not stimulus sensitive or repetitive abnormal chewing, ocular or pedalling movements. seizures were then classified after clinical observation and correct description of seizure type. the time of occurrence of the seizure was categorized according to the age at onset as seizure occurring within the first 24 hours, between 24 to 72 hours and after 72 hours. it was considered early if seizures started within 72 hours of life and late if started after 72 hours. the frequency of seizure was also recorded as single or multiple episodes. gestational age was determined according to modified ballard scale.[7] the different modes of delivery were also recorded. the apgar scores at one and five minutes after birth were noted. maternal risk factors as family history of neonatal seizure, maternal illness, maternal medication, complications during pregnancy (prolonged second stage of labour and placental or cord complications) were also recorded. the primary etiology of the seizure was ascertained through clinical history, neuroimaging studies [computer tomography (ct), cranial usg and/or magnetic resonance imaging (mri)] when indicated. laboratory tests as cerebrospinal fluid (csf) analysis , serum glucose, serum electrolyte level and arterial blood gas analysis were done in required cases. some infants underwent toxoplasma gondii, rubella, cytomegalovirus and herpes simplex virus (torch) screen for congenital infection. diagnosis of neonatal sepsis was based on clinical manifestations, sepsis work-up and positive blood culture. cranial usg was done in almost all infants. some had at least one additional modality of imaging, such as cranial ct or mri. the intracranial hemorrhage group included infants with extra-axial (epidural, subdural and subarachnoid) hemorrhage or intra-parenchymal hemorrhage. developmental cerebral defect, cerebral infarction and hydrocephalus if any present, were also documented. we divided etiology into seven groups: (1) hypoxic ischemic encephalopathy (hie), (2) transient metabolic disturbance, (3) infection, (4) intracranial hemorrhage, (5) developmental cerebral defect, (6) benign familial neonatal seizure and (7) unknown etiology, if diagnostic evaluation revealed no etiology. the drug of first choice was intravenous phenobarbitone at a loading dose of 20-40 mg/ kg and a maintenance dose of 3-8 mg/kg/day. in case of persistence or recurrence of seizures, we administered intravenous phenytoin at a loading dose of 20mg/kg and a maintenance dose of 4-8 mg/kg/ day. if seizure still persisted, continuous intravenous infusion of midazolam at 1-10 microgram/kg/ day was given. few neonates had to be ventilated because of refractory seizure despite continuous infusion of midazolam. the number of antiepileptic drugs (aed) needed for control of seizures was also recorded. all the survivors were followed up for at least three times in the first 18 months of life i.e. around two months, between six and nine completed months and between 11 and 18 completed months in the high-risk clinic of pediatric outpatient department. they were evaluated thoroughly by physical examination and developmental assessment. at the same time infants were seen by physiotherapist, ophthalmologist and audiologist whenever necessary. in this study we evaluated the outcome by developmental progress, growth of head, visual impairment, hearing impairment and the presence of seizure after nicu discharge. statistical analysis: data were entered to and analyzed using statistical package for social sciences (spsstm) singh sd. et al. etiological profile of neonatal seizures jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 version 16. quantitative data were presented in mean ± sd and qualitative data in frequency and percentages. the association of neonatal seizures in different clinical conditions were assessed by pearson chi square test and fisher's exact test. the risk factors for different adverse outcomes were assessed applying binary logistic regression analysis. p value less than 0.05 was considered significant. results: among total neonates admitted to nicu during the study period, 117 (12.26%) neonates had developed clinical seizure. seventy five (64.1%) neonates were male and 42 (35.9%) were female. the male to female ratio was 1.7:1. one hundred (85.47%) neonates were term, whereas 17(14.52%) were preterm. the mode of delivery in 73 (62.39%) neonates was vaginal delivery , 37 (31.62%) was cesarean section (cs) and 7 (5.98%) was instrumental delivery. twenty seven (23.07%) neonates were born to mother who had history of prolonged second stage of labor and nine (7.69%) to those with history of placental or cord complications. fifty two (44.44%) neonates had first episode of seizure before 24 hours, 31 (26.49%) between 24 and 72 hours and 34 (29.05%) after 72 hours (late onset). in this study, 62 (53%) neonates had single episode of seizure while 55 (47%) had multiple episodes of seizure. abnormal neuroimaging were seen only in 11 (9.4%) neonates. among all neonates 78 (66.66%) needed only one antiepileptic medication to control seizure while 39 (33.33%) needed multiple drugs (table 1). the most common etiology for neonatal seizure was birth asphyxia (n=69, 59%), followed by infection (n=20, 17%) and transient metabolic disturbance (n=16, 13.7%). there was one neonate with no identified etiology (fig.1). sixteen (13.67%) patients died during or after neonatal period. among 101 neonates discharged after survival, 18(15.4%) patients had repeated seizures during the follow up period, 31(26.5%) had developmental delay, 19(16.2%) had vision impairment and 26(22.2%) had hearing impairment. low apgar score at one minute (p=0.003), low apgar score at five minutes (p=0.001), early onset of seizures (p<0.001), multiple episodes of seizure (p<0.001), multiple anti-epileptics used to control seizure (p<0.001) were notable risk factors for adverse outcome (table 1). analysis of various risk factors for developmental delay by binary logistic regression showed that neonates with single episode of seizure were less likely to develop developmental delay table 1. outcome of neonatal seizures in different clinical conditions (n=117) variables normal outcome adverse outcome statistics sex male 44 35 x2 (df=1, n=117)= 0.245, p=0.621female 23 15 gestational age term 59 41 x2 (df=1, n=117)=0.847, p=0.358preterm 8 9 mode of delivery vaginal 43 30 x2 (df=2, n=117)=2.508, p=0.285cesarean section 22 15 instrumental 2 5 onset of seizures within 24 hours 20 32 x2 (df=2, n=117)= 15.207, p= <0.00124 to 72 hours 25 6 after 72 hours 22 12 apgar at 1 min 0-3 17 27 x2 (df=2, n=117)=11.665, p=0.0034-6 31 18 7-10 19 5 apgar at 5 mins 0-3 1 7 f (df=2, n=117)=14.096, p=0.001 4-6 27 29 7-10 39 14 type of seizure subtle 16 16 x2 (df=3, n=117)=20.696, p=<0.001 tonic 35 12 clonic 13 6 mixed 3 16 episodes of seizure single 56 6 x2 (df=1, n=117)=58.896, p=<0.001multiple 11 44 aed single 63 16 x 2 (df=1, n=117)=50.237, p=<0.001multiple 4 34 neuroimaging normal 18 10 x2 (df=1, n=44)=2.946, p=0.086abnormal 6 10 singh sd. et al. etiological profile of neonatal seizures jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 birth asphyxia n=69 (59%) hie ii n=48 (69.56%) hie iii n=21 (30.43%)transient metabolic disturbance n=16 (14%) -hypoglycemia n=6 (37.5%) hyponatremia n=3 (18.75%) hypernatremia n=6 (37.5%) hypocalcemia n=1 (6.25%) infection n=20 (17%) meningitis n=10(50%) septicemia n=9(45%) congenital n=1(5%) benign neonatal seizure n=3(3%) developmental cerebral dysgenesis n=4(3%) ich n=4 (3%) unknown… fig. 1. etiological distribution of neonatal seizure (n=117) variables frequency (%) aor (95% ci) p value sex male female 67(66.33) 34(33.66) 45938(0.087-2.4e+10) 0.110 gestational age term preterm 88(87.12) 13(12.87) 0.00(0.00-2.20) 0.073 mode of delivery vaginal delivery c.s instrumental delivery 64(63.36) 32(31.68) 5(4.95) 101.14(0.00-9.47e+7) 19.01(0.00-1.71e+7) 0.424 0.510 0.674 apgar score at 1 min 0-3 4-6 7-10 32(31.68) 47(56.53) 22(21.78) 0.20(0.00-461.91) 0.13(0.00-70.29) 0.809 0.685 0.528 apgar score at 5 mins 0-3 4-6 7-10 4(3.96) 47(46.53) 50(49.50) 4.8e+11(0.00-1.2e+29) 1650291(0.40-6.6) 0.182 0.188 0.065 maternal risk factors prolonged second stage of labour placental or cord complications 19(18.81) 8(7.93) 0.012(0.00-28.98) 0.11(0.003-4.79) 0.267 0.252 onset of seizure <24hours 24-72 hours >72 hours 39(38.61) 30(29.70) 32(31.68) 0.012(0.00-2.36) 0.00(0.00-1.57) 0.100 0.062 episode of seizure single multiple 62(61.38) 39(38.68) 0.00(0.00-0.67) 0.044 abnormal neurological finding yes no 11(29.72) 26(70.27) 326(0.33-3270842) 1155.79(0.25-5.37e+7) 0.218 0.198 antiepileptic medication single multiple 77(76.23) 24(23.76) 0.001(0.00-7.94) 0.137 table 2. risk factors for developmental delay (n=117) as compared to multiple episodes of seizure [aor (95%ci)=0.00(0.00-0.67), p=0.044]. the odds of having developmental delay was 33% to 100% lower in those neonates with single episode of seizure in comparison to multiple episodes. the incidence of developmental delay was high among the neonates whose apgar score was low at one minute and among those that developed seizure within 24 hours; however, these findings were statistically not significant (table 2). post neonatal seizures were more common in male term babies delivered vaginally; however, it singh sd. et al. etiological profile of neonatal seizures jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 variables frequency (%) aor (95% ci) p value sex male female 67(66.33) 34(33.66) 0.374 (0.022-6.337) 0.495 gestational age term preterm 88(87.12) 13(12.87) 0.574 (0.028-11.757) 0.718 mode of delivery normal vaginal delivery c.s instrumental delivery 64(63.36) 32(31.68) 5(4.95) 0.229 (0.001-38.077) 0.816 (0.004-164.363) 0.572 0.940 0.551 apgar score at 1 min 0-3 4-6 7-10 32(31.68) 47(56.53) 22(21.78) 104 (1.24-870) 8.28 (0.34-200) 0.043 0.193 0.123 apgar score at 5 mins 0-3 4-6 7-10 4(3.96) 47(46.53) 50(49.50) 205162 (0.00-1.17) 0.28 (0.007-12.09) 0.997 0.514 0.808 maternal risk factors prolonged second stage of labour placental or cord complications 19(18.81) 8(7.93) 1.8 (0.10-31.40) 2.48e+9 (0.00) 0.669 0.998 onset of seizure <24hours 24-72 hours >72 hours 39(38.61) 30(29.70) 32(31.68) 0.11(0.03-3.74) 1.09 (0.08-14.65) 0.220 0.948 episode of seizure single multiple 62(61.38) 39(38.68) 0.00 (0.00-) 0.994 abnormal neurological finding yes no 11(29.72) 26(70.27) 0.177(0.08-3.77) 0.437 (0.16-11.65) 0.268 0.621 antiepileptic medication single multiple 77(76.23) 24(23.76) 0.64(0.07-5.67) 0.689 table 3. risk factors for post neonatal seizure ( n=117) was not statistically significant. low apgar score (03) at one minute was the single most risk factor for post neonatal seizure(p=0.043). the neonates with low apgar score (0-3) had 104 times more odds of developing post neonatal seizures in comparison to those with normal apgar score (7-10) (table 3). multivariable binary logistic regression analysis showed that multiple episodes of seizure (p<0.001) and apgar score (4-6) at five minutes (p=0.046) were statistically significant risk factors for hearing impairment. similarly, mode of delivery especially vaginal delivery (p=0.01) and cesarean section (p=0.03) were less likely to result in vision impairment in comparison to instrumental delivery. multiple episodes of seizure (p=0.005) and abnormal neurological findings (p=0.045) were also found to be statistically significant risk factors for vision impairment (table 4). discussion: the overall incidence of neonatal seizures in our study was 12.26%. this incidence is similar to that in established intensive care units which is as high as 25% in nicu.[8] the seizures were more common in males (63.36%) which is similar to the study done by alyasiri aa[9](63.9%), sabzehaei et al.[3] (57%) and jasim m et al.[4](54.5%).the majority of neonates who developed seizures were full term (85.47%) which is comparable to the finding of alyasiri aa (91%).[9] a majority of neonates in singh sd. et al. etiological profile of neonatal seizures jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 frequency (%) hearing impairment vision impairment aor (95% ci) p value aor (95% ci) p value sex male female 67 (66.33) 34 (33.66) 10.77 (1.41-82.71) 0.022 6.27 (0.79-49.70) 0.08 gestational age term preterm 88 (87.12) 13 (12.87) 0.765 (0.07-7.86) 0.822 0.14 (0.01-1.70) 0.12 mode of delivery vaginal delivery c.s instrumental delivery 64 (63.36) 32(31.68) 5 (4.95) 0.58 (0.02-12.2) 0.24 (0.01-5.34) 0.73 0.37 0.004 (0.00-0.38) 0.009 (0.00-0.63) 0.01 0.03 apgar score at 1 min 0-3 4-6 7-10 32 (31.68) 47 (56.53) 22 (21.78) 2.70 (0.09-81.61) 3.63 (0.29-45.04) 0.56 0.31 17.40 (0.33-915) 2.54 (0.18-35.03) 0.15 0.48 apgar score at 5 mins 0-3 4-6 7-10 4 (3.96) 47 (46.53) 50 (49.50) 25.43 (0.45-1409) 10.66 (1.03-109) 0.114 0.046 42.02 (0.69-255) 7.69 (0.45-131.55) 0.07 0.15 maternal risk factor prolonged second stage labor placental or cord complication 19 (18.81) 8 (7.93) 0.77 (0.12-4.90) 2.69 (0.15-47.75) 0.78 0.49 4.13 (0.30-56.38) 0.11 (0.005-2.841) 0.28 0.18 onset of seizure <24hours 24-72 hours >72 hours 39 (38.61) 30 (29.70) 32 (31.68) 1.20 (0.12-11.47) 1.03 (0.14-7.59.0) 0.86 0.97 0.07 (0.003-1.584) 0.96 (0.108.95) 0.09 0.97 episode of seizure single multiple 62(61.38) 39(38.68) 0.014 (0.002-0.124) <0.001 0.002 (0.00-0.15) 0.005 abnormal neurological finding yes no 11 (29.72) 26 (70.27) 0.46 (0.05-3.81) 0.47 0.121 (0.16-0.016) 0.045 antiepileptic medication single multiple 77 (76.23) 24(23.76) 1.32 (0.19-8.89) 0.77 1.03 (0.13-7.78) 0.97 our study population were born via vaginal delivery (62.39%). similar results were also seen in the study done by talebian a et al. in iran with seizure incidence in vaginal delivery of 65.61% compared to 34.4% in cs.[10] we found that 52(44.44%) of the neonates had seizure of early onset. this is similar to the findings of faiz n et al.[8] in which early onset seizure was found in 59% and in another study by alyasiri aa [9] where early onset seizure was found in 50.8%. in our study, perinatal asphyxia was the leading cause of neonatal seizures (59%) although the incidence varies in different studies as a result of the inconsistent diagnostic criteria used. this finding is comparable to studies by sahana et al.[11] and loman am et al.[12]in which neonatal seizures following hie had occurred in 57.8% and 53.9% respectively. infections were the second most common cause of seizure in our study which comprised almost 17.09% which was similar to study by alyasiri aa (16.4%). [9] another common cause of neonatal seizure in the current study was transient metabolic disturbance table 4. risk factors for vision and hearing impairment ( n=117) (n=16, 13.6%), which was comparable to studies by sahana et al.[11] in our study, hypoglycemia was the most common transient metabolic disturbance (n=6) comprising 5.12% of total etiology and 37.5% of transient metabolic disturbance. this was supported by the other studies as well.[9,10] in this study, beside three major etiologies, the other etiologies for seizure were intracranial hemorrhage, developmental cerebral dysgenesis and benign neonatal seizure. many other studies reported similar findings.[9,13] we found statistically significant relationship between low apgar scores (0-3) at one and five minutes, early onset seizure (<24 hours), multiple episodes of seizure, number of antiepileptic drugs needed to control seizure and neonatal outcome. similar to our study, other studies by lai yh et al.[14] and pisaniet f et al.[15] found that low apgar scores at one and five minutes and early onset of seizure were prognostic factors for poor outcome. we did not find a significant relationship between abnormal neuroimaging finding and seizure outcome (p=0.086). this finding differs from other reports in which abnormal neuroimaging has been associated with worse outcome.[14,15] this could possibly be explained by the fact that only minor anomalies were found in neuroimaging in most of the neonates and only few neonates had major malformations or pathological conditions. the only variable significantly related to developmental delay was multiple episodes of seizure (p=0.044). the finding differs from other reports in which abnormal neuroimaging and prematurity were significantly related to developmental delay while multiple episodes was not.[13] developmental delay was more dependent on etiology and duration of seizure rather than the episode of seizure. similar to our study, another study by echandia et al. showed low five minutes apgar score was not an effect modifier neither a confounder of the association between neonatal seizure and developmental delay. [16] the only variable significantly related to post neonatal seizure was low apgar score at one minute. eighteen (15.4%) newborns recruited to our study developed seizure later in life which is comparable to the study done by francesco p et al.[17]where 17.6% of the newborns developed epilepsy later in life. the study also showed no significant relation of mode of delivery, gestational age and onset of seizure with post neonatal seizure similar to our study. the present study found significant occurrence of hearing loss among infants with the history of low apgar score at five minutes. this finding was similar to another study done in gauhati medical college hospital, india.[18] similar to another study by pisani f et al.[15] this study also showed association of multiple episodes of seizure with poor neurologic outcome including vision and hearing loss. limitation: since neonatal seizures are often subclinical, eeg recording of electrographic seizures is crucial for estimation of true seizure burden which could not be done in our setup. the number of neonates was less as it was a single center study and follow up was not done for longer periods. conclusion: the most common cause of neonatal seizures was hie followed by infection and transient metabolic disturbances. neonatal seizures predominated in term, male newborns and vaginal delivery with low apgar score. furthermore, the follow up showed an increased risk of developmental delay and hearing impairment in most infants. we found five variables in neonates with neonatal seizures for providing early prognostic information on adverse outcome: low apgar scores at one and five minutes, early onset seizure, multiple episodes of seizures and multiple anti-epileptics needed to control seizures. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. j. lumbini. med. coll. vol 6, no 2, july-dec 2018 jlmc.edu.np singh sd. et al. etiological profile of neonatal seizures references: 1. mwaniki m, mathenge a, gwer s, mturi n, bauni e, newton cr, berkley j, idro r. neonatal seizures in a rural kenyan district hospital: aetiology, incidence and outcome of hospitalization. bmc medicine. 2010 dec;8(1):16. pmid: 20136524 doi: 10.1186/1741-70158-16 [publisher full text] 2. jensen fe. developmental factors in the pathogenesis of neonatal seizures. journal of pediatric neurology. 2009 jan 1;7(1):5-12. pmid: 20191097 doi: 10.3233/jpn2009-0270 [publisher full text] 3. sabzehei mk, basiri b, bazmanoun h the etiology, clinical type, and short outcome of seizures in newbornshospitalized in besat hospital/hamadan/iran. iranian journal of child neurology. 2014;8(2):24-28. pmid: 24949047 [publisher full text] 4. marzoki jm. clinco-biochemical profile of neonatal seizures. al-qadisiyah medical journal. 2010;6(10):161-74. [publisher full text] 5. silverstein fs, jensen fe. neonatal seizures. annals of neurology. 2007 aug;62(2):112-20. pmid: 17683087 doi: 10.1002/ana.21167 [publisher full text] 6. van der heide mj, roze e, van der veere cn, ter horst hj, brouwer of, bos af. long-term neurological outcome of term-born children treated with two or more anti-epileptic drugs during the neonatal period. early human development. 2012 jan 1;88(1):33-8. pmid: 21835564 doi: 10.1016/j.earlhumdev.2011.06.012 7. ballard jl, novak kk, diver ma. a simplified method for diagnosis of gestational age in the newborn infant. journal of pediatrics 1979; 95:769-774. 8. faiz n, malik m, azam m, afzal u. etiology and type of neonatal seizures. annals of pakistan institute of medical sciences 2009;5(2):77-86. 9. alyasiri aa. etiology and short outcome of neonatal seizures in babylog gynecology and pediatrics teaching hospital. medico research chronicles 2015;2(1)30-40 10. talebian a, jahangiri m. rabiee m, masoudialavi n, akbar h, sadat z. the etiology and clinical evaluations of neonatal seizures in kashan, iran. iranian journal of child neurology. 2015;9(2):29. pmid: 26221160 [publisher full text] 11. g sahana, b anjaiah. clinical profile of neonatal seizures. international journal of medical and applied sciences 2014; 3(1):21-7. 12. loman am, ter horst hj, lambrechtsen fa, lunsing rj. neonatal seizures: aetiology by means of a standardized work-up. european journal of paediatric neurology. 2014 may 1;18(3):360-7. pmid: 24630570 doi: 10.1016/j. ejpn.2014.01.014 13. nunes ml, martins mp, barea bm, wainberg rc, costa jc. neurological outcome of newborns with neonatal seizures: a cohort study in a tertiary university hospital. arquivos de neuro-psiquiatria. 2008 jun;66(2a):168-74. pmid: 18545776 doi: 10.1590/ s0004-282x2008000200005 [publisher full text] 14. lai yh, ho cs, chiu nc, tseng cf, huang yl. prognostic factors of developmental outcome in neonatal seizures in term infants. pediatrics & neonatology. 2013 jun 1;54(3):166-72. pmid: 23597533 doi: 10.1016/j. pedneo.2013.01.001 [publisher full text] 15. pisani f, sisti l, seri s. a scoring system for early prognostic assessment after neonatal seizures. pediatrics. 2009 oct 1;124(4):e580-7. pmid: 19752080 doi: 10.1542/peds.2008-2087 [publisher full text] 16. echandía ca, ruiz jg. low apgar score and neonatal seizures: neuromotor development at 1 year age. colombia médica. 2006 mar;37(1):21-30. 17. pisani f, piccolo b, cantalupo g, copioli c, fusco c, pelosi a, tassinari ca, seri s. neonatal seizures and postneonatal epilepsy: a 7-y follow-up study. pediatric research. 2012 aug;72(2):186-93. pmid: 22580721 doi: 10.1038/pr.2012.66 [publisher full text] 18. biswas ak, goswami sc, baruah dk, tripathy r. the potential risk factors and the identification of hearing loss in infants. indian journal of otolaryngology and head & neck surgery. 2012 sep 1;64(3):214-7. pmid:22998022 doi: 10.1007%2fs12070-011-0307-6 [publisher full text] j. lumbini. med. coll. vol 6, no 2, july-dec 2018 jlmc.edu.np singh sd. et al. etiological profile of neonatal seizures bier’s block: a case report kalpana kharbuja,a,c mahesh sharma,a,c nil raj sharmab,c —–————————————————————————————————————————————— abstract: introduction: intravenous regional anesthesia (ivra) has been first described in 1908 by the german surgeon august kg bier. although the technique was convenient to perform and effective in giving surgical anesthesia, the recent plexus block techniques have largely replaced the “bier’s block” instantly because of time limitations and safety considerations of ivra. throughout the years, modifications in procedure and new pharmacologic adjuvants have shown to prevent toxic reactions to anesthetics and mitigate limitations of ivra, still ivra can be preferred as choice of anesthesia for short procedures. case report: we present a case of 86 yr old male who was operated for radius fracture after a fall injury under bier’s block or ivra technique. conclusion: ivra can be the choice of anesthesia for short procedures because of rapid onset of anesthesia, easy administration and cheaper cost with special considerations on its side effects, complications which can be the outcome of technical errors. keywords: intravenous anesthesia • nerve block • plexus block • regional ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, b professor and head c department of anesthesiology and critical care lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. mahesh sharma e-mail: maheshsharmalmc2@gmail.com how to cite this article: kharbuja k, shrama m, sharma nr. bier's block: a case report. journal of lumbini medical college, 2015;3(1):23-4. doi: 10.22502/ jlmc.v3i1.65. ___________________________________________________________________________________ j. lumbini. med. coll. vol 3, no 1, jan-june 2015 case report jlmc.edu.np https://doi.org/10.22502/jlmc.v3i1.65 introduction: in august 1908, kg bier, professor of surgery at berlin, first described a technique in which a local anesthetic solution (procaine) was administered intravenously into a limb with the arterial blood supply occluded by a tourniquet.1 although the technique was easy to perform, providing a quite rapid onset of surgical anesthesia and an acceptable muscular relaxation; time limitations and safety considerations remained as a matter paramount importance. on the other hand, more reliable and safe plexus block techniques was introduced in clinical practice few years later which largely replaced the “bier’s block” nevertheless, ivra has not been completely abandoned (e.g., herreros recommended in 1946 the use of ivra on the battlefield and international symposia on ivra have been held in 1966 and 1979).2,3 also, the new procedures and pharmacologic adjuvants has been introduced to prevent toxic reactions to the anesthetic solution and mitigate limitations of ivra. the current study was a reported case of two days old right distal radius fracture acquired after a fall which was corrected with closed reduction with k wire fixation using external fixation all performed under the ivra technique (bier’s block). case report: an 86-year-old patient presented in emergency department with two days old closed comminuted right distal radius fracture with alleged history of fall injury. he was planned for closed reduction with k-wire fixation with external fixator. medical history included chronic hypertension for last 10 years. he was under enalapril 2.5 mg with hypertension under control for last four years. there was no known allergy history to local anesthesia. on examination, he was averagely nourished with pulse 23 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 jlmc.edu.np kharbuja k. et al. bier's block: a case report. rate: 68 bpm, blood pressure of 140/90 mm hg and respiratory rate (rr) of 14 per min. all other systemic examinations were within normal limits. airway examination revealed modified mallampati class iii, adequate mouth opening and neck extension. the blood investigations were normal. informed consent was taken. he was premedicated with lorazepam two mg tablet and pantoprazole 40 mg tablet. on the day of surgery, in operating table standard monitors were applied. baseline vitals were recorded and under aseptic precaution 18 gauze venous access was taken on left dorsum of hand, opposite to block side for intravenous fluid managements. a double pneumatic tourniquet was placed on padding layer of soft cloth with proximal cuff high on upper arm. 18 gz cannula was inserted in right dorsum of hand and cannula was flushed with normal saline before capping. the entire arm was elevated for two minutes for passive exsanguinations. then upper esmarch bandage was wrapped around arm spirally from hand to distal cuff of double tourniquet to exsanguinate extremity completely. then proximal cuff was inflated 100 mm hg above systolic pressure. ten milliliters of plain 2% local anaesthesia was diluted to 40 ml and injected via cannula. arm was lowered to table after injection and iv cannula from anesthetized side was removed and pressure was quickly applied over puncture site in sterile manner. distal cuff was deflated within 10 minutes. total duration of surgery was around 40 minutes. hemodynamic parameters remained stable with systolic blood pressure (sbp) 130-150 mm hg, diastolic blood pressure (dbp) 80100 mm hg, heart rate (hr) 82-98 bpm, spo2 9699%. postoperative period was uneventful. discussion: injection of local anesthesia into venous system of the extremity previously exsanguinated and isolated from the central circulation, with tourniquet application, is involved in ivra and is called bier's block. ivra is easy to administrate, its overall cost is low, it is applicable to all age groups, the onset of surgical anesthesia is quite rapid, and after the tourniquet (a device introduced for limb amputation by war surgeons) is released, normal sensation and motor power return rapidly.4 short elective surgical procedures (< 90 min) can be performed on the hand and the forearm, usually on soft tissues. while in case of an emergency bone fractures, this technique can be utilized for surgery, even in children.5,6 reduction or manipulation of fractures, ganglionectomies, carpal tunnel syndrome, dupuytren's contractures, complex regional pain syndrome (crps) can be done under this block. the preferred drug for the bier's block is prilocaine which is the drug of choice while lidocaine (0.5% diluted to 40 ml), nysora (2%, 15-20 ml) can also be used. it is essential that plain noradrenaline containing solutions are used. bupivacaine should never be used for bier's block. ivra contraindications include patient’s refusal, allergy to local anesthetic, infection, a personal history of seizures, peripheral neurologic diseases, cardiac arrhythmias, a-v shunt, conditions precluding exsanguination and/or the use of an ischaemic tourniquet, e.g. scleroderma, raynaud’s disease, tumors, increased intracranial pressure, sickle cell disease (possible), deep vein thrombosis or thrombophlebitis, vascular insufficiency. complication as hematoma, systemic side effect of local anaesthesia, engorgement of extremity and ecchymosis can be observed with this procedure. conclusion: even after the development of many new techniques, ivra still is a good choice of anaesthesia for short procedures because of rapid onset, easy administration, and low cost. references: 1. bier a. uber einen neuen weg lokalanästhesie an den gliedmassen zu erzcugen. ann klin chir. 1908;86:1007-16. 2. colberne ec. the bier block for intravenous regional anesthesia: technique and literature review. anesth analg. 1970;49:935-40. 3. herreros lg. regional anesthesia for the intravenous route. anesthesiology. 1946;7:558. 4. laffin j. combat surgeons. 2 ed. phoenix mill (gloucestershire): sutton publishing ltd;1999. 5. carrel ed, eyring ej. intravenous regional anesthesia for childhood fractures. j trauma 1971;11:301-5. 6. fitzgerald b. intravenous anaesthesia in children. br j anaesth. 1976;48:485-486. 24 https://doi.org/10.22502/jlmc.v10i1.475 original research article prevalence and associated factors of overweight and obesity in reproductive women of a municipality in western nepal keshav raj bhandari, a,e deepak bahadur pachhai, b,f shova parajuli, c,g kamal kandel, a,h hari prasad upadhyay d,i abstract: introduction: overweight and obesity are major health related problems and cause economic burden on societies around the world. this study aimed to estimate the prevalence of overweight and obesity, and to determine the associated factors among reproductive women in a municipality in western nepal. methods: a community-based cross-sectional study was performed and data was collected by convenience sampling method including 353 women aged 15-45 years. overweight and obesity were defined according to who body mass index classification. chi-square test was used to assess the factors associated with overweight and obesity. odds ratio was computed using binary logistic regression analysis. results: the prevalence of overweight and obesity was 55% (overweight 49% and obesity 6%). age (p < 0.001), education (p = 0.02), occupation (p = 0.012), marital status (p = 0.008), presence of chronic disease (p < 0.001), dietary pattern (p = 0.01), restaurant visit (p = 0.002) and stress (p = 0.003) were significant associated factors for overweight including obesity among reproductive age women. the odds of being overweight or obesity was higher but not statistically significant in women aged 25-35 years (or = 2.57 ; 95% ci: 0.89-7.4, p = 0.082), in married women (or = 1.54; 95% ci: 1.08-2.02), and in parous women (or = 2.38; 95 % ci: 4.05-27.57). the odds of being overweight or obesity were significantly higher in the respondents who had no chronic disease compared to those who had a chronic disease (or = 6.81, 95% ci: 2.10-10.16). conclusion : we observed a high prevalence of overweight and obesity in our sample. age, education, occupation, marital status, presence of chronic disease, dietary pattern, restaurant visit and stress were associated with overweight or obesity. keywords : obesity, overweight, prevalence, reproductive age, women submitted: 06 february, 2022 accepted: 26 august, 2022 published: 22 september, 2022 a lecturer b associate professor c bachelor of nursing d assistant professor e department of community medicine, lumbini medical college, prabhas, palpa f department of statistics, patan multiple campus, kathmandu g mayadevi technical college, rupandehi butwal h department of pharmacology, lumbini medical college, prabhas, palpa i department of statistics, birendra multiple campus , bharatpur, chitwan. corresponding author: keshav raj bhandari lecturer, department of community medicine, lumbini medical college, prabhas, palpa, nepal e-mail: krbhandari54@gmail.com orcid: https://orcid.org/0000-0002-5083-6493 introduction: overweight and obesity refer to a body weight greater than what is healthy. obesity is a chronic condition defined by an excess amount of body fat. a certain amount of body fat is required for conserving energy, thermoregulation, shock absorption, and other functions.[1] the prevalence of obesity has nearly tripled worldwide since 1975. in 2016, more than 1.9 billion (39%) adults, aged 18 years and above, were overweight and more than 650 million (13%) were found to be obese.[2] how to cite this article: bhandari kr, pachhai db, parajuli s, kandel k, upadhyay hp. prevalence and associated factors of overweight and obesity in reproductive women of a municipality in western nepal. journal of lumbini medical college. 2022;10(1):9 pages. doi: https://doi.org/10.22502/jlmc.v10i1.475 epub: 2022 september 22 j. lumbini. med. co ll. vol 10, no 1, jan-june 2022 https://doi.org/10.22502/jlmc.v10i1 https://orcid.org/0000-0002-5083-6493 https://www.medicinenet.com/shock/article.htm bhandari kr, et al. overweight and obesity in reproductive women of a municipality in western nepal obesity is best determined by body mass index (bmi). it is measured as a person’s weight in kilograms (kg) divided by height in meters (m) squared. because a person's weight relative to height is explained by bmi, the strong correlation was found with total body fat content in adults.[1] overweight and obesity are major risk factors for a variety of chronic diseases, including diabetes, cardiovascular diseases, and cancer. the mortality rates also increase with increase in bmi.[3] the prevalence of overweight and obesity combined was over one third among women in a health center-based study in palpa.[4] the risk of obesity is increasing in reproductive age group.[5] so this study was carried out to determine the prevalence of overweight and obesity, and to identify the associated factors in a community in palpa district. methods : this cross-sectional study was conducted among 15-49 year-old women in tansen municipality ward number 7 by convenience sampling technique from november 2021 to january 2022. according to koirala m et al., the prevalence of obesity and overweight in women was 35.6%.[4] taking this study as a reference, the required minimum sample size calculated was 353 at 5% level of significance and 5% margin of error. women aged 15-49 years were included in the study. the women who reported pregnancy and who were not able to participate in the study due to any illness were excluded from the study. a structured questionnaire was used in this study as a data collection tool. the women were explained about the objectives of the study. the questionnaire was then distributed to the women who provided informed consent to participate in the study. confidentiality of the women was maintained as no individual identification was included in the questionnaire. weight was taken in an electronic bathroom scale and the same scale was used for all the respondents. before measurement, the scale of the machine was set to zero and respondents were asked to remove any ‘heavy’ items (key, mobile, hand bag etc.). the respondents were weighed barefoot and dressed in the lightest clothes possible. while measuring weight, they were asked to look straight ahead and stay still on the scale. the height of each respondent was measured with a standard stadiometer. bmi was then calculated for each respondent. overweight was defined as having a bmi between 25.0 and 29.9 kg/m 2 and obesity as having a bmi equal or greater than 30 kg/m 2 .[2] this study included some selected socio-demographic variables (age, ethnicity, education, occupation, marital status, family structure) , behavioral variables (exercise, sleeping pattern, restaurant visit, dietary pattern, consumption of alcohol, consumption of junk food, diet schedule, fasting, habit of food choice, time spent sitting in a day at same place, presence of stress), reproductive factor (parity) and presence of any chronic disease. statistical analysis was performed with statistical package for social sciences (spss v.23) software. chi-square test was used to find the association between bmi classification and different categorical variables and odds ratio (or) was calculated by using binary logistic regression analysis. a p-value less than 0.05 was considered statistically significant. ethical clearance for the study was obtained from the institutional review committee of the institution (irc-lmc 06-c/021). results: a total of 353 reproductive age women with average age 30 ± 0.56 years having minimum and maximum age 16 years and 49 years respectively were included in the study. about half of the women (172, 49%) belonged to the age group 15-25 years and almost one-fourth (80, 23%) to the age group 36 49 years (table 1). representatives from various ethnic groups namely janajati (176, 50%), brahmin/chhetri (150, 42%) and dalit (27, 8%) were included in the study. most of the women (168, 48%) had j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np bhandari kr, et al. overweight and obesity in reproductive women of a municipality in western nepal completed at least bachelor level of education and a few of them (30, 8%) had completed basic level schooling only. the majority of the women were housewives (216, 61%) and were married (276, 78%). table 1. demographic profile of the respondents (n= 353) variables frequency (%) age (years) 15-25 172 (49) 26-35 101 (28) 36-49 80 (23) cast brahmin/chhetri 150 (42) janajati 176 (50) dalit 27 (8) educational level informal 43 (12) basic 30 (8) secondary 112 (32) higher 168 (48) occupation housewife 216 (61) job 40 (11) business 26 (8) student 71 (20) marital status married 276 (78) unmarried 77 (22) family structure nuclear 184 (52) joint 169 (48) the mean bmi of the women was 24.7 ± 3.56 kg/m 2 ranging from 18.5 to 30.36 kg/m 2 . more than half (55%) of the women were overweight or obese and 4% of the women were underweight (table 2). table 2. body mass index (bmi) classification of the respondents according to who guideline bmi category frequency (%) underweight 15 (4) normal weight 146 (41) overweight 173 (49) obese 19 (6) table 3 shows that two thirds of the women were non-vegetarian (243, 69%). all of the women consumed junk food and more than half of the women (216, 61%) had a habitual diet as ‘lunch, snacks and dinner’ in a day. more than half of the women (197, 56%) would visit a restaurant for their meal one or more times a week. the prevalence of fasting in a week and having a habit of food choice were 45% and 5% respectively. table 4 shows that age, education, occupation, marital status and parity were statistically significantly associated with overweight including obesity. table 5 shows that women who were already suffering from other diseases had significantly higher chance of being overweight or obese. the prevalence of being overweight including obesity (55%) in vegetarian women was comparatively greater than non-vegetarian women (40%) which was statistically significant (p = 0.01). women with no stress were likely to have normal weight as compared to those who were always stressed. binary logistic regressions were used for statistically significant variables. table 6 shows the output of logistic regression of bmi for different characteristics. regarding the age, respondents in the age group 15-25 years had higher odds of being overweight or obese (or = 1.628, 95% ci: 0.43-6.126) as compared to those respondents who were in the age group more than 35 years and the odds of the respondents in j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np bhandari kr, et al. overweight and obesity in reproductive women of a municipality in western nepal table 3. lifestyle profile of the respondents (n= 353) variables frequency (%) diet vegetarian 110 (31) nonvegetarian 243 (69) alcoholic habit yes 3 (1) no 350 (99) consumption of junk food yes 353 (100) diet schedule breakfast, lunch, snacks, dinner (four times a day) 137 (39) lunch, snacks, dinner (three times a day) 216 (61) restaurant visit 2-3 times a week 72 (20) once in a week 125 (36) occasionally 156 (44) fasting in a week 1 day in a week 160 (45) never 193 (55) habit of food choice yes 16 (5) no 337 (95) sitting at the same place continuously less than two hours 166 (47) two hours or more 187 (53) the age group 25-35 years were 2.565 (95% ci: 0.886-7.426) times higher as compared to those respondents who were more than 35 years. this result was found to be statistically insignificant. regarding the education, the odds of being overweight or obese in respondents who had primary education were 1.286 (95% ci: 0.419-3.943) times higher as compared to those respondents who had informal education and 2.342 (95% ci: 0.855-6.417) times higher in those with secondary education as compared to those respondents who had informal education. this result was also found to be statistically insignificant. regarding the occupation, the odds were raised in respondents who were housewives by 5.673 (95% ci: 0.595-14.119) times as compared to those respondents who were students. this result was also found to be statistically insignificant. regarding marital status, respondents who were married were more likely (or = 1.540, 95% ci: 1.08-2.020) to be overweight as compared to those respondents who were unmarried. this result was also found to be statistically insignificant. regarding the presence of chronic disease, respondents who had no chronic disease were more likely to be overweight (or = 6.819, 95% ci: 2.098-10.160) j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np bhandari kr, et al. overweight and obesity in reproductive women of a municipality in western nepal table 4. association of obesity with demographic variables variables bmi category, n (%) p-value* bmi ≤25 bmi >25 age (years) 15-25 116 (67) 56 (33) < 0.001 25-35 42 (42) 59 (58) >35 38 (48) 42 (52) education informal 19 (44) 24 (56) 0.002 primary 15 (50) 15 (50) secondary 51 (45) 61 (55) higher 111(66) 57 (34) occupation housewife 108 (50) 108 (50) 0.012 job 24 (60) 16 (40) business 13 (50) 13 (50) student 51 (72) 20 (28) marital status unmarried 53 (88) 24 (32) 0.008 married 143 (52) 133 (48) parity none 59 (71) 24 (29) < 0.001 1 time 20 (38) 33 (62) 2 time 80 (60) 54 (40) >2 times 37 (45) 46 (55) *chi-square test. as compared to those respondents who had a chronic disease. this result was found to be statistically significant. discussion: the present study was undertaken to assess the prevalence of overweight and obesity and their associated factors among reproductive age group women at tansen municipality, where socio-demographic, behavioral and reproductive factors were assessed. this study reported the prevalence of overweight/obesity to be 55% (overweight 49% and obesity 6%) with the mean bmi of 24.7±3.56 kg/m 2 . according to tripathi n et al.,the prevalence of overweight including obesity was 49.6% (overweight 33.7% and j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np bhandari kr, et al. overweight and obesity in reproductive women of a municipality in western nepal table 5. association of bmi with lifestyle related variables characteristics bmi category n (%) p value* bmi ≤25 bmi >25 presence of chronic disease no 161 (62) 98 (38) <0.001 yes 35 (37) 59 (63) dietary pattern vegetarian 50 (45) 60(55) 0.01 non vegetarian 146 (60) 97 (40) restaurant visit 2-3 times a week 53 (74) 19 (26) 0.002 once a week 62 (50) 61 (50) occasionally 81 (52) 75 (48) stress always 12 (55) 10 (45) 0.003 sometimes 130 (51) 127 (49) never 54 (73) 20 (27) *chi square test obesity 15.9%) with the mean bmi of 25.67±4.5 kg/m 2 .[6] similarly, studies from dharan, bharatpur, and bhaktapur reported 42%, 50.48%, and 32.1% of reproductive age women to be overweight/obese respectively.[7,8,9] the national level nepal health and demographic survey (ndhs) and nepal maternal mortality survey (nmms) 2016 reported the prevalence of overweight including obesity among 15-49 years women to be 22% which was lower than the finding of the present study.[10] according to koirala m et al. and vaidya a et al., the prevalence of overweight including obesity were 35.6% and 33% in their studies respectively.[4,11] the socio-demographic significant factors associated with obesity among respondents were age, education, occupation, marital status and parity of the women and lifestyle related significant factors were presence of chronic disease, dietary pattern, and restaurant visit for meal and stress. a study conducted in bharatpur metropolitan showed that age, marital status, parity, stress, sleeping time, calorie intake, carbohydrate intake, physical activity and fruits consumption were found to be significantly associated factors of overweight.[8] also, a study in kaski district concluded that factors associated with overweight/obesity were age (aor= 13.85, 95% ci: 5.77-40.80), business as occupation (aor=7.39, 95%ci: 2.25-14.17), fast food consumption of three or more times a week (aor=3.42, 95% ci: 1.01-11.63), energy intake above the recommended daily allowances (rda) (aor=5.45; 95% ci: 2.19-13.55), low or moderate physical activity level (aor=2.84; 95% ci: 1.18-6.83) and multiparty (aor=17.80; 95% ci: 4.04-89.06).[6] j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np bhandari kr, et al. overweight and obesity in reproductive women of a municipality in western nepal table 6: logistic regression of bmi for different characteristics characteristics p-value or 95% c.i. for or lower upper age (years) 15-25 0.471 1.628 0.433 6.126 25-35 0.082 2.565 0.886 7.426 >35 (ref) 0.120 education informal (ref) 0.266 primary 0.660 1.286 0.419 3.943 secondary 0.098 2.342 0.855 6.417 higher 0.458 1.551 0.487 4.940 occupation housewife 0.131 5.673 0.595 14.119 job 0.135 4.202 0.641 12.565 business 0.355 3.023 0.290 9.486 student (ref) 0.309 marital status unmarried (ref) married 0.235 1.540 1.080 2.020 parity none (ref) yes 0.347 2.380 4.050 27.565 presence of chronic disease no 0.001 6.819 2.098 10.160 yes (ref) dietary pattern vegetarian (ref) non-vegetarian 0.032 .544 0.311 .950 restaurant visit 2-3 times a week 0.166 1.735 0.795 3.786 once a week 0.962 .979 0.412 2.324 occasionally (ref) 0.131 stress always 0.830 1.138 0.351 3.687 sometimes 0.000 3.438 1.723 6.860 never (ref) 0.001 constant 0.004 0.020 j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np bhandari kr, et al. overweight and obesity in reproductive women of a municipality in western nepal in the present study, with reference to women aged more than 35 years, the odds of overweight including obesity were 1.628 (95% ci: 0.43-6.126) times raised among the women 15-25 years and 2.56 (95% ci; 0.886-7.426) times raised among women of age 25-35 years (p > 0.05). this finding was consistent with the studies conducted by koirala m. et al., bhattarai p et al., subedi s et al., and shrestha s et al. which revealed that obesity was significantly associated with the age of the respondents.[4,7,8,9] regarding the education of the women, this study revealed that education was associated with obesity as women having primary education (or = 1.286, 95% ci: 0.419-3.943) and those having secondary education or= 2.324, 95% ci: 0.8556.147) were more likely to be overweight as compared to those who had informal education though these results were statistically insignificant. this finding was consistent with the study conducted by koirala m et al.[4] the study conducted by tripathi n et al. and shrestha s et al. showed that education was not a significant factor for overweight including obesity. the study revealed that as compared to the housewife, the overweight including obesity was likely to be more in women with job and business.[6,9] a study conducted in kaski district showed women having self-run business as occupation (or=7.39) exhibited significantly higher odds for being overweight including obesity (p= 0.001).[6] according to shrestha s, occupation was not a significant factor associated with obesity (p=0.808).[9] married women had significantly higher odds of overweight or obesity in comparison to unmarried women (or=2.436; 95% ci: 1.080-2.02, p= 0.008). this finding was consistent with a study conducted by koirala m et al. (p = 0.02), and bhattarai p et al. (p=0.019).[4,7] the findings of the study revealed that higher parity was significantly associated with overweight including obesity. compared to nulliparous women or women with parity two or more than two, women with parity one were more likely to be overweight. a similar study done by tripathi n et al. concluded that the women who had more than two parity were more likely to be overweight than nulliparous women (aor=17.803).[6] the prevalence of being overweight including obesity in vegetarian women was comparatively greater than in non-vegetarian women. however, a study done by koirala m et al. concluded that non vegetarian women are likely to be more at risk for overweight including obesity.[4] according to shrestha s et al. there is no association between dietary pattern and obesity (p = 0.279).[9] the contrasting findings in this study might be due to role of other confounding factors. the prevalence of overweight including obesity in women with no chronic disease was comparatively greater than in women with such conditions which was consistent with the study conducted in bhaktapur.[9]. in contrast, the prevalence of overweight in chronic disease women was comparatively higher in another study.[12] the stressful women were more likely to be overweight or obese in this study which is consistent to study done in bharatpur, nepal.[8] . there are some limitations of this study. the study used non-probability sampling technique (convenience sampling) rather than probability sampling which may not be representative of all women in this study area. conclusion: the overall prevalence of overweight including obesity among reproductive age women in tansen was high. the study concluded that age, education, occupation, marital status, parity and stress were associated with prevalence of overweight and obesity. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np bhandari kr, et al. overweight and obesity in reproductive women of a municipality in western nepal references: 1. balentine jr. obesity and overweight [internet]. san clemente: medicinenet; 2021 [cited]. available from: https://www.medicinenet.com/obesity_w eight_loss/article.htm#what_is_obesity 2. world health organization. obesity and overweight [internet]. geneva: world health organization; 2021 [cited on july 23]. available from: https://www.who.int/news-room/fact-she ets/detail/obesity-and-overweight 3. bhaskaran k, dos-santos-silva i, leon da, douglas ij, smeeth l. association of bmi with overall and cause-specific mortality: a population-based cohort study of 3·6 million adults in the uk. lancet diabetes endocrinol. 2018;6(12):944-53. pmid: 30389323 doi: https://doi.org/10.1016/s2213-8587(18)3 0288-2 4. koirala m, bajracharya s, koirala m, neupane s, bhandari kr. risk factors for obesity in nepalese women:a cross-sectional study. journal of lumbini medical college. 2019;7(2):93-99. doi: https://doi.org/10.22502/jlmc.v7i2.294 5. hu fb. obesity epidemiology. oxford: oxford university press; 2008. 498p 6. tripathi n, koirala a, dbhakal r. factors associated with overweight and obesity among reproductive age women of kaski district, nepal . journal of health and allied sciences . 2020;10(1):1-7. doi: https://doi.org/10.37107/jhas.173 7. bhattarai p, bhattarair, khadkadb. risk factors associated with overweight and obesity among women of reproductive age residing in dharan sub-metropolitan city, nepal. himalayan journal of science and technology. 2018;(0)2:26-33. doi: https://doi.org/10.3126/hijost.v2i0.25837 8. subedi s, bhattarai r, bista r. risk factors associated with overweight and obesity among reproductive aged females residing in bharatpur metropolitan city. adv obes weight manag control. 2020;10(3):75‒82. doi: https://doi.org/10.15406/aowmc.2020.10. 00310 9. shrestha s, devkota n, shrestha r. risk factors associated with obesity among middle aged adults residing in bhaktapur, nepal. journal of chitwan medical college. 2018;8(25):45-50. available from: https://www.nepjol.info/index.php/jcmc /article/view/23750 10. ministry of health nepal, new era, icf. nepal demographic and health survey 2016. kathmandu: ministry of health, nepal; 2017. available from https://www.dhsprogram.com/pubs/pdf/fr 336/fr336.pdf 11. vaidya a, shakya s, krettek a. obesity prevalence in nepal: public health challenges in a low-income nation during an alarming worldwide trend. international journal of environment research and public health. 2010;7(6):2726-44. pmid: 20644698 . doi: https://www.mdpi.com/1660-4601/7/6/27 26 12. kearns k, dee a, fitzgerald ap. chronic disease burden associated with overweight and obesity in ireland: the effects of a small bmi reduction at population level. bmc public health. 2014 ;14(0):143. pmid: 24512151 . doi: https://doi.org/10.1186/1471-2458-14-14 3 j. lumbini. med. coll . vol 10, no 1, jan-june 2022 jlmc.edu.np https://www.medicinenet.com/obesity_weight_loss/article.htm%23what_is_obesity%20 https://www.medicinenet.com/obesity_weight_loss/article.htm%23what_is_obesity%20 https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight https://pubmed.ncbi.nlm.nih.gov/?term=bhaskaran+k&cauthor_id=30389323 https://pubmed.ncbi.nlm.nih.gov/?term=dos-santos-silva+i&cauthor_id=30389323 https://pubmed.ncbi.nlm.nih.gov/?term=leon+da&cauthor_id=30389323 https://pubmed.ncbi.nlm.nih.gov/?term=douglas+ij&cauthor_id=30389323 https://pubmed.ncbi.nlm.nih.gov/?term=smeeth+l&cauthor_id=30389323 https://pubmed.ncbi.nlm.nih.gov/30389323/ https://doi.org/10.1016/s2213-8587(18)30288-2 https://doi.org/10.1016/s2213-8587(18)30288-2 https://doi.org/10.22502/jlmc.v7i2.294 https://www.researchgate.net/project/factors-associated-with-overweight-and-obesity-among-reproductive-age-women-of-kaski-district-nepal https://www.researchgate.net/project/factors-associated-with-overweight-and-obesity-among-reproductive-age-women-of-kaski-district-nepal https://www.researchgate.net/project/factors-associated-with-overweight-and-obesity-among-reproductive-age-women-of-kaski-district-nepal https://www.researchgate.net/journal/journal-of-health-and-allied-sciences-2091-2579 https://www.researchgate.net/journal/journal-of-health-and-allied-sciences-2091-2579 https://doi.org/10.37107/jhas.173 https://doi.org/10.3126/hijost.v2i0.25837 https://doi.org/10.15406/aowmc.2020.10.00310 https://doi.org/10.15406/aowmc.2020.10.00310 https://www.nepjol.info/index.php/jcmc/article/view/23750 https://www.nepjol.info/index.php/jcmc/article/view/23750 https://pubmed.ncbi.nlm.nih.gov/20644698/ https://www.mdpi.com/1660-4601/7/6/2726 https://www.mdpi.com/1660-4601/7/6/2726 https://pubmed.ncbi.nlm.nih.gov/24512151/ https://doi.org/10.1186/1471-2458-14-143 https://doi.org/10.1186/1471-2458-14-143 j. lumbini. med. coll. vol 9, no 1, jan-june 2021 robinson j, et al. covid-19: intranasal and oral routes of vaccination.robinson j, et al. covid-19: intranasal and oral routes of vaccination. jlmc.edu.np ___________________________________________________________________________________ submitted: 07 april, 2021 accepted: 18 april, 2021 published: 10 may, 2021 amedical student, bassociate professor, department of pharmacology, csir seewoosagur ramgoolam medical college, belle rive, vacoasphoenix, mauritius. corresponding author: indrajit banerjee e-mail: indrajit18@gmail.com orcid: https://orcid.org/0000-0003-2880-4695_______________________________________________________ perspectivehttps://doi.org/10.22502/jlmc.v9i1.427 jared robinson,a,c alexandra leclézio,a,c indrajit banerjeeb,c covid-19: intranasal and oral routes of vaccination how to cite this article:how to cite this article: robinson j, leclézio a, banerjee i. covid-19: intranasal and robinson j, leclézio a, banerjee i. covid-19: intranasal and oral routes of vaccination. journal of lumbini medical college. oral routes of vaccination. journal of lumbini medical college. 2021;9(1):3 pages. doi: 2021;9(1):3 pages. doi: https://doi.org/10.22502/jlmc.v9i1.427 epub: 2021 may 10.epub: 2021 may 10. the mainstay protocol exercised by global health leaders to control the spread of severe acute respiratory syndrome corona virus (sars-cov-2) has been screening, the identification of cases, isolation thereof, contact tracing and nation-wide lockdowns. the development of vaccinations against the sars-cov-2 virus has marked a new dawn for the war against corona virus disease (covid-19). [1,2] first generation immunization against covid-19: the first set of vaccinations to be produced were janssen and novavax, johnson and johnson, oxford astrazeneca, pfizer-biontech, moderna, and covaxin. all of these produce various side effects with some to the severity that multiple deaths have been recorded. this first generation of vaccines developed against covid-19 are all administered via the conventional intramuscular route. a more alarming fact is that this first generation of vaccines have a dwindling efficacy and confer little immunity against the new variants of the sars-cov-2 virus. [3] second generation immunization against covid-19: with the innate drawbacks and side effects of the traditional vaccines, coupled with the discovery of the new variants of the sars-cov-2 virus; a newer second generation of immunization against the virus is under development. the two new novel methods of immunization are the intranasal vaccine by oxford astra zeneca taking place at oxford university’s jenner institute and the oral vaccine which is being developed by oravax medical, a joint venture between an israeli-american company known as oramed and the indian company premas biotech.[4,5,6] covid-19 intranasal vaccine: the intranasal route of drug administration has been a popular route of delivery for drugs such as antihistamines. it is a rapid, easy, cost effective and high yield route for drug administration. the intranasal vaccine has been developed and is based on a poultry virus which has been designed to produce the spike proteins of sars-cov-2. it has shown promising results in animal studies, with a marked decrease and stoppage of viral shedding. this vaccine has now entered phase 1 clinical trials. [4,5,6,7] advantages of the intranasal vaccine: the cost effectiveness will allow for a greater international production capacity. the ease of administration nullifies the need for highly trained medical and paramedical staff. this innate advantage makes this vaccine a better hope for the planet to maintain herd immunity at a more rapid and safe rate due to its scalability. it is indicated that covid vaccines will have to be developed alongside the discovery of new variants, thus making the vaccine an annual or even biannual necessity. mass immunization is a monumental and logistical nightmare and thus a vaccine administered via the intranasal will make such vaccination campaigns licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 robinson j, et al. covid-19: intranasal and oral routes of vaccination.robinson j, et al. covid-19: intranasal and oral routes of vaccination. jlmc.edu.np more feasible.[4,7,8,9] covid-19 oral vaccine: the oral vaccine is based off of the protein oral delivery (pod) system developed by oramed. [6] it is developed using a virus like particle (vlp), it will be a triple antigen vaccine with the intent to hone in on three important viral structural proteins. the premise of the vaccine will be to evoke both a systemic and local immune response via iga and igg. current animal pilot studies have shown promising results with antibody production after a single capsule dose.[10,11] advantages of the oral vaccine: the oral vaccine will be both a more cost effective and widely greater accepted method of receiving the immunization. the production output of the oral vaccine coupled with its hardy nature and no need for a sophisticated cold chain will ensure people in the most remote and rural settings will have access to the vaccine. nepal is an example where the distribution of drugs on a wide basis is challenging due to economical, topographical and transportation obstacles; the oral route will thus make the attainment of herd immunity in such a nation a feasible possibility. the oral vaccine will confer a double layer of both systemic and local immunity, via iga and igg secretion thus decreasing shedding. [6] patient compliance: the intranasal route is a painless route of administration. it is less invasive and is needle free thus ensuring that patients suffering from trypanophobia will not be averse to being immunized. the ability of a patient to self-administer the vaccine will aid and increase patient compliance, thus aiding and boosting immunization rates.[9] the familiarity of oral administration and ease of use of this vaccine will increase patient compliance as the process of taking the vaccine will not be an entirely foreign concept.[10] storage: an innate challenge with the conventional first generation of vaccinations was the sanctity of the cold chain. the intranasal vaccine will eliminate these complications as storage would be simpler and more cost effective and thus make the logistical supply chain more feasible.[11] shelf life: the first-generation vaccinations have a short shelf-life which has led to the expiry of thousands of doses. both the oral and intranasal vaccines will have a longer shelf-life and will thus reduce wastage whilst simultaneously allowing for the better management of the international vaccine supply, thereby optimizing the vaccination rollout. [12] conclusion: the only long-term solution to this deadly pandemic will be the establishment of herd immunity across the entire globe. the current vaccinations available on the market are proving near impossible to achieve herd immunity with, due to a plethora of drawbacks. the new variants of covid-19 are of a great concern and thus, it is believed that a yearly “flu-like” immunization against covid-19 will be a necessity in future. the current vaccinations available on the market will not suffice and thus it is evident that the second generation via their novel routes of administration have both the cost and scalability potential to ensure a global vaccination roll out which is logistically sound and plausible. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 robinson j, et al. covid-19: intranasal and oral routes of vaccination.robinson j, et al. covid-19: intranasal and oral routes of vaccination. jlmc.edu.np references: 1. banerjee i, robinson j, kashyap a, mohabeer p, shukla a, leclézio a. the changing pattern of covid-19 in nepal: a global concern-a narrative review. nepal j epidemiol. 2020;10(2):845-55. pmcid: pmc7423402 pmid: 32874698 doi: https://doi.org/10.3126/ nje.v10i2.29769 2. fauci as, lane hc, redfield rr. covid-19 navigating the uncharted. n engl j med. 2020;382(13):1268-9. pmid: 32109011 doi: https://doi.org/10.1056/nejme2002387 3. peiris m, leung gm. what can we expect from first-generation covid-19 vaccines? lancet. 2020;396(10261):1467-9. pmid: 32971042 doi: https://doi.org/10.1016/s0140-6736(20)31976-0 4. ku mw, bourgine m, authié p, lopez j, nemirov k, moncoq f, et al. intranasal vaccination with a lentiviral vector protects against sars-cov-2 in preclinical animal models. cell host microbe. 2021;29(2):236-249.e6. pmid: 33357418 doi: https://doi.org/10.1016/j.chom.2020.12.010 5. wang j, peng y, xu h, cui z, williams ro 3rd. the covid-19 vaccine race: challenges and opportunities in vaccine formulation. aaps pharm sci tech. 2020;21(6):225. pmid: 32761294 doi: https://doi.org/10.1208/s12249020-01744-7 6. pharmaceutical technology. oramed forms joint venture to develop new oral vaccines for covid-19. available from: https://www. pharmaceutical-technology.com/news/oramedjoint-venture-oral-vaccines/ (accessed 7 april 2021). 7. bharat biotech. bbv154. available from: https:// www.bharatbiotech.com/intranasal-vaccine.html (accessed 7 april 2021). 8. financial times. trial set to start of astrazeneca covid vaccine as nasal spray. available from: https://www.ft.com/content/48fe2e97-f9e5-4291b965-0728bfc42213 (accessed 7 april 2021). 9. joi p. covid-19 vaccines: could a squirt up the nose be just as good as a shot in the arm? available from: https://www.gavi.org/vaccineswork/covid19-vaccines-could-squirt-nose-be-just-goodshot-arm (accessed 7 april 2021). 10. shahiwala a. formulation approaches in enhancement of patient compliance to oral drug therapy. expert opin drug deliv. 2011;8(11):15219. pmid: 21995544 doi: https://doi.org/10.1517/1 7425247.2011.628311 11. weir e, hatch k. preventing cold chain failure: vaccine storage and handling. cmaj. 2004;171(9):1050. pmid: 15505266 doi: https:// doi.org/10.1503/cmaj.1041565 12. sookaromdee p, wiwanitkit v. new covid-19 vaccines, its cost and shelf life: a cost effectiveness analysis. arch med res. 2020;s0188-4409(20):32249-9. pmid: 33485639 doi: https://doi.org/10.1016/j. arcmed.2020.12.008 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 6, no 2, july-dec 2018 ___________________________________________________________________________________ submitted: 15 may, 2018 accepted: 02 december, 2018 published: 08 december, 2018 a lecturer, department of paediatrics b associate professor, department of paediatrics c resident, department of paediatrics d lumbini medical college and teaching hospital, pravas, palpa corresponding author: laxman poudel e-mail: laxmanpaudel8@gmail.com orcid: https://orcid.org/0000-0002-8341-0982_______________________________________________________ —–————————————————————————————————————————————— abstract: introduction: preterm deliveries contribute to major morbidity and mortality in developing countries. they are a leading cause of admission in neonatal care units. advances in the management have ensured better survival of preterm births, however cost, care and resource limitations influence the outcome.this study was conducted to determine the prevalence, risk factors, morbidity patterns and outcome of preterm admissions to a neonatal unit of a tertiary care center. methods: this was a retrospective study where all preterm admissions over a period of two years were evaluated for maternal risk factors and morbidity pattern. outcome was measured in terms of survival rate and case fatality rate. mann whitney u test and fisher's exact test were used to see the association between various parameters and clinical outcome. results: preterm admissions constituted16.48% of all neonatal unit admissions with a male to female ratio of 1.32:1. common risk factors for preterm births were prelabour rupture of membrane (31.2%) followed by hypertensive disorders in pregnancy (15.1%) and antepartum hemorrhage (8.6%). common morbidities were sepsis (40.9%), jaundice (28%) and respiratory distress syndrome (rds) (14%). case fatality rate was significantly high in rds (45.1%) and perinatal asphyxia (11.1%). overall survival rate was 75.26%. conclusion: preterm births were an important cause for admissions in neonatal unit. sepsis, jaundice, rds and necrotizing enterocolitis were common morbidities observed. since clinical outcome was related to gestational age, improving antenatal care, timely interventions and early referral of high risk pregnancies to tertiary level centers might improve the survival rate keywords: gestational age, nicu, preterm neonates, neonatal unit original research articlehttps://doi.org/10.22502/jlmc.v6i2.218 laxman paudela,d balkrishna kalakhetib,d kiran sharmac,d prevalence and outcome of preterm neonates admitted to neonatal unit of a tertiary care center in western nepal introduction: world health organization (who) defines preterm birth as a birth occurring before 37 completed weeks of gestation. each year 15 million babies are born preterm worldwide and1.1 million infants die due to preterm complications. south asian and african countries contribute 60% of world’s preterm deliveries and 80% account for preterm deaths.[1] in nepal 81,000 preterm babies are born annually and 4,300 children under five years die due to preterm complications.[2] 85% preterms are born between 32-37 weeks of gestation.[2] cause for prematurity is multifactorial. major causes include prelabour rupture of membrane (prom), uteroplacental insufficiency, intrauterine vascular lesions, uterine overdistension and cervical incompetence.[3] various factors influence successful management of prematurity. level of antenatal care, gestational age, gender, availability of resources and adequately trained personnel play a role in early diagnosis and management of preterm complications.[4] despite good neonatal care, premature deliveries have short term consequences like feeding difficulties, hypothermia, hypoglycemia, respiratory distress syndrome (rds), jaundice and necrotizing enterocolitis (nec) while long term consequences include motor disability and cognitive problems.[5] neonatal intensive care is a major how to cite this article: paudel l, kalakheti b, sharma k. prevalence and outcome of preterm neonates admitted to neonatal unit of a tertiary care center in western nepal. journal of lumbini medical college. 2018;6(2):6 pages. doi: 10.22502/jlmc.v6i2.218. epub: 2018 dec 8. https://orcid.org/0000-0002-8341-0982 paudel l et al. prevalence and outcome of preterm neonates admitted to neonatal unit jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 factor that ensures survival of preterms. present study was conducted to determine the prevalence and outcome of preterm neonatal admissions and to identify the risk factors for the same. methods: this was a retrospective study carried out in neonatal intensive care unit (nicu) of lumbini medical college, palpa, which is one of the tertiary centers located in western nepal. it is equipped with two ventilators, six radiant warmer beds, one incubator and six cots while special care baby unit (scbu) is equipped with two warmer beds, three general beds and four cots. both units are manned with six pediatricians, five residents and nursing staff. this study was carried out from january 2018 to march 2018 for a period of three months. during this period, hospital records of all preterm admissions in nicu and scbu from january 2016 till december 2017 were studied. ethical approval was taken from institutional review committee, before commencement of the study. babies delivered at less than 37 completed weeks of gestation were included in the study irrespective of birth weight while those born at or after 37 completed weeks were excluded. all information were retrieved from the hospital records which included gestational age at birth, place of birth, gender, birth weight, risk factors for preterm deliveries and medical problems seen during admission and outcome. preterm babies were classified based on their gestational age into mild preterm (born between 32 to <37 completed weeks), very preterm ( born between 28 to 31 completed weeks) and extremely preterm ( born before 28 completed weeks).[6] gestational age was calculated using the first day of mother’s last menstrual period(lmp).if lmp was uncertain , gestational age was calculated using the modified ballard score.[7] clinical diagnosis was made based on criteria set to diagnose the underlying conditions for preterm deliveries. hypoglycemia was defined as blood sugar level below 50 mg/dl.[8] sepsis was diagnosed based on clinical suspicion and laboratory values as leukocytosis, band cells and toxic granules in peripheral blood smear and positive c-reactive protein (crp) and blood culture.[9] rds was diagnosed based on clinical and radiological evidence once other causes of distress were excluded. nec was diagnosed based on clinical and bell staging.[10]similarly, maternal chorioamnionitis was diagnosed based on maternal pyrexia with passage of foul smelling amniotic fluid. data were entered in excel spreadsheet and analyzed using statistical package for social sciences (spsstm) version 20. case fatality rate was calculated and association between birth weight and period of gestation was analyzed. association between different variables and clinical outcome was seen using mann whitney u test and fisher's exact test as appropriate. p value less than 0.05 was considered statistically significant. results: during the study period, 564 neonates were admitted in the neonatal unit of which 93 were preterm. there were 53 males and 40 females with a male to female ratio of 1.32:1 .seventy one (76.3%) were inborn babies while 22 (23.7%) were outborn. seventy six (81.7%) were hospital deliveries, nine (9.7%) were home deliveries, seven (7.5%) conducted by trained birth attendants (tba) and remaining one (1.1%) was unattended deliveries on the way to hospital. sixty two (66.7%) preterms were born via vaginal delivery while 31 (33.3%) by lower segment cesarean section. table 1 shows the gestational age wise distribution of preterm deliveries. mean gestational age (±sd) was 31.1±2.33 weeks. the most common table 1. gestational age wise distribution of preterm neonates (n=93) gestational age frequency (n) percentage (%) extremely preterm < 28 weeks 4 4.3 very preterm 28-31completed weeks 27 29.0 mild preterm 32 -36 completed weeks 62 66.7 total 93 100.0 gestational age at delivery was 34 weeks (n =17) followed by 36 weeks (n= 16). eighty deliveries were between gestational age of 31 to 36 weeks. mean birth weight (±sd) was 1811.56±421.064 grams. risk factors for preterm births: the most common risk factor for preterm delivery was prom (31.2%) followed by hypertensive disorders in pregnancy (hdp) (15.1%) and antepartum haemorrhage (aph)(8.6%) paudel l et al. prevalence and outcome of preterm neonates admitted to neonatal unit jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 as shown in table 2. primary diagnosis was only considered in case of maternal risk factors and preterm morbidities. nineteen deliveries showed no maternal risk factors and were labelled idiopathic. morbidity and mortality pattern: in this study, sepsis was present in 40.9 % followed by jaundice in 28% and rds in 14 % cases (table 3). though some overlap in the diagnosis was there, only the primary disease was taken as morbidity factor. case fatality rate was highest in rds (46.15%). clinical outcome: mean duration (±sd) of hospital stay was 8.86±6.07 days. among 93 neonates admitted, 70 (75.3%) improved and were discharged, 8 (8.6%) died while 15 (16.1%) were discharged against medical advice. seventy of the preterms survived with overall survival rate of 75.3%. there was no statistically significant association between mode of delivery and mortality (p=0.712) but low birth weight was significantly associated with mortality (p=0.0026) (table 4). category of prematurity and clinical outcome among 93 preterm babies admitted, 62 (66.7%) were mild preterm followed by 27 (29.0%) very preterm and remaining 4 (4.3%) were extremely preterm births (table 1). excluding those cases which left against medical advice (n=15), statistically maternal risk factors frequency (n) percentage (%) prom 29 31.2 idiopathic 19 20.4 hypertensive disorders in pregnancy 14 15.1 antepartum hemorrhage 8 8.6 teenage pregnancy 6 6.5 multiple pregnancy 5 5.4 previous cesarean section 4 4.3 maternal chorioamnionitis 4 4.3 maternal febrile illness 2 2.2 rh negative mother 1 1.1 severe oligohydramnios 1 1.1 total 93 100.0 table 2. maternal risk factors for preterm delivery (n=93) morbidity frequency (n) percentage (%) mortality case fatality rate (%) sepsis 38 40.9 1 2.63 jaundice 26 28.0 0 0.00 respiratory distress syndrome 13 14.0 6 46.15 perinatal asphyxia 9 9.7 1 11.11 necrotizing enterocolitis 2 2.2 0 0.00 birth defects 1 1.1 0 0.00 birth injury 1 1.1 0 0.00 hypoglycemia 1 1.1 0 0.00 late onset sepsis 1 1.1 0 0.00 meconium aspiration syndrome 1 1.1 0 0.00 total 93 100.0 8 table 3. morbidity and mortality patterns in preterm neonates (n=93) variables mortality improved statistics birth weight (gm), mean+sd 1466.25+516.41 1893.43+415.12 mann whitney u=144.500, n=78, p=0.0026 mode of delivery lscs 2 24 f=0.279, n=78, p=0.712 vaginal 6 46 significant association was found between gestational age and clinical outcome (table 5). in very preterm category, there was significantly high mortality. on post hoc analysis using bonferroni correction, adjusted p value was calculated to be 0.0083. among the three categories of prematurity, only the extremely preterm category (p=0.000011) was found to be statistically significantly associated with mortality. table 4. association of birth weight and mode of delivery with clinical outcome (n=78) paudel l et al. prevalence and outcome of preterm neonates admitted to neonatal unit jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 discussion: preterm admissions constitute one of the important causes for admissions in nicu. in this study, preterm admissions were 16.4%. this is similar to 14% of all admissions in a study done by ankur gupta et al.[11] and is lower than 24% in a study done at an institute in southern nigeria. [12] another study done at a teaching hospital in nigeria showed the rate of preterm admissions to be 16.4%.[13] the reason for difference in incidence in different studies could be due to geographical and ethnic variations and duration of study. studies at various institutes have revealed variable number of preterm male to female ratio among nicu admissions. our study showed male to female ratio of 1.32:1. study done by ankur gupta et al. [11] showed more preterm females with male to female ratio of 0.84:1. in another study by kunleolowu et al. [12] slightly more preterm males were reported with a male to female ratio of 1.1:1 the reason for more male preterm admissions could be due to special attention and care preferably given to male babies. due to the social preference of male babies, they are brought more to the hospital for healthcare. in our study, the most common risk factor for prematurity was prom followed by hdp and aph. study by kuppusamy et al.[14] reported anemia followed by hdp as risk factors for prematurity. this is similar to findings in another study by chowdarareddy et al.[15] all of these studies have hdp as common risk factor because hdp predisposes to acute and chronic uteroplacental insufficiency leading to antenatal and perinatal hypoxia with adverse outcome as prematurity.[16] shrestha et al. [17] , reported lack of antenatal care as the commonest risk factor for preterm deliveries which is similar to the study by kunle-olowu et al.[12] kuppusamy et al. [14] and uma et al. [18] from india reported prom as a major risk factor for prematurity. the commonest morbidity in the present prematurity category clinicaloutcome statistics death discharged < 28 weeks 3 1 f=12.722, n=78, p=0.001* 28 – 31 weeks 3 20 32 – 36 weeks 2 49 table 5. association between category of prematurity and clinical outcome (n=78) * adjusted p value=0.0083 (bonferroni correction) study was sepsis followed by jaundice and rds. this is similar to the findings of the study by shrestha et al.[17] who reported sepsis and jaundice as the commonest morbidities in their preterm infants. neonatal jaundice followed by rds and sepsis was the commonest cause for morbidity in other studies.[12,19,20] respiratory problems followed by jaundice and infection was the most common morbidity reported by kunle-olowu et al.[12] this highlights the importance of infection control in management of preterm babies who are at risk of sepsis due to immature immune system. also there is immediate attention needed to prevent and manage jaundice in these preterm babies. the case fatality rate was highest in preterms with rds followed by perinatal asphyxia and sepsis. shrestha et al.[17] also reported respiratory problems as the commonest cause of death in their preterm infants. limited intensive facilities and unavailability of exogenous surfactant might be the factors for high mortality in rds in our center. the overall survival rate was 75.26% which increased with increasing gestational age in our study and only one of the four babies born before 28 weeks survived. survival rate was 95% in a study by ankur gupta et al.[11] and 65.9% in a study by kunle-olowu et al.[12] with survival of only one (11.1%) of the nine babies born at less than 28 weeks. reason for low survival in this institute could be lack of sophisticated diagnostic facilities, inadequate ventilators and inavailability of exogenous surfactants. limitations: this study did not assess certain parameters directly linked to maternal risks for preterm deliveries like socio-economic status, cigarette smoking and alcohol consumption, maternal malnutrition and direct trauma to abdomen. follow up of neonates discharged against medical advice could not be done as well. conclusion: preterm neonates in our center are one of the contributors of nicu admissions. sepsis, jaundice and rds are major causes for admission with prom as the commonest maternal risk factor. since clinical outcome is related to gestational age, improving antenatal care, timely interventions and early referral of high risk pregnancies to tertiary paudel l et al. prevalence and outcome of preterm neonates admitted to neonatal unit jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 references: 1. howson ecp, kinney mv, lawn je. march of dimes, pmnch, save the children, who. born too soon: the global action report on preterm birth. [internet] world health organization. geneva, 2012. available from: http://www.who.int/pmnch/media/news/2012/201204_ borntoosoon-report.pdf 2. us agency for international development. nepal: profile of preterm and low birth weight prevention and care [internet]. usaid; 2015. available from: https://reliefweb. int/sites/reliefweb.int/files/resources/nepal_2.pdf 3. butler as, behrman re, editors. preterm birth: causes, consequences, and prevention. national academies press; 2007 may 23. available from: https://www.ncbi.nlm.nih. gov/books/nbk11362/pdf/bookshelf_nbk11362.pdf 4. barton l, hodgman je, pavlova z. causes of death in the extremely low birth weight infant. pediatrics. 1999 feb 1;103(2):446-51. pmid: 9925839 doi: 10.1542/ peds.103.2.446 [publisher full text] 5. lindström k. long-term consequences of preterm birth: swedish national cohort studies. inst för klinisk forskning och utbildning, södersjukhuset/dept of clinical science and education, södersjukhuset; 2011 may 6. [publisher full text] 6. lumley j. defining the problem: the epidemiology of preterm birth. bjog: an international journal of obstetrics & gynaecology. 2003 apr;110 suppl 20:3-7. pmid: 12763104 doi: 10.1046/j.1471-0528.2003.00011.x [publisher full text] 7. ballard jl, novak kk, driver m. a simplified score for assessment of fetal maturation of newly born infants. the journal of pediatrics. 1979 nov 1;95(5):769-74. pmid: 490248 8. kliegman, r., stanton, b., st. geme, j., schor, n., behrman, r. and nelson, w. (2016). nelson textbook of pediatrics. philadelphia: elsevier; 2016. p. 517 9. kliegman, r., stanton, b., st. geme, j., schor, n., behrman, r. and nelson, w. (2016). nelson textbook of pediatrics. philadelphia: elsevier; 2016. p 636-7. 10. bell mj, ternberg jl, feigin rd, keating jp, marshall r, barton l, brotherton t. neonatal necrotizing enterocolitis. therapeutic decisions based upon clinical level centers might improve the survival rate. acknowledgement: dr. susan thapa and dr. sameer adhikari. conflict of interest: none declared. financial disclosure: no funds were available. staging. annals of surgery. 1978 jan;187(1):1-7. pmid: 490248 [publisher full text] 11. gupta a, shetty d, madhava kk. prevalence and consequences of preterm admissions at the neonatal intensive care unit of tertiary care centre in south india: a retrospective study. international journal of current advanced research. 2017 may 28; 06(05):3728-30. doi: 10.24327/ijcar.2017.3730.0357 [publisher full text] 12. kunle-olowu oe, peterside o, adeyemi oo. prevalence and outcome of preterm admissions at the neonatal unit of a tertiary health centre in southern nigeria. open journal of pediatrics. 2014 mar 6;4(01):67. doi: 10.4236/ ojped.2014.41009 [publisher full text] 13. ugwu gi. pattern of morbidity and mortality in the newborn special care unit in a tertiary institution in the niger delta region of nigeria: a two year prospective study. global advanced research journal of medicine and medical sciences. 2012 jul;1(6):133-8. 14. kuppusamy n, vidhyadevi a. prevalence of preterm admissions and the risk factors of preterm labor in rural medical college hospital. int j sci stud. 2016 dec 1;4(9):125-8. doi: 10.17354/ijss/2016/629 [publisher full text] 15. chowdareddy n, kumar yc, thomas a, deepthi ku, ravichander m. mortality pattern of preterm infants and etiological factors of preterm births in rural tertiary care centre: a retrospective study. international journal of scientific and research publications. 2014 mar;4(3):2-3. [publisher full text] 16. orbach h, matok i, gorodischer r, sheiner e, daniel s, wiznitzer a, koren g, levy a. hypertension and antihypertensive drugs in pregnancy and perinatal outcomes. american journal of obstetrics and gynecology. 2013 apr 1;208(4):301-e1-6. pmid: 23159698 doi: 10.1016/j.ajog.2012.11.011 17. shrestha s, dangol ss, shrestha m, shrestha rp. outcome of preterm babies and associated risk factors in a hospital. journal of the nepal medical association. 2010 oct 1;50(180):286-90. pmid: 22049892 18. uma s, nisha s, shikha s. a prospective analysis of etiology and outcome of preterm labor. journal of obstetrics and gynecology of india. 2007 jan 1;57(1):4852. 19. onalo r, olateju ke. trend and seasonality in admissions and outcome of low birth weight infants in gwagalada abuja, nigeria. international journal of tropical disease and health. 2013;3(3):190-8. [publisher full text] 20. khan mr, maheshwari pk, shamim h, ahmed s, ali sr. morbidity pattern of sick hospitalized preterm infants in karachi, pakistan. journal of the pakistan medical association. 2012;62(4):386-88. pmid: 22755286 [publisher full text] http://www.who.int/pmnch/media/news/2012/201204_borntoosoon-report.pdf http://www.who.int/pmnch/media/news/2012/201204_borntoosoon-report.pdf https://reliefweb.int/sites/reliefweb.int/files/resources/nepal_2.pdf https://reliefweb.int/sites/reliefweb.int/files/resources/nepal_2.pdf https://www.ncbi.nlm.nih.gov/books/nbk11362/pdf/bookshelf_nbk11362.pdf https://www.ncbi.nlm.nih.gov/books/nbk11362/pdf/bookshelf_nbk11362.pdf http://dx.doi.org/10.1542/peds.103.2.446 http://dx.doi.org/10.1542/peds.103.2.446 http://pediatrics.aappublications.org/content/pediatrics/103/2/446.full.pdf https://openarchive.ki.se/xmlui/bitstream/handle/10616/40491/thesis_karolina_lindstrˆm.pdf?sequence=1&isallowed=y https://doi.org/10.1046/j.1471-0528.2003.00011.x https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1046/j.1471-0528.2003.00011.x https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1396409/pdf/annsurg00360-0009.pdf http://dx.doi.org/10.24327/ijcar.2017.3730.0357 http://journalijcar.org/sites/default/files/issue-files/1894-a-2017.pdf http://dx.doi.org/10.4236/ojped.2014.41009 http://dx.doi.org/10.4236/ojped.2014.41009 https://file.scirp.org/pdf/ojped_2014031410110870.pdf https://dx.doi.org/ 10.17354/ijss/2016/629 http://www.ijss-sn.com/uploads/2/0/1/5/20153321/ijss_dec_oa25_-_2016.pdf http://www.ijss-sn.com/uploads/2/0/1/5/20153321/ijss_dec_oa25_-_2016.pdf http://www.ijsrp.org/research-paper-0314/ijsrp-p2707.pdf https://doi.org/10.1016/j.ajog.2012.11.011 http://www.sdiarticle1.org/prh/ijtdh_19/2013/original_manuscript_66.pdf http://www.sdiarticle1.org/prh/ijtdh_19/2013/original_manuscript_66.pdf http://jpma.org.pk/pdfdownload/3364.pdf present potential of exfoliative cytology in detection of cervical cancer: pattern of epithelial cell abnormality sushila jain,a,c anuj poudel,a,d sk jainb,d —–————————————————————————————————————————————— abstract: introduction: conventional pap smear is the mainstay for cervical cancer screening in developing countries and women should be motivated for cervical screening program to detect early dysplastic cells. this study was carried out to find out the prevalence of abnormalities in pap smears, particularly pattern of epithelial cell abnormality in women attending lumbini medical college in western nepal. methods: a cross-sectional study was carried out and 1066 pap smears were studied to look for epithelial cell abnormality according to revised bethesda system 2001. results: out of 1066 patients who underwent pap smear examination, 71 (6.6%) revealed epithelial cell abnormality; most were low grade squamous intra-epithelial lesions (lsil) occupying 4.59% at the age between 23 to 29 years. squamous cell carcinoma was found in 0.37 % of patients at the age 40 years and above. in our scenario, per vaginal discharge was the major finding of the patients who showed premalignant features. conclusions: women above 40 years are at a risk of premalignant as well as malignant lesions and these women should undergo screening for abnormal cells at the age of 18 or when sexual activity starts and as per recommendations to look for early dysplastic cells. cervical screening program should be motivated by the national policy makers and also by health professionals. ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer b professor c department of gynecology and obstetrics, lmcth d department of pathology lumbini medical college teaching hospital (lmcth), palpa, nepal corresponding author: dr. sushila jain e-mail: sush18in@yahoo.com how to cite this article: jain s, paudel a, jain sk. present potential of exfoliative cytology in detection of cervical cancer: pattern of epithelial cell abnormality. journal of lumbini medical college. 2013;1(1):17-20. doi:10.22502/ jlmc.v1i1.6. ___________________________________________________________________________________ j. lumbini. med. coll. vol 1, no 1, jan-june 2013 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v1i1.6 introduction: invasive carcinoma of uterine cervix, regardless of type, develops from precursor lesion or abnormal surface epithelium, which in its classic form, is known as carcinoma in situ. precursor lesions do not produce any specific alteration of the cervix visible to the naked eye so these lesions earlier were a rarity to diagnose. since the introduction of mass screening by smears, these lesions are quite common. for the detection of premalignant lesions of the cervix in a developing country and low resource setting, pap smear test is one of the best methods.1 according to the bethesda system 2001 for reporting, epithelial cell abnormality originates either from the squamous or glandular cells. in the category of squamous cells are ascus (atypical squamous cells of undetermined significance) and asc-h (atypical squamous cells cannot exclude high grade intraepithelial lesions). the positive predictive value for hsil (high grade squamous intraepithelial lesion) in asc-h is higher than asc-us but lower than hsil.2,3 term squamous intraepithelial lesion (sil) is subdivided into low grade which show perinuclear halo and mild dyskaryosis, and lesion showing moderate to severe dyskaryosis and carcinoma in situ, term hsil. smears showing 17 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np jain s. et al. present potential of exfoliative cytology in detection of cervical cancer no epithelial abnormalities are depicted under the category of negative for intraepithelial lesion or malignancy in the revised bethesda system.4,5 screening with pap smear has seen to be accompanied by a dramatic reduction in the incidence of invasive cancer. though liquid base cytology is popular, conventional pap smear test is the main stay in the developing countries. moreover, various studies reveal that majority of patients with cervical cancer are from the developing countries probably due to absence of an efficient cancer screening system. it is therefore important to identify scenario of epithelial cell abnormality.6,7 by the use of revised bethesda system, various aspects of pap smear interpretation have been clarified like adequacy, categorization, interpretation and results. hence, using the bethesda system, we have undertaken the study in pap smear of women visiting the gynaecology outpatient department in lumbini medical college teaching hospital(lmcth), palpa. methods: this study was carried out in the department of pathology, lmcth. a crosssectional study was carried out from march 2010 to october 2012. significant history was carried out (parity, menstrual history) and findings of per vaginal examination (discharge, healthy/ unhealthy cervix) noted. cervical smear was collected with the help of ayre spatula, immediately fixed in alcohol for minimum of 30 minutes followed by pap staining, microscopy and interpretation. a total 1066 cases were studied. all unsatisfactory smears were asked for a repeat. reporting and adequacy was assessed according to revised 2001 bethesda system. results: out of 1066 pap smears, 71 (6.6%) showed cervical epithelial cell abnormality. the most frequent epithelial cell abnormality was lsil. other patterns were as shown in table 1. table 1: different categories of diagnosis in pap smear (n=1066) pap result n % nsis 995 93.3 995 93.3 asc-us 5 0.46 5 0.46 lsil 49 4.59 49 4.59 hsil 13 1.21 13 1.21 scc 4 0.37 the mean parity was 3.43 and the majority of patients had parity more than three. most of the epithelial cell abnormality was found between 18 to 30 years of age and predominantly were lsil (table 2). the most frequent finding in our study was hsil and squamous cell carcinoma (in the biopsy examined). overall age of incidence was reproductive age, with peak in the 33-40 years, mean being 39.73 years. our study also showed wide age range (20-60 years). most of the patients were married under 19 years of age as shown in table 3. per vaginal discharge were the major findings of the patients, cervical erosion and nabothian cyst in decreasing order of frequency as shown in table 4. table 2: epithelial cell abnormality in pap smear in different age groups age (yrs) ascus lsil hsil scc <18 0 0 0 0 18-22 2 20 1 0 23-29 2 22 2 0 >30 1 7 9 4 total 5 49 13 4 table 3: age at first marriage of the patient with abnormal pap smear age (yrs) ascus lsil hsil scc <15 0 1 1 1 15-19 2 19 7 2 20-24 2 18 4 1 25-29 1 10 1 0 >30 0 1 0 0 total 5 49 47 4 18 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jain s. et al. present potential of exfoliative cytology in detection of cervical cancer jlmc.edu.np table 4: findings of patients with abnormal pap smear ascus lsil hsil scc erosion 2 12 8 0 nabothian cyst 3 10 2 0 discharge 0 27 3 0 growth 0 0 0 4 discussion: to some extent, our study provides overall picture of epithelial cell abnormalities in the pap smear cytology of women attending this hospital in developing country. it is evident that unlike in the developed countries, pap smear screening is not well organized. most patients with abnormal cytology detected by screening process are the symptomatic ones presenting either with growth, erosion, discharge etc. pap smear in these cases is done as a part of investigation for the management of patients. this signifies that cervical cancer screening is based only on clinical impression which is quite unpredictable in relation to cytologic screening. therefore, facilities for pap screening should be extended up to primary health care level. other studies on the prevalence of cervical epithelial cell abnormality revealed 4.3% in a tertiary hospital in kuwait, 5% in a referral hospital in saudi arabia, 0.95% in jewish israeli women, 1.66% in the western region of saudi arabia and 7.9% in south western saudi arabia.8-10 our studies revealed increased prevalence (6.6%) possibly because women visiting tertiary hospital only when they have specific complaints such as something coming out per vaginum, lower abdomen pain or discharge. it is obvious that they had come to visit hospital when the dyskaryotic cells in the cervical epithelium had already occurred. eldman et al. studied pap smear from 29295 patients over a period of one year and abnormalities were as follows: 9.9% asc-us, 2.5% lsil, 0.6% hsil, and 0.2% invasive cancer. they also showed that adolescent with an age range of 13-22 had a significantly higher rate of lsil.11,12 another study in brazil, where 1822441 pap smears were examined over a period of five years, showed that low grade lesions were common at 15-30 years. patients older than 40 years had the greatest incidence of invasive cancer. in comparison to previous studies, our study revealed the following scenario: 0.46% ascus, 4.59% lsil, 1.21% hsil and 0.37% squamous cell carcinoma.13 unfortunately, only a few percentage (12.2%) of women had undergone biopsy and histopathological examination. significant discrepancies were found between our study and the previous studies from other countries: the lower rate of asc-us and higher rate of lsil, probably due to lack of routine pap smear screening and presentation with an advanced form. drop out of some cases to private clinics could also be possible significant variation of asc-us and lsil. moreover, as described in the revised bethesda system, criteria for ascus might differ subtly among laboratories. most of the patients in our study were married women when they were in there teens and these patients had increased risk of hpv infection as predisposition of the immature cervix of the adolescent to persistent hpv infection, which could develop cancer. therefore, another strategy should also be oriented in sex education, family planning and if possible hpv vaccination. conclusions: our study highlights that patients above 40 years are at risk of premalignant as well as malignant lesions and no specific finding of premalignant lesion is present on visual inspection of cervix. hence, women should properly go to screening program as per recommendation. conflict of interest declared: none financial declaration: none 19 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np jain s. et al. present potential of exfoliative cytology in detection of cervical cancer references: 1. toews ha. the abnormal pap smear: a rationale for follow up. can fam physician 1983; 29: 759-62. 2. elmslie tj. the pap smear and cervical cancer screening. can fam physician 1987; 33: 131-7. 3. adhikari ak, banik u, numaga j, suzuki e, inada t, okabe n. heterogeneity of the fi bre sequence in subgenus c adenoviruses. j clin pathol 2004; 57:6127. 4. chhieng dc, roberson j, gidley j. bethesda 2001. impact on the reporting of gynaecologic cytology. acta cyto 2004; 48:355-62. 5. solomon d, schiff man m. ascus lsil triage study group. qualification of ascus. acomparision of equivocal hsil in cervical cytology in the ascus lsil triage study. am j clin pathol 2001; 116:386-94. 6. jamal aa, al-maghrabi ja. profi le of pap smear cytology in the western region of saudi arabia. saudi med j 2003; 24:1225-9. 7. cho h, kim jh. treatment of the patients with abnormal cervical cytology: a “see-and-treat” versus three-step strategy. j gynecol oncol 2009; 20:164-8. 8. kapila k, george ss et al. changing spectrum of squamous cell abnormalities observed in mubarak al-kabeer hospital, kuwait, over a 13-years period. med pnic pract 2006; 15:253-9. 9. abdullah ls. pattern of abnormal pap smear in developing countries: a report from a large referral hospital in saudi arabia using a 2001 bethesda system; ann saudi med 2007; 27:268-72. 10. sadan o, schejter e et al. premalignant lesions of the uterine cervix in large cohort of israeli jewish women. arch gynecol obstet 2004; 269:188-91. 11. edelman ha, fox a. cervical pap smear abnormalities in inner bronx adolescents: prevalence, progression, and immune modifiers. cancer cytopathol 1999; 110:123-7. 12. bishop a, wells e. cervical cancer: evolving prevention strategies for developing countries. reprod health matters 1995; 6:60-71. 13. wang pd, lin rs. sociodemographic factors of pap smear screening in taiwan. taipei wanhawa district centre, taiwan. public health 1996; 110:123-7. 20 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 garbuja ck et al. perception of educational environment among nursing students of different colleges: a cross-sectional study. 251 jlmc.edu.np ___________________________________________________________________________________ submitted: 19 september, 2020 accepted: 2 december, 2020 published: 9 december, 2020 alecturer, college of nursing, bprogram coordinator, clumbini medical college and teaching hospital, palpa, nepal. dcollege of medical sciences, bharatpur, chitwan, nepal. eunited mission hospital, palpa, nepal. corresponding author: chandra kumari garbuja e-mail: : garbujachandra@gmail.com orcid: https://orcid.org/0000-0002-6540-3391_______________________________________________________ abstract: introduction: learners are key figures for whom the provision and perception of positive, progressive and encouraging interactive educational environment at any educational institution is very crucial. the study aimed to find the perception of nursing students of two different medical colleges regarding their educational environment. methods: a cross-sectional descriptive study was conducted among 190 students through the use of internationally validated, non-culturally specific questionnaire. the responses were made on five points likert scale scored from 0 to 4. the overall score was interpreted as very poor, plenty of problems, more positive than negative and excellent based on obtained score of 0-50, 51-100, 101-150 and 151-200 respectively. descriptive statistics and one way analysis of variance test was used to analyze the collected data. results: there were 98 (51.6%) participants from college of medical sciences and 92 (48.4%) from lumbini medical college and teaching hospital. the overall score of perception of educational environment were 142.13±14.90 (74.64%) and 144.34±15.59 (76.14%) in the two centers respectively which means more positive than negative perceptions. only nature of accommodation was found statistically significant with students’ perception of teachers (p = 0.014). conclusion: majority opined a more positive than negative perception towards educational environment. good communication skills of teachers, knowledgeable teachers, teaching to develop their competence level were some positive perceptions. whereas, teachers being authoritarian, focus on short term and factual learning, lack of support system were the areas which could be improved. key words: educational environment, nursing students, perception original research articlehttps://doi.org/10.22502/jlmc.v8i2.403 chandra kumari garbuja,a,c sunita rana,a,c pratima thapa,a,d mohan singh ranab,e perception of educational environment among nursing students of different colleges: a crosssectional study how to cite this article:how to cite this article: garbuja ck, rana s, thapa p, rana ms. perception of educational environment among nursing students of different colleges: a crosssectional study. journal of lumbini medical college. 2020;8(2):251-258. doi: https://doi.org/10.22502/jlmc.v8i2.403 epub: 2020 december 9. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: learners are the key figures in any teaching learning process on whom desired modification in behaviors are expected. learning environment had always been an integral part of human existence since the beginning. as dewey and child said, “organisms, selves, characters, minds, are so intimately connected with their environment that they can be understood only in relation to them”, the understanding of associated factors to teachinglearning process is very important for effective enhancement of learning process.[1] learning is a complex, and demanding process which demands an ideal provision of academic environment, as well as a teacher equipped with virtues of sound knowledge, credibility, preparedness and effective communication skills.[2,3] moreover, the horizon is not only limited within classroom but is beyond that which encompasses other factors like student-teacher relationship, teaching-learning strategies, physical facilities as well as address to j. lumbini. med. coll. vol 8, no 2, july-dec 2020 garbuja ck et al. perception of educational environment among nursing students of different colleges: a cross-sectional study. 252 jlmc.edu.np students’ psychological and emotional needs to list some.[4]various studies revealed that educational environment in terms of self-perception of self, selfperception of teachers, academic self-perception, self-perception of atmosphere and social perception are important to understand and have found that students’ satisfaction is strongly linked with quality of educational program.[2,5,6,7,8,9,10] many studies were conducted to assess the perception of educational environment of students of other various academic fields. but, to our best knowledge, very limited studies have been conducted regarding perception of nursing students in context of nepal. thus, this study aimed to find the perception of nursing students of lumbini medical college and teaching hospital (lmcth), palpa and college of medical sciences (cms), chitwan regarding their educational environment. methods: a cross sectional descriptive study design was adopted to find the perception of educational learning environment of all academic years (1st, 2nd, 3rd and 4th) of bachelor of science in nursing (b.sc nursing) students of two medical colleges affiliated to kathmandu universitylmcth, palpa and cms, chitwan. ethical clearance was obtained from the institutional research committee of both institutions (irc-lmc 05-g/020 and ref number: 2020-072). required sample size was estimated using formula, n= z2 σ2/d2. based on a study conducted by imanipour et al.[11], where mean=2.09, standard deviation (σ)=0.49, absolute precision (d2)=0.006 (4% of mean) and z5%= 1.96, and adding 10%of nonresponse rate, the calculated sample size was 169. as, there were total 197 students in both colleges, total enumerative sampling method was applied. all b.sc nursing students of both colleges who gave voluntary consent to participate were included. those who did not give voluntary consent or were absent during data collection period were excluded. the data was collected over a period of two weeks from 5th to 19th august 2020 via google form. confidentiality and anonymity was maintained strictly. internationally validated, non-culturally specific inventorydundee ready education environment measure (dreem) whose cronbach’s alpha coefficient value was 0.86, was used for data collection.[2] the self-administered questionnaire consisted of two sections: section a: socio-demographic characteristics: age, ethnicity, residence (province), year of enrollment and nature of accommodation. section b: items related to perception of learning environment based on dreem. dreem consists of 50 items with fivepoint likert scale where 0=strongly disagree, 1=disagree, 2=uncertain, 3=agree and 4=strongly agree. the items are categorized into five subscales as: student’s perception of learning (spl) 12 items, student’s perception of teachers (spt) 11 items, student’s academic self perception (sasp) 8 items, student’s perception of atmosphere (spa) 12 items and student’s social self perception (sssp) 7 items. there are nine negative items (items 4,8,9,17,25,35,39,48 and 50) for which reverse scoring was done while entering the data. the maximum score obtained is 200 which is interpreted as: 0-50=very poor, 51-100= plenty of problems, 101-150= more positive than negative and 151-200= excellent. regarding individual items, those with a mean score of ≥3.5 are regarded as especially strong areas, items with a mean score of ≤2.0 need particular attention and items with mean scores between 2 and 3 are areas of the educational environment that could be improved.[7,12] the data collected was checked for completeness, coded and entered in microsoft excel 2007 and transformed in statistical package for social sciences (spsstm) software version 16. descriptive statisticsfrequency, percentage, mean and standard deviation and inferential statisticsone-way analysis of variances (anova) based on normality test was used to find statistical association between subscales of dreem and selected demographic variables. the confidence interval was set at 95 % and the p value <0.05 was considered as statistically significant. results: the total number of participants involved were 190 among which 98 (51.6%) were from cms and 92(48.4%) from lmcth making a response rate of 96.44%. the mean age of participants was j. lumbini. med. coll. vol 8, no 2, july-dec 2020 garbuja ck et al. perception of educational environment among nursing students of different colleges: a cross-sectional study. 253 jlmc.edu.np 21.06±1.35 years. majority (46.9% in cms and 58.7% in lmcth) of participants were brahmin in both colleges. more than half (66.4% and 77.2%) of participants were from bagmati in cms and province 5 in lmcth respectively. the details are depicted in table1. table 1. demographic characteristics of participants variables college lmcth (n=92) n (%) cms (n=98) n (%) age, in years ≤ 19 9 (9.2) 11 (12.0) 20-22 79 (80.6) 63 (68.4) >22 10 (10.2) 18 (19.6) mean ± sd = 21.06 ± 1.35, range = 18-26 years ethnicity brahmin 46 (46.9) 54 (58.7) chhetri 19 (19.4) 13 (14.1) janajati 29 (29.6) 22 (23.9) dalit 3 (3.1) 3 (3.3) muslim 1 (1.0) 0 (0) residence (province) 1 2 (2.0) 0 (0) 2 2 (2.0) 3 (3.3) bagmati 65 (66.4) 11 (12.0) gandaki 14 (14.3) 3 (3.3) 5 14 (14.3) 71 (77.2) karnali 1 (1.0) 2 (2.1) sudurpaschim 0 (0) 2 (2.1) year of enrollment 1st 13 (13.2) 12 (13.0) 2nd 27 (27.6) 24 (26.1) 3rd 29 (29.6) 30 (32.6) 4th 29 (29.6) 26 (28.3) nature of accommodation hostel 24 (24.5) 43 (46.7) own house 55 (56.1) 17 (18.5) rent room 16 (16.3) 30 (32.6) relatives’ home 3 (3.1) 2 (2.2) the overall score of perception of participants on educational environment of both colleges are more positive than negative with mean scores of 142.13±14.90 (74.64%) in cms and 144.34±15.59 (76.14%) in lmcth. among the five subscales, participants of both colleges scored less in students’ social self-perception with mean percent of 58.27% in cms and 73.29% in lmcth respectively. whereas, participants from cms scored more (68.77%) in students’ perception of learning subscale and participants from lmcth scored 80.77% in students’ academic self-perception which is presented in table 2. on analysis of individual items based on year of enrollment of both colleges, first year participants perceived teaching is less stimulating as they scored less (2.92±0.49) than other years. all the participants had scored more than 3.5 which mean that the teaching had helped to develop their confidence level. the participants of fourth year scored highest (2.09±1.06) in teaching being too teacher centered item. in itemsteachers being authoritarian (2.16±1.28) and teachers get angry in class (2.56±1.15), participants of first year had scored highest. in learning empathy in nursing profession item, fourth year participants had scored more (3.41±0.65). the participants of second year scored less (1.92±1.10) in atmosphere being relaxed during ward teaching item. the details are listed in table 3. it was found that age and year of enrollment of participants had no significant difference in perception of educational environment and its subscale (p>0.05). significant difference was found only between nature of accommodation and students’ perception of teachers (p=0.014) as depicted in table 4. discussion: the study was conducted with the aim to assess perception of educational environment among nursing students of two different colleges. the participants of both colleges responded a more positive than negative perception of their educational environment. this finding is similar to studies conducted among nursing students’ of nepal, sri lanka, india, pakistan and iran.[2,6,9,13,14] the finding of positive perception is also comparable with other studies conducted among other undergraduates. [3,8,15,16,17] in contrast to this, studies conducted in egypt and iran had negative perception.[18,19] disparities in targeted population, and sample size, experiences and challenges faced by students over time could be some possible reasons. regarding the analysis of subscales of dreem, the results had higher scores which mean j. lumbini. med. coll. vol 8, no 2, july-dec 2020 garbuja ck et al. perception of educational environment among nursing students of different colleges: a cross-sectional study. 254 jlmc.edu.np table 2. scores of overall perception of educational environment and its subscales using dundee ready educational environment measure (dreem) (n=190) characteristics no. of items obtainable score mean ± sd (mean percent) interpretation cms lmcth student’s perception of learning 12 0-48 34.91±3.95 (68.77%) 35.29 ± 4.14 (77.76%) more positive approach student’s perception of teachers 11 0-44 30.36±4.53 (66.04%) 32.13 ± 4.38 (76.18%) moving in the right direction students’ academic selfperception 8 0-32 23.73±3.86 (67.31%) 23.51 ± 3.77 (80.77%) feeling more on the positive side students’ perception of atmosphere 12 0-48 35.20±5.49 (65.58%) 34.58 ± 5.20 (80.32%) a more positive atmosphere students’ social selfperception 7 0-28 17.90±2.92 (58.27%) 18.82 ± 3.50 (73.29%) not too bad overall perception of educational environment 50 0-200 142.13±14.90 (74.64%) 144.34 ± 15.59 (76.14%) more positive than negative table 3. mean scores of individual items of dreem(n=190). sn domain items year of enrollment a student’s perception of learning 1st 2nd 3rd 4th 1 i am encouraged to participate in teaching sessions. 3.12±0.83 3.15±0.60 3.34±0.63 3.31±0.57 2 the teaching is often stimulating. 2.92±0.49 3.12±0.73 3.07±0.69 3.02±0.56 3 the teaching is student centered. 2.96±0.67 2.85±0.63 3.12±0.85 2.98±0.85 4 the teaching helps to develop my competence. 3.52±0.58 3.50±0.78 3.54±0.67 3.59±0.59 5 the teaching is well focused. 3.28±0.61 3.06±0.75 3.20±0.73 3.30±0.66 6 the teaching helps to develop my confidence. 3.56±0.50 3.52±0.67 3.54±0.67 3.61±0.49 7 the teaching time is put to good use. 3.08±0.70 3.19±0.86 3.19±0.73 3.24±0.61 8 the teaching over-emphasizes factual learning.® 1.16±0.80 0.90±0.63 0.97±0.66 0.91±0.75 9 i am clear about the learning objectives of the course. 2.80±0.57 3.17±0.58 3.41±0.69 3.33±0.61 10 the teaching encourages me to be an active learner. 3.24±0.52 3.37±0.56 3.49±0.62 3.50±0.54 11 long term learning is emphasized over short term learning. 2.84±0.64 2.77±0.61 3.07±0.76 2.74±0.85 12 the teaching is too teacher centered. ® 1.64±0.99 1.65±0.98 1.86±1.05 2.09±1.06 b student’s perception of teachers 13 the teachers are knowledgeable. 3.48±0.58 3.62±0.63 3.47±0.59 3.41±0.56 14 the teachers are patient with students. 3.08±0.64 2.77±0.89 2.97±0.71 2.57±0.86 15 the teachers ridicule the students. ® 2.88±1.09 2.73±1.14 2.61±1.24 2.41±1.01 16 the teachers are authoritarian. ® 2.16±1.28 1.83±1.06 1.71±1.06 1.93±1.04 17 the teachers have good communication skills with students. 3.32±0.62 3.33±0.70 3.27±0.63 3.20±0.68 18 the teachers are good at providing feedback to students. 3.04±0.67 3.48±0.72 3.32±0.68 3.35±0.78 19 the teachers provide constructive criticism here. 2.32±1.21 2.42±0.99 2.80±0.94 2.46±1.02 20 the teachers give clear examples. 3.24±0.52 3.48±0.54 3.19±0.65 3.26±0.62 21 the teachers get angry in class. ® 2.56±1.15 2.02±1.12 1.85±1.09 2.09±1.20 22 the teachers are well prepared for their classes. 3.44±0.58 3.63±0.59 3.34±0.54 3.37±0.56 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 garbuja ck et al. perception of educational environment among nursing students of different colleges: a cross-sectional study. 255 jlmc.edu.np 23 the students irritate the teachers. ® 2.64±0.99 2.42±1.10 2.53±1.22 2.43±1.14 c students’ academic self-perception 24 learning strategies which worked for me before continue to work for me now. 2.68±0.62 2.50±0.85 2.73±0.63 2.46±0.94 25 i am confident about my passing this year. 2.88±0.52 2.71±0.69 3.44±0.65 3.17±0.74 26 i feel i am being well prepared for my profession. 2.92±0.70 2.69±0.85 3.20±0.68 3.06±0.81 27 last year’s work has been a good preparation for this year’s work. 2.40±0.70 2.52±0.93 3.05±0.72 2.87±0.72 28 i am able to memorize all i need. 2.60±0.57 2.12±0.85 2.64±0.82 2.67±0.80 29 i have learned a lot about empathy in my profession. 2.96±0.79 3.27±0.68 3.29±0.94 3.41±0.65 30 my problem solving skills are being well developed here. 3.08±0.49 3.08±0.58 3.24±0.75 3.26±0.52 31 much of what i have to learn seems relevant to a career in healthcare. 3.04±0.45 3.13±0.59 3.37±0.61 3.31±0.54 d students’ perception of atmosphere 32 the atmosphere is relaxed during the ward teaching. 2.40±0.91 1.92±1.10 2.53±0.89 2.11±1.00 33 this school is well timetabled. 3.08±0.49 3.29±0.63 3.36±0.80 3.04±0.75 34 cheating is a problem in this school. ® 2.56±1.29 2.65±1.20 2.68±1.16 2.80±1.13 35 the atmosphere is relaxed during lectures. 2.80±0.76 3.04±0.71 3.07±0.76 2.78±0.88 36 there are opportunities for me to develop interpersonal skills. 3.04±0.45 3.15±0.72 3.36±0.71 3.26±0.62 37 i feel comfortable in class socially. 3.16±0.55 3.23±0.70 3.39±0.74 3.30±0.60 38 the atmosphere is relaxed during seminars/tutorials. 2.92±0.70 3.10±0.63 3.14±0.68 2.91±0.65 39 i find the experience disappointing. ® 2.60±0.86 2.33±1.09 2.66±1.01 2.72±0.99 40 i am able to concentrate well. 2.84±0.37 2.79±0.82 2.97±0.52 3.04±0.51 41 the enjoyment outweighs the stress of the course. 2.60±0.81 2.50±0.91 2.49±0.87 2.61±0.89 42 the atmosphere motivates as a learner. 2.92±0.70 3.10±0.63 3.08±0.67 3.09±0.68 43 i feel able to ask questions i want. 3.08±0.49 2.94±0.93 3.03±0.89 3.07±0.64 e students’ social self-perception 44 there is a good support system for students who get stressed. 2.80±0.57 2.46±1.30 2.58±1.22 2.65±0.80 45 i am too tired to enjoy the course. ® 2.28±1.13 2.13±0.99 2.58±0.96 2.46±0.98 46 i am rarely bored on this course. 1.72±1.02 1.63±0.99 1.98±1.23 2.00±1.11 47 i have good friends in this school. 3.16±0.74 3.12±0.80 3.46±0.59 3.54±0.60 48 my social life is good. 3.04±0.61 3.10±0.72 3.17±0.91 3.52±0.63 49 i seldom feel lonely. 1.92±1.25 1.79±1.27 2.22±1.11 2.11±1.11 50 my accommodation is pleasant. 2.76±0.66 2.60±0.97 3.05±0.70 3.11±0.53 *®reverse scoring participants were directed towards more positive approaches of educational environment in both colleges. these positive findings in all subscales were similar with other studies as well.[2,5,13,20] but other studies showed only lower score in students’ social self-perception subscale.[7,21] lack of good support system, unfriendly social life and unpleasant nature of accommodation might be the possibilities. according to miles et al., individual items with mean scores of ≥3.5 are regarded as strong areas, 2 and 3 are the areas which could be improved and ≤2.0 requires particular attention. [12]the participants determined that teaching had helped them to develop their competence level as a strong area. this finding is inconsistent with the study conducted in dharan, nepal where none of the items had scored as such.[2] the items related j. lumbini. med. coll. vol 8, no 2, july-dec 2020 garbuja ck et al. perception of educational environment among nursing students of different colleges: a cross-sectional study. 256 jlmc.edu.np to teachers and teaching practicesteachers being knowledgeable and providing feedback to students, teaching time being put to good use, teaching being well focused, well prepared teachers for classes, good communication skills among teacher-students were the areas that had scored above 3. whereas, school being well time-tabled, enhancement of problemsolving skills of students, learning seems relevant to career in healthcare, social comfort in classroom, having good friends in schools, good social life were the items that also showed in positive direction. and these findings were similar with other studies. [2,7,17] the positive perception of educational environment of participants means that they have good teaching-learning process and fosters deeper learning outcomes.[22] but still, the present findings revealed some problematic areas in some individual items which requires major improvements or could be improved.all the participants opined that teaching over emphasizes in factual learning, teaching being too teacher centered, and teachers are authoritarian. these finding is similar with studies conducted among nursing students of nepal and pakistan.[2,9] even participants from other disciplines of different countries had also marked the same mentioned items that required major improvements.[4,19,20,22,23] the other areas that could be improved are provision of constructive criticism, emphasis over long term learning, comfortable environment during ward teaching and provision of good support system when they are stressed. other studies also support these areas that could be improved as their score range is in between 2 and 3.[2,4,7,11,22] conclusively, staying away from home environment, difficulty to manage theoretical and practical learning simultaneously could be the reasons so emphasis on the critical areas, provision of mentorships, personal and academic counseling sessions can be provided. the study found significant association with only students’ perception of teachers with nature of accommodation but not with other subscales and total scores of perception of educational environment which is consistent with the finding of study conducted by salih et al.[15] age of participants and year of enrollment had no impact on perception of educational environment in the current study. this is consistent with the study conducted by urimubenshi et al.[24] but studies conducted in dharan, nepal and south korea showed statistical relationship with year of enrollment.[2,4] the differences might be due to different study settings and sample size. the study has highlighted the useful insights about the strong, weak and areas for improvement of effective educational environment for nursing undergraduates. despite these, study has some limitations. nature of the study design and also determination of impact of lockdown due to covid-19 pandemic was not assessed, so the findings cannot be generalized. conclusion: the perception of educational environment among nursing students of both colleges was directed towards positive direction rather than negative ones. the students opined positive perceptions towards learning environment, teachers, academic and social environment, but still some key factors like teachers being authoritarian, teacher centered teachings, table 4. association of perception of educational environment and its subscales with nature of accommodation of participants(n=190). scales hostel own house rent room relatives’ home p-value student’s perception of learning 35.68±3.52 34.37±4.50 35.43±3.99 34.60±3.20 0.250 student’s perception of teachers 31.73±4.53 30.25±4.29 32.39±4.59 27.60±3.84 0.014 student’s academic selfperception 23.88±3.76 23.86±3.46 22.86±4.35 23.80±4.26 0.499 students’ perception of atmosphere 35.16±4.81 34.63±4.44 35.02±7.22 34.20±5.35 0.932 students’ social selfperception 18.52±2.92 18.05±3.17 18.63±3.88 17.80±1.92 0.739 overall perception of educational environment 144.98±13.86 141.18±14.07 144.34±19.01 138.00±16.32 0.390 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 garbuja ck et al. perception of educational environment among nursing students of different colleges: a cross-sectional study. 257 jlmc.edu.np lack of support system, over emphasis on factual learning, focus on short term learning are to be noted and improved for effective learning outcomes. acknowledgement: all the class coordinators of lumbini medical college and teaching hospital (lmcth) and college of medical sciences (cms). conflict of interest: the authors declare that no competing interests exist. financial disclosure: no 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___________________________________________________________________________________ submitted: 12 september, 2021 accepted: 05 july, 2021 published: 12 july, 2021 aassociate professor, college of nursing blecturer, college of nursing cassistant lecturer, college of nursing dmanipal college of medical sciences, pokhara nepal. ekathmandu medical college, kathmandu, nepal. corresponding author: sandhya shrestha e-mail: shrestha_sandhu@yahoo.com orcid: https://orcid.org/0000-0003-3536-8158_______________________________________________________ abstract introduction: covid-19 is a pandemic that emerged and rapidly spread throughout the world in no time. nursing students are the foundation of nursing profession and they have enormous role to control the spread of the disease in society. the present study was conducted to assess knowledge, practice and anxiety related to covid-19 among nursing students of nepal and to find out the correlation between anxiety and knowledge and practice. methods: a descriptive cross-sectional survey was conducted among 214 proficiency certificate level and bachelor of sciences in nursing students of nursing programme, manipal college of medical sciences. data were collected from 25th may to 2nd june 2020 through self-developed structured questionnaire to measure knowledge and practice whereas, a validated “self -rating anxiety scale (sas)” was used to measure anxiety level via google form. data were analyzed using descriptive and inferential (spearman rho correlation) statistics. results: majority (73.80%) were from age group 16-20 years of age with mean age of 19.33±1.96 years. majorities (83.60%) were hindus. more than half (57.50%) of the respondents had adequate knowledge regarding corona virus infection, 58.90% had good practice and only 6.10% had mild to moderate anxiety level. there was no significant correlation of anxiety with knowledge (p=0.857) and practice (p=0.375). conclusion: the study showed that more than half of the nursing students had inadequate knowledge, poor practices regarding corona virus infection and very few had mild to moderate anxiety level. anxiety was not related to knowledge and practice regarding corona virus infection. keywords: anxiety; covid-19; knowledge; nursing students; practices original research articlehttps://doi.org/10.22502/jlmc.v9i1.405 sandhya shrestha,a,d jyoti badan tuladhar,b,e namrata thapa c,d knowledge, practices and anxiety related to corona virus disease-19 (covid -19) among nursing students in nepal how to cite this article:how to cite this article: shrestha s, tuladhar jb, thapa n. knowledge, practices and anxiety related to corona virus disease-19 (covid -19) among nursing students in nepal. journal of lumbini medical college. 2021;9(1):7 pages. doi: https://doi.org/10.22502/jlmc.v9i1.405. epub: july 12, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: corona virus disease 2019 (covid-19) is a respiratory illness which spreads from person to person. the virus that causes covid-19 is a novel corona virus that was first identified during an investigation into an outbreak in wuhan, china. [1] the recent outbreak of respiratory illness “covid-19” has gained attention globally and has been recognized as a major public health threat by us centers for disease control and prevention (cdc).[2] the nurses are the backbone of the health care delivery system around the world, and the student nurses are the future professionals who have the vital role in nursing profession. and, to the best of our knowledge, limited studies have been done before; hence, the present study was conducted to assess knowledge, practices and anxiety related to novel corona virus among nursing students and find j. lumbini. med. coll. vol 9, no 1, jan-june 2021 shrestha s, et al. knowledge, practices and anxiety related to corona virus disease-19 (covid -19) among nursing students in nepal jlmc.edu.np out the correlation between anxiety with knowledge and practice. methods: a cross-sectional descriptive study was conducted from 25th may to 2nd june 2020 among students of proficiency certificate level (pcl), and bachelor of sciences in nursing currently studying in manipal college of medical sciences, pokhara, nepal. using census method, sample size was 217. with only response rate of 98.61%, the final sample size was 214. data collection was done via google form after obtaining consent from the respondents. data entry and analysis was done using statistical package for social sciences version 16. both descriptive (frequency, percentage, mean, range and standard deviation) and inferential (spearman rho correlation) statistics were used for data analysis. institutional review committee of the manipal teaching hospital had provided ethical approval (memg/irc/324/ga). the self-administered structured tool consisted of four partspart 1 -demographic variables – (age, religion, marital status, family type, level of study, residence, information about covid-19, source of information) part 2-self-developed structured knowledge related questionnaire on covid-19 consisted of 30 items. each item was responded as “true “and “false” which was scored as “1” and “0’” respectively and ranged from 0 to 30. mean obtained score was calculated and the respondents scoring equal and above the mean was classified as “adequate knowledge” and the respondents scoring below the mean was classified as “inadequate knowledge”.[3,4,5] part 3-self-developed practice related questionnaire on prevention of corona virus infection (15 items) measured on 5-point likert scale as never-1, rare -2, sometimes-3, usually -4 and always5. total scores range was 5 to 75. based on mean, practice was categorized as “good (score equal and above the mean)” and “poor (score below the mean)”. [6,7] part 4-a valid and reliable tool‘self-rating anxiety scale (sas)’ with 20 items was used to measure the anxiety of the respondents due to covid-19. it was measured as “a little of the sometime-1”, “some of the time -2”, “good part of the time -3” and “most of the time 4”.[8] after designing initial draft, validation of the tool was done through the experts from community and psychiatric nursing. pretest was done among 10% (21) of samples size to assess any constraints and to identify approximate time taken for completing the self-administered questionnaire. calculated cronbach’s alpha value was 0.70 for knowledge questionnaire, 0.72 for practice questionnaire and 0.70 for anxiety scale. the p value was set at <0.05. results nearly three fourth (73.80%) of the respondents were from age group 16-20 years with the mean age 19.33±1.96years. majorities (83.60% and 97.7%) were hindus and unmarried respectively. most (86.40%) of the respondents belonged to nuclear family. many (55.60%) were from pcl nursing faculty. more than half (52.71 %) had received information about covid-19 from internet source. most (99.1%) of the respondents answered correctly on causes of covid-19, more than three fourth (79.0%) correctly responded that virus strain of covid-19 is sars-cov-2. almost all (99.1%) of the respondents gave correct response on items regarding symptoms. likewise, 96.7% and 87.9% of them gave correct response on items regarding transmission and on items regarding preventive measures for covid-19 infection respectively. a majority (85.5%) responded correctly that who declared covid-19 as public health emergency on 30th january 2020. more than half (55.6%) gave correct response that antibiotics is not the first line treatment for covid-19. almost all (99.5%) of the respondents responded that personnel protective equipment should be worn by health care workers while caring patient suffering from covid-19. the details are depicted in table 1. table 2 depicts practices of the respondents regarding prevention of covid-19. more than two third (68.7%) of the respondents were washing hands with soap and water for 20 seconds. a majority (84.1%) always covered their nose and mouth with a tissue or flexed elbow during sneezing or coughing and 84.6% used face mask while going to the crowd. nearly one fourth (23.4%) of the respondents increased the frequency of cleaning and disinfecting items such as mobiles, door handles and j. lumbini. med. coll. vol 9, no 1, jan-june 2021 shrestha s, et al. knowledge, practices and anxiety related to corona virus disease-19 (covid -19) among nursing students in nepal jlmc.edu.np surfaces and 69.6% were eating healthy foods and maintaining healthy life styles. similarly, more than three fourth (78.0%) of them were avoiding places where a large number of people gathered and about two third (68.7%) always cancelled or postponed visiting with friends and relatives. table 3 depicted that 57.5% had adequate knowledge, 58.9% had good practice and only 6.1% had mild to moderate anxiety level among the respondents. there was negligible positive (r=0.012, p=0.857) correlation between anxiety and knowledge and negligible negative (r=-0.061, p=0.375) correlation between anxiety and practice respectively but were not statistically significant as shown in table 4. discussion: this study attempts to find the knowledge, practice and anxiety related to covid-19 among nursing students and to find out relationship of anxiety with knowledge and practice. the present study findings showed that more than half (57.50%) respondents had adequate knowledge regarding covid-19 which is similar to findings of other studies.[3,6,9,10] however, it contradicts with the findings from study conducted in saudi arabia where knowledge was poor.[11] the difference might be due to different study settings and availability of adequate source of information etc. people would gather information on covid-19 from television, radio, internet, ring tones on all mobile phone service providers, discussion among peer groups etc. the present study revealed that more than half (52.71%) of the respondents got information of covid-19 table 1: respondents’ knowledge on covid-19 (n=214). sn statements response true n (%) false n (%) 1 covid-19 is respiratory infectious disease. (t) 212(99.1) 2(0.9) 2 virus is the cause of covid-19. (t) 212(99.1) 2(0.9) 3 covid-19 is a highly contagious disease. (t) 212(99.1) 2(0.9) 4 virus strain of covid-19 is (sars-cov-2). (t) 169(79.0) 45(21.0) 5 origin of corona virus is wuhan, china. (t) 210(98.1) 4(1.9) 6 high fever, dry cough and dyspnea are hallmark symptoms of covid-19. (t) 212(99.1) 2(0.9) 7 incubation period is 2–14 days. (t) 207(96.7) 7(3.3) 8 diagnostic method for covid-19 is rrt-pcr testing, immunoassay and ct scan. (t) 160(74.8) 54(25.2) 9 covid-19 virus spread via respiratory droplets. (t) 207(96.7) 7(3.3) 10 covid-19 disease was an immunodeficiency disease. (f) 125(58.4) 89(41.6) 11 older adults, people who have serious chronic medical conditions like heart disease, diabetes and lung disease are at highest risk for covid-19. 208(97.2) 6(2.8) 12 people should eat healthy diet, well cooked meat and egg. (t) 188(87.9) 26(12.1) 13 who declared the covid-19 outbreak as public health emergency of international concern on 30th january 2020. (t) 183(85.5) 31(14.5) 14 who declared covid-19 as pandemic on 11th march,2020. (t) 162(75.7) 52 (24.3) 15 antibiotics is the first line treatment for covid-19. (f) 95(44.4) 119 (55.6) 16 corona virus is treated with other antiviral drugs in the market. (f) 98(45.8) 116 (54.2) 17 enquire at a nearby public health centers if symptoms are observed within 14 days from contacting a corona virus patient or visited to affected country. (t) 213(99.5) 1(0.5) 18 social distance is important when going out in public. (t) 209(97.7) 5(2.3) 19 all public should wear n95 mask while going in crowd. (f) 187(87.4) 27(12.6) 20 using personnel protective equipment by health care worker is mandatory while caring patient suffering from covid-19. (t) 213(99.5) 1(0.5) j. lumbini. med. coll. vol 9, no 1, jan-june 2021 shrestha s, et al. knowledge, practices and anxiety related to corona virus disease-19 (covid -19) among nursing students in nepal jlmc.edu.np from internet followed by multimedia which is in line with a study conducted by tork hm and kim js.[12,13] most (96.2%) responded correctly that older adults with serious chronic medical conditions like heart disease, diabetes and lung disease are at highest risk for covid-19 infection which is similar to other studies conducted in saudi arab and china. [14,15] more than half (58.9%) of the respondents in the present study were having good practices against covid-19 infection which is similar to the studies conducted in other settings.[16,17,18] the present study showed that majority (68.7%) of respondents always washed hands more often than usual which is consistent to previous studies as well.[19,20,21,22,23,24] majority (84.5%) of the respondents always used face masks when going to the crowd which is in line with other studies.[6,25] table 4. correlation between anxiety level with knowledge and practice of respondents (n =214). variables r value p-value anxiety knowledge .012 .857 practice -.061 .375 table 2. respondents' practice on prevention of covid-19 (n=214). sn statements always usually sometime rare never n (%) n (%) n(%) n (%) n (%) 1 wash hands more often than usual with soap and water for 20 sec. 147(68.7) 62(29.0) 5(2.3) 2 use hand disinfectant containing more than 60% alcohol. 93(43.5) 87(40.7) 21(9.8) 9(4.2) 4(1.9) 3 avoid coughing around people as much as possible. 180(84.1) 29(13.6) 2(0.9) 3(1.4) 4 cover nose and mouth with a tissue or flexed elbow during sneezing or coughing. 189(88.3) 22(10.3) 1(0.5) 2(0.9) 5 use disposable tissue and throw it in the trash bin and cover after using it 154(72.0) 46(21.5) 7(3.3) 3(1.4) 4(1.9) 6 use face mask when going to crowd. 181 (84.6) 29(13.6) 3(1.4) 1(0.5) 7 avoid touching eyes, nose and mouth as far as i can. 91 (42.5) 97 (45.3) 19(8.9) 7 (3.3) 8 increase the frequency of cleaning and disinfecting items (i.e. mobiles, door handles and surfaces). 50 (23.4) 113 (52.8) 41(19.2) 8(3.7) 2(0.9) 9 reduce going to closed space due to covid-19. 120(56.1) 68 (31.8) 18(8.4) 7(3.3) 1(0.5) 10 keep eating healthy foods and maintain healthy life styles. 149(69.6) 55 (25.7) 10(4.7) 11 discuss with family, friends what to do if infected with covid-19. 98(45.8) 87(40.7) 28(13.1) 1(0.5) 12 reduce the use of public transportation due to covid-19. 160(74.8) 31(14.5) 3(1.4) 16 (7.5) 4(1.9) 13 avoid places where a large number of people have gathered. 167(78.0) 40(18.7) 5(2.3) 1 (0.5) 1(0.5) 14 shopping less frequently 120(56.1) 53(24.8) 13(6.1) 20(9.3) 8(3.7) 15 cancel or postpone visiting with friends and relatives. 147(68.7) 50(23.4) 13(6.1) 3(1.4) 1(0.5) table 3. level of knowledge, practice and anxiety regarding covid-19 of respondents (n=214). characteristics n (%) knowledge adequate 123 (57.5) inadequate 91 (42.5) practice good 126 (58.9) poor 88 (41.1) anxiety normal 201 (93.9) mild to moderate 13 (6.10) j. lumbini. med. coll. vol 9, no 1, jan-june 2021 shrestha s, et al. knowledge, practices and anxiety related to corona virus disease-19 (covid -19) among nursing students in nepal jlmc.edu.np the present study revealed that only few (6.1%) of respondents were having mild to moderate anxiety level which contradicts the study conducted in israel where high level of anxiety was prevalent among nursing students.[26] these may be due to of lock down of the country, universities had started online classes while students were staying in their own home with family rather than in hostel and also they were not exposed as frontliners for caring patients. the limitation of this study was that as it was conducted in only one college, the results cannot be generalized. and also, there are chances of recall bias on information. conclusion: the study revealed that half of the respondents had adequate knowledge and good preventive practices related to covid-19. and very few were having mild to moderate anxiety level. there was negligible relation of anxiety with knowledge and practice related to covid-19. this result suggested that half of the nursing students needed specific education on emerging infectious diseases and preventive behaviors to fortify their knowledge and practices during the outbreak. hence, the nurse educators should take initiation in this matter to enhance their knowledge and practice level as they are also a part of health care delivery system. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available for the study. references: 1. center for disease control and prevention (cdc). covid-19 [internet]. us department of health and human services: usa; 2021. 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influenza pandemic. j infect. 2009;59(2):122-7. pmid: 19592114 doi: https://doi.org/10.1016/j.jinf.2009.06.004 24. rubin gj, amlot r, page l, wessely s. public perceptions, anxiety, and behavior change in relation to the swine flu outbreak: cross sectional telephone survey. bmj. 2009;339(0):b2651. doi: https://doi.org/10.1136/bmj.b265 25. baloran et. knowledge, attitudes, anxiety, and coping strategies of students during covid-19 pandemic. journal of loss and trauma 2020;25(8):635-42. doi: https://doi.org/10.108 0/15325024.2020.1769300 26. savitsky b, findling y, ereli a, hendel t. anxiety and coping strategies among nursing students during the covid-19 pandemic. nurse educ pract. 2020;46(0):102809. pmid: 32679465 doi: https://doi.org/10.1016/j. nepr.2020.102809 psychological distress in patients having globus pharyngeus: a case-control study anup acharya,a,c madan mohan singh,b,c bandana pokhareld —–————————————————————————————————————————————— abstract: introduction: globus sensation is described as a constant feeling of a lump or foreign body in the throat in absence of pain and dysphagia. it is a common complaint in ear nose and throat clinics. etiology of this condition remains multifactorial and unclear. psychiatric disorder has been described as one of the cause of globus. the objective of this study is to evaluate the occurrence of psychological distress in patients complaining of globus sensation in throat coming to our centre. methods: a case-control study was done. patients coming to outpatient of ear nose and throat department of lumbini medical college teaching hospital with complain of globus and not having an organic explanation of the condition were included. age, sex and socio-economic condition matched control group was selected from healthy visitors (patient parties). validated nepali version of ghq-12 was used to assess the psychological distress. results: psychological distress was present in 72.69% of the cases and 39.91% in the control group. the difference was statistically significant. conclusion: psychological distress was significantly higher in the patients with globus pharyngeus compared to the control group. it was also present in a larger fraction of the control group. the patient who present with globus should undergo psychiatric evaluation after organic causes have been ruled out. we recommend a national policy to evaluate the population for their psychiatric health. keywords: case-control study • gastro-esophageal reflux • globus • psychological • stress —————————————————————————————————————————————— ___________________________________________________________________________________ a assistant professor b associate professor and head cdepartment of ent head and neck surgery lumbini medical college teaching hospital d lecturer (psychiatric nursing), college of nursing lumbini medical college teaching hospital corresponding author: dr. anup acharya e-mail: anupent@gmail.com how to cite this article: acharya a, singh mm, pokharel b. psychological distress in patients having globus pharyngeus a case control study. journal of lumbini medical college. 2014;2(2):45-7. doi: 10.22502/jlmc.v2i2.57. ___________________________________________________________________________________ j. lumbini. med. coll. vol 2, no 2, july-dec 2014 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v2i2.57 that it is equally present in both sexes.6 our record shows that 13% of the outpatient department (opd) patients complained of globus sensation in their throat. despite history and examination, we cannot find the cause in majority of the patients. preliminary treatment with anti-reflux medication in these patients, as gastro-esophageal reflux is very common in developing countries,7 does not produce results in many of them. we have started assessment of their psychological distress as a potential cause of globus. general health questionnaire (ghq) is one of the instruments used to detect psychiatric disorder in the general medical out-patients. it assesses the respondent’s current state and is sensitive to shortterm psychiatric disorders. the ghq -12, the shortest version and commonly used screening tool, has been found to be reliable and well-validated to determine whether an individual is at risk of developing a psychiatric disorder.8-11 methods: a case-control study was done by including introduction: globus sensation is described as a constant feeling of a lump or fullness in the throat in absence of pain and dysphagia. the aetiology of globus remains multifactorial and unclear. gastroesophageal reflux, pharyngeal inflammation, cricopharyngeal spasm, sinusits and psychogenic factors remain the most common cause of globus.1,2 it is reported to have been experienced by up to 45% of the population.1 many believe that it is primarily a disease of female,3-5 though other studies suggest 45 j. lumbini. med. coll. vol 2, no 2, july-dec 2014 jlmc.edu.np acharya a. et al. psychological distress in patients having globus pharyngeus patients who came to opd of ear nose and throat (ent) department in lumbini medical college (lmc) throughout july 2014 to september 2014 with complain of globus sensation in throat. thorough history taking and ent examinations were done. fiberoptic naso-pharyngo-laryngoscopy was done in all cases. those patients who had a positive history or clinical finding suggesting any organic condition like gastro-esophageal reflux, pharyngeal inflammation, sinusitis, postnasal drip, chronic tonsillitis, chronic laryngitis, thyroid disorders were excluded from the study. a control group which matched age, sex and socio-economic conditions was selected from the patient parties (visitors) who did not have any medical complains or conditions. permission was obtained from the ethical committee of lmc. each participant in both the study and control group was verbally explained about the purpose of the study, instructions for questionnaire, declaration on their anonymity and confidentiality. verbal consent was taken. the validated nepali version of ghq-12 was used for this study.12 questions were verbally presented one by one to the participants and the responses were registered. the person involved in the interview did not know to which group the participant belonged to. this ensured reduction of bias. ghq scoring method (0-0-1-1) was adopted for this study. the scores were summed up to get a total which ranged from 0 to 12. a score of 3 or more was considered to be positive for psychological distress. data was collected in microsoft excel 2007™ and was imported to ibm spss 21™ for descriptive and inferential statistics. p value less than 0.05 was considered to be statistically significant. results: there were a total of 238 patients each in the study and the control group. the demographic details of participants in each group are shown in table 1. chi-square goodness of fit was calculated variables study group control male (n) 80 81 female (n) 158 157 total (n) 238 238 mean age (yrs) 44.55 43.1 sd (yrs) 5.79 5.38 table 1: demographic details of participants comparing the frequency of occurrence of female and male patients having globus in the study group. significant deviation from the hypothesized value (0.5) was found. female appeared to be more commonly affected than male (table 2). chi-square test of independence was calculated comparing the grading of ghq-12 scores in study group and controls. it showed a significant relationship; participants in study group were likely to have higher ghq-12 score than the controls (table 3). gender n (%) female 158 (66.39%) male 80 (33.61%) total 238 x2(1)=25.563, p<0.001 table 2: sex distribution of patiens having globus in study group table 3: ghq-12 scores of two groups variables study group control ghq-12 score <3 65 143 ≥ 3 173 95 x2(1)=51.951, p<0.001 discussion: globus pharyngeus is likely to occur more frequently in female patients (table 2). in our study it occurred in about twice than that of male. this finding is in support of several studies.3-5 it may be due to many factors; gender based violence, low or subordinate social status, undervalued domestic work, less pay, expected work as a homemaker and a breadwinner, and difficulty to advance in their careers.13 psychological distress in study group was significantly higher than that of control (table 3). this finding support the fact that psychiatric disorder is one of the etiological factor of globus pharyngeus.1,2 the patient who present with globus should be evaluated for any organic cause like gastro-esophageal reflux, pharyngeal inflammation, cricopharyngeal spasm, sinusitis, malignancy etc. and if no obvious cause found, should be sent for psychological evaluation. this has become a routine in our centre. a study conducted for evaluation of psychological distress in population similar to 46 j. lumbini. med. coll. vol 2, no 2, july-dec 2014 acharya a. et al. psychological distress in patients having globus pharyngeus jlmc.edu.np ours, found that distress was present in 37.5% of the general population.11 comparing findings of our control group with this result, there was no significant difference in the occurrence of psychological distress (x2(1)=0.539, p=0.44). this confirms that our control group represented the general population so far the evaluation of psychological distress is concerned. the authors were aware of the prevalent psychiatric illness in the general population but we did not know it was so common. in nepal, mental health has been a neglected and overlooked issue for a long time. most of the people think that suffering from mental illness is the same as being mad, becoming unfit to remain in society and the family. they are the targets of stigma and discrimination to the point where they hesitate to come forward for appropriate treatment.14 the patients in the study group and the participants in the control group who were identified as having psychological distress need further assessment by psychiatrist or psychologist to confirm that they indeed have a psychiatric disorder. they will be in a position to truly recognize what type and what severity of psychiatric disorder do they have. conclusion: patients presenting with globus and found to have no organic cause have a high rate of psychological distress. they should be referred to psychologist or psychiatrist for proper psychiatric evaluation. even the seemingly normal population of our county has a high rate of psychological distress. a national policy to address them is today’s necessity. conflict of interest: the principal author did not take part in editorial decisions. references: 1. lee be, kim gh. globus pharyngeus: a review of its etiology, diagnosis and treatment. world j gastroenterol. 2012 may;18(20):2462-71. doi: 10.3748/wjg.v18.i20.2462. 2. mitchell s, olaleye o, weller m. review: current trends in the diagnosis and management of globus pharyngeus. international journal of otolaryngology and head & neck surgery. 2012;1(3):57-62. doi: 10.4236/ijohns.2012.13013. 3. harar rp, kumar s, saeed ma, gatland dj. management of globus pharyngeus: review of 699 cases. j laryngol otol. 2004;118(7):522–7. doi: 10.1258/0022215041615092. 4. ali khm, wilson ja. what is the severity of globus sensation in individuals who have never sought health care for it? the journal of laryngology & otology. 2007;121(9):865-8. doi: 10.1017/s0022215106003380. 5. goldberg dp, gater r, sartorius n, ustun tb, piccinelli m, gureje o, et al. the validity of two versions of the ghq in the who study of mental illness in general health care. psychol med. 1997;27(1):191-7. 6. goldberg dp, hillier vf. a scaled version of the general health questionnaire. psychol med. 1979;9(1):139-45. 7. perez-perez gi, sack rb, reid r, santosham m, croll j, blaser mj. transient and persistent helicobacter pylori colonization in native american children. j clin microbiol. 2003;41(6):2401-7. 8. zulkefly ns, baharudin r. using the 12-item general health questionnaire (ghq-12) to assess the psychological health of malaysian college students. global journal of health science. 2010;2(1):73-8. doi: 10.5539/gjhs.v2n1p73. 9. guggenheim fg. somatoform disorders. in: kaplan hi, sadock va. (eds). comprehensive textbook of psychiatry (7 ed.). baltimore: lippincott williams and wilkins; 2000. p.1504–32. 10. caylakli f, yavuz h, erkan an, ozer c, ozluoglu ln. evaluation of patients with globus pharyngeus with barium swallow pharyngoesophagography. laryngoscope. 2006;116:37–39. doi: 10.1097/01. mlg.0000191457.78244.96. 11. khattri jb, poudel bm, thapa p, godar st, tirkey s, ramesh k, et al. an epidemiological study of psychiatric cases in a rural community of nepal. nepal journal of medical sciences. 2013;2(1):52-6. 12. koirala nr, regmi sk, sharma vd, khalid a, nepal mk. sensitivity and validity of the general health questionnare-12 (ghq-12) in a rural community setting in nepal. nepalese j psychiatry. 1999;1(1):34-40. 13. world health organization. gender and women's mental health. geneva: mental health;2014 october. [internet] available from: http://www.mental_health/prevention/ genderwomen/en. 14. 14. devkota m. mental health in nepal: the voices of koshish. psychology international. 2011 july;22(2):7-8. 47 bhuwan edited--bhuwan article edited ds feb 20.docx https://doi.org/10.22502/jlmc.v10i2.496 original research article endoscopic transcanal type i cartilage tympanoplasty for anterior perforation of tympanic membrane: a cross-sectional study bhuwan raj pandey,a,c madan mohan singhb,c abstract: introduction: repair of anterior perforation of tympanic membrane is difficult mainly due to inadequate exposure, minimal tympanic membrane remnant, impaired vascular supply, and delayed healing. methods: this analytical cross-sectional study was done in a tertiary center over a period of 12 months from 25 april 2021 to 24 april 2022. there were 47 patients who underwent endoscopic transcanal type i cartilage tympanoplasty for anterior perforation. all operations were performed using an underlay technique and by transcanal approach. in all the cases, perichondrium with tragal cartilage was used as graft for the reconstruction of tympanic membrane. evaluation was done after three months post-operatively in terms of graft uptake and post-operative hearing status. results: the overall graft uptake success rate after three months post-operatively was 89.4%. the pre-operative mean pure-tone average was 34.72 ± 6.45 db, (range 17 db to 43 db). the mean postoperative pure-tone average was 22.09 db ± 9.30 (range 10 to 41 db). the mean difference between preoperative pure tone average and postoperative pure tone average was 12.63 db ± 8.96 (p < 0.05). the mean preoperative air-bone gap average was 23.38 db ±7.98 (range 6 to 40 db) and mean postoperative air-bone gap of 13.45 ± 6.89 (range 5 to 32 db). this resulted in improvement in the air-bone gap by 9.93 db (p < 0.05). conclusion: endoscopic transcanal tympanoplasty is a minimally invasive procedure, which provides complete exposure of anterior tympanic membrane perforation thus avoiding external incisions and canalplasty. keywords: cartilage, endoscopy, graft, tympanic membrane perforation, tympanoplasty submitted: august 31, 2022. accepted: january 25, 2023. published: march 5, 2023. aassistant professor, department of otolaryngology bassociate professor, department of otolaryngology clumbini medical college and teaching hospital, palpa, nepal corresponding author: bhuwan raj pandey assistant professor, department of otorhinolaryngology lumbini medical college& teaching hospital, palpa, kathmandu university email: entbhuwan@gmail.com orcid:https://orcid.org/0000-0002-4698-1946 introduction: tympanoplasty for closing anterior perforation of the tympanic membrane is considered a difficult reconstructive challenge due to its poor visualization, inadequate anterior margin, graft stabilization and decreased graft viability.[1] there are different surgical techniques to repair anterior how to cite this article: pandey br, singh mm. endoscopic transcanal type i cartilage tympanoplasty for anterior perforation of tympanic membrane: a cross-sectional study. lumbini med coll. 2022;10(2): 9 pages. doi: https://doi.org/10.22502/jlmc.v10i2.496 epub: march 5, 2023. j. lumbini med. coll. vol 10, no 2, jul-dec 2022 https://doi.org/10.22502/jlmc.v10i2.496 https://orcid.org/0000-0002-4698-1946 https://doi.org/10.22502/jlmc.v10i2.496 pandey br, et al. endoscopic transcanal type i cartilage tympanoplasty for anterior perforation perforations including sandwich graft tympanoplasty, over-under tympanoplasty, mediolateral graft tympanoplasty, anterior hitch technique, window shade technique and hammock tympanoplasty.[2] the various techniques used for the repair of perforations have different success rate, however in many studies perforations with involvement of the anterior quadrant of the tympanic membrane have shown poor surgical outcome in terms of graft uptake and hearing outcome.[3] the limited visualization of anterior quadrants perforation may require more invasive procedures. in such situation, transcanal endoscopic surgery provides a wide surgical view, which provides minimally invasive and safe surgical approach avoiding unnecessary postauricular incision and canalplasty.[4] the present study aimed to evaluate the graft success rate and hearing outcomes for endoscopic transcanal type i tympanoplasty in repairing anterior perforations of the tympanic membrane using perichondrium with tragal cartilage graft. methods: this was an analytical cross-sectional study conducted in the department of otorhinolaryngology of lumbini medical college and teaching hospital, palpa, nepal over a period of 12 months from 25 april 2021 to 24 april 2022. ethical approval was obtained from the institutional review committee of the institution prior to study (irc-lmc 09-a/021). informed consents were taken from the study participants. a detailed history, clinical examination, otoscopic examination and audiological evaluation were done in all cases pre-operatively. all the surgeries were done by the main author to reduce bias and patients were called for follow-up after one week to remove ear canal pack and then three months after surgery. pure-tone audiometry (pta) were performed pre-operatively and three months post-operatively after the surgery. air conduction (ac) threshold was measured at frequencies of 250, 500, 1000, 2000, 4000, and 6000 hz, and bone conduction (bc) threshold was measured at frequencies of 500, 1000, 2000, and 4000 hz. pure-tone averages (ptas) were then determined based on the threshold values at 500, 1000, 2000 and air bone gap (abg) pta values were calculated. the sample size was calculated using the following formula: 𝑛≥ 𝑧 1− α2 2 𝑋 𝑝 1−𝑃( ) 𝑑 2 where, z= standard normal value for 95% confidence interval (1.96) alpha (α) =type 1 error rate p= proportion of patients with successful graft uptake is 96%[5] d= marginal error rate=7% the minimum required sample size was 31. however, sample size of 47 was taken for the study. inclusion criteria ● chronic otitis media (com), mucosal inactive type ● central perforations involving anterior quadrant, which may range from small to subtotal in size. ● normal external auditory canal ● no sensorineural hearing loss exclusion criteria ● active ear discharge(≤ six weeks) ● perforations involving only posterior quadrant j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np pandey br, et al. endoscopic transcanal type i cartilage tympanoplasty for anterior perforation ● any focus of infection in the nose, paranasal sinuses and throat ● patients unwilling to participate in the study procedure: instruments: all the procedures were performed by transcanal approach using a zero degree, 4-mm rigid endoscope (tekno) of 18 cm length. surgical techniques: surgeries were done under local anesthesia. general anesthesia was reserved for uncooperative patients. ear was prepared and draped under sterile conditions without hair shaving. the preauricular area and postauricular area were infiltrated with 2% lidocaine hydrochloride and 1: 200000 epinephrine. transcanal injections of 0.5 ml were administered in all four quadrants using a 1ml syringe under direct endoscopic visualization and blanching of the canal skin was observed. firstly, the anterior perforation margin and tympanic annulus were visualized through endoscope. the perforation margin was circumferentially freshened with a curved pick. an incision was made along the anterior ear canal (at approximately 2 o’clock in the right ear or 10 o’clock in the left ear) and brought circumferentially. a tympanomeatal flap was elevated 6 mm lateral to annulus and the middle ear space was entered inferiorly. the tympanic annulus was identified and then elevated anteriorly all the way to the 2 or 10 o’ clock incision originally made. posteriorly the tympanic annulus was elevated with the rosen needle to dissect the annulus away from the chorda tympani nerve. cotton soaked with epinephrine was applied to reduce bleeding from the edges of the flap. after the middle ear cavity was exposed, the integrity and mobility of the ossicular chains were examined. after finishing the middle ear work, graft was harvested. tragal cartilage with perichondrium was used as graft material in all cases. a 1.5 cm long incision with the help of a no. 15 blade was made 2 mm medially from tragal tip. the skin was undermined and tragus with perichondrium was harvested. perichondrium was separated from both sides. at first, the perichondrium graft was placed using the underlay technique under the tympanic annulus and pushed anteriorly. the perichondrium layer was then lifted again and then barred cartilage was kept under the perichondrium. if the middle ear space was compromised due to a medialized handle of malleus, the cartilage was notched vertically to fit the handle of malleus. previously lifted perichondrium was also placed back over the barred cartilage. no gelfoam was kept in middle ear. the tympanomeatal flap was placed back in the posterior canal wall and external auditory canal was packed with absorbable gelatin sponge. no mastoid dressing was required. the patients were discharged on the first postoperative day. the packing and stitches were removed one week post-operatively. follow up was done in the outpatient department after three months and pta was done in all cases. data was entered and analyzed with statistical package for social sciences (spss tm) software version 20. descriptive statistics was presented as frequencies, percentage, mean and standard deviation (sd). comparison of the quantitative variables was made with paired-sample t test and fisher exact test was applied for qualitative data. a p-value less than 0.05 was considered statistically significant. results: a total of 47 patients involving anterior quadrant perforation of tympanic membrane were included in the study. there were 25 (53.2%) male and 22 (46.8%) female with male to female ratio of 1.13:1. among the j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np pandey br, et al. endoscopic transcanal type i cartilage tympanoplasty for anterior perforation total number of patients, minimum age in this study was nine years and maximum age was 57 years with mean age of 25.30±12.67 years with maximum number of patients between the age group of 21 to 40 years. the perforation was right-sided in 30 patients (63.9%) and left-sided in 17 patients (36.1%) as shown in table 1. the success rate of graft uptake at three months post-operative is shown in table 2. the graft uptake was compared between genders as shown in table 3. table 1: demographic and clinical parameters of the study population (n = 47). age group (years) no. of cases (%) male female perforation side right left ≤20 17 (36.2%) 9 (19.2%) 8 (17.0%) 10 (21.3%) 7 (14.9%) 21-40 22 (46.8%) 12 (25.5%) 10 (21.3%) 17 (36.2%) 5 (10.6%) ≥41 8 (17.0%) 4 (8.5%) 4 (8.5%) 3 (6.4%) 5 (10.6%) table 2: surgical success rate (n=47) graft uptake no of patients percentage perforation closure 42 89.4 residual perforations 5 10.6 table 3: analysis of gender-wise graft uptake. gender graft uptake p=0.654*yes no male 23 (48.9%) 2 (4.3%) female 19 (40.4) 3 (6.4%) *fisher exact test j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np pandey br, et al. endoscopic transcanal type i cartilage tympanoplasty for anterior perforation the maximum number of patients have more than 20 db air bone gap and these patients have better outcome in postoperative period as shown in table 4. table 4: preoperative and postoperative air bone gaps in the study participants (n=47). air bone gap (db) preoperative n (%) postoperative n (%) ≤10 2 (4.3%) 19 (40.4%) 11-20 15 (31.9%) 19 (40.4%) ≥20 30 (63.8%) 9 (19.2%) the mean preoperative pure-tone average was 34.72 ± 6.45 db, (range: 17 db to 43 db). the mean postoperative pure-tone average was 22.09 ± 9.30 db (range: 10 to 41 db). the mean difference between preoperative pure tone average and postoperative pure tone average was 12.63 ± 8.96 db which was statistically significant (t=9.66, df=46, p<0.05). similarly, the mean preoperative air-bone gap average was 23.38 db ±7.98 (range 6 to 40 db) and mean postoperative air-bone gap of 13.45 ± 6.89 (range: 5 to 32 db). this resulted in improvement in the air-bone gap by 9.93 db (t=6.94, df=46, p<0.05) as shown in table 5. table 5: analysis of preand post-operative hearing outcome (n=47) parameters mean (db) standard deviation p value* pre-operative pure tone average 34.72 6.45 t=9.66,df=46, p<0.05 post-operative pure tone average 22.09 9.30 pre-operative air bone gap 23.38 7.98 t=6.94, df=46, p<0.05 post-operative air bone gap 13.45 6.89 *paired-sample t test discussion: transcanal endoscopic repair of tympanic membrane perforations for com is gaining popularity among otorhinolaryngologists. the most common surgical technique used is underlay with transcanal or post-auricular approach and it is preferred over overlay because it gives better access to middle ear and the ossicles.[6] the success rate of tympanoplasty is affected by various factors j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np pandey br, et al. endoscopic transcanal type i cartilage tympanoplasty for anterior perforation such as visualization of the perforation area and support for the graft anteriorly. anterior perforations are more difficult to repair using the underlay technique.[7] there are few studies that have described endoscopic transcanal tympanoplasty for repair of anterior perforation of the tympanic membrane. the concept of grafting tragal cartilage and perichondrium was introduced by goodhill.[8] the cartilage perichondrium composite grafts is frequently used nowadays during endoscopic ear surgery. cartilage is easier to fit on the eardrum perforation site, thicker and less prone to resorption and retraction.[9] so doubts have been raised about its conduction properties due to thickness of cartilage. however, atef et al. concluded thinning the cartilage to half of its thickness adds more to the technical difficulties without an actual hearing gain.[10] in a study done by kalcioglu et al. there was no significant difference in either graft uptake or post-operative hearing in the patients undergoing type i tympanoplasty by temporalis fascia and cartilage perichondrium grafts.[11] gamra et al. evaluated the anatomical and audiological results of type 1 cartilage tympanoplasty in the reconstruction of tympanic membrane perforations and they achieved functional results similar to the temporal fascia.[12] in our study, we used tragal perichondrium with cartilage as a graft material with the help of endoscope and the overall success rate for graft take up was 89.4% after three months of post-operative period. seidman et al. performed transcanal tympanoplasty in 45 patients in anterior perforations and reported 88% graft uptake with temporalis fascia graft.[13] tseng et al. did endoscopic transcanal myringoplasty for anterior perforations in 59 patients and had graft uptake of 93% with follow up of six months but they used temporalis fascia or tragal perichondrium as graft material.[2] similarly, özdemir et al. performed endoscopic transcanal type 1 cartilage tympanoplasty using tragal cartilage perichondrium as graft materials in 104 patients, of which 35.6% had anterior quadrant involvement.[14] they had overall graft uptake of 93.2% (n=97) with significant improvement in hearing results, regardless of the perforation location and size. peng et al. performed hammock tympanoplasty technique for anterior perforation in 25 patients. the graft uptake rate was 96%, with a follow-up period of 3.5 ± 1.7 years.[5] the procedure of this study was similar to our study but it was done via a postaural approach using a microscope. they used temporalis fascia and cartilage as graft material but we used tragal cartilage and perichondrium as graft materials. our procedure was minimally invasive with a single incision for tragal cartilage and all the procedures were completed by the per-meatal approach without mastoid bandage. mohanty et al. did comparative study between cartilage and fascia graft and reported graft uptake rate of 91.95% using composite cartilage perichondrium island graft in transcanal endoscopic cartilage myringoplasty for anterior perforation in 87 patients with a minimum follow-up of one year.[15] the pre-operative mean air conduction in our study was 34.72 ± 6.45 db and post-operatively it was 22.09 db ± 9.30 with mean gain of 12.63 ± 8.96 db. those patients who had more hearing loss pre-operatively benefited more than those with a minimal pre-operative hearing loss and improvement was significant where pre-operative air bone gap was more than 20 db. most of the studies mentioned above have hearing improvement j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np http://jlmc.edu.np pandey br, et al. endoscopic transcanal type i cartilage tympanoplasty for anterior perforation post-operatively with varying results in graft uptake.[16,17] in our study, most of the patients were in the age group of 21 to 40 years. male were predominant over female however, there was no significant association between gender and graft success uptake rate, which was similar to another study.[17] emir et al. showed that being a male gender was good prognostic factor.[18] the basic requirement for successful closure is contact between graft and tympanic membrane remnant. the zero degree rigid endoscope provides complete exposure of tympanic perforation anteriorly which helps in elevating the anterior tympanic annulus. the perichondrium graft is kept underneath the anterior annulus with support of cartilage under an excellent endoscopic exposure, avoiding medialization of the graft in the middle ear. so in our surgical procedure perichondrium graft had reduced gap between tragal cartilage and tympanic membrane remnant. using a perichondrium-supported graft as the graft material makes an important contribution to epithelialization in the tympanic membrane in the postoperative period. this study has some limitations which include a limited sample size. the hearing assessment was done after three months postoperatively only. a study involving a larger sample size with longer follow up is recommended. conclusion: endoscopic transcanal tympanoplasty is a minimally invasive procedure that provides complete exposure of anterior tympanic membrane perforation thus avoiding external incisions. this technique has the advantages of wider field of view and superior visualization. furthermore, the perichondrium with cartilage is a good grafting material for anterior quadrant perforation, which gives a good graft uptake success rate and hearing outcome. conflict of interest: the authors declare that no competing interests exist source of funds: none references: 1. schraff s, dash n, strasnick b. 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anterior quadrant tympanic perforations a prospective study in a tertiary care hospital. auris nasus larynx. 2018;45(5):936-942. pmid: 29397250 doi: https://doi.org/10.1016/j.anl.2018.01.0 02 16.visvanathan v, vallamkondu v, bhimrao sk. achieving a successful closure of an anterior tympanic membrane perforation: evidence-based systematic review. otolaryngol head neck surg. 2018;158(6):1011-1015. pmid: 29533700 doi: https://doi.org/10.1177/019459981876 4335 17.singh mn, hamam pd, lyngdoh nc, priyokumar os. evaluation of hearing j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np https://pubmed.ncbi.nlm.nih.gov/29937855/ https://doi.org/10.1016/j.joto.2017.08.005 https://doi.org/10.1016/j.joto.2017.08.005 https://pubmed.ncbi.nlm.nih.gov/26988908/ https://doi.org/10.3109/00016489.2016.1139744 https://doi.org/10.3109/00016489.2016.1139744 https://doi.org/10.1001/archotol.1967.00760040482004 https://doi.org/10.1001/archotol.1967.00760040482004 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https://pubmed.ncbi.nlm.nih.gov/29533700/ https://doi.org/10.1177/0194599818764335 https://doi.org/10.1177/0194599818764335 http://jlmc.edu.np pandey br, et al. endoscopic transcanal type i cartilage tympanoplasty for anterior perforation status in pre and post-operative endoscopic type i tympanoplasty and its influencing factors. journal of medical society 2014;28(3):166-70. available from: https://www.jmedsoc.org/text.asp?201 4/28/3/166/148502 18. emir h, ceylan k, kizilkaya z, gocmen h, uzunkulaoglu h, samim e. success is a matter of experience: type 1 tympanoplasty : influencing factors on type 1 tympanoplasty. eur arch otorhinolaryngol. 2007;264(6):595-9. pmid: 17235531 doi: https://doi.org/10.1007/s00405-006-02 40-6 j. lumbini med. coll. vol 10, no 2, jul-dec 2022 jlmc.edu.np https://www.jmedsoc.org/text.asp?2014/28/3/166/148502 https://www.jmedsoc.org/text.asp?2014/28/3/166/148502 https://pubmed.ncbi.nlm.nih.gov/17235531/ https://doi.org/10.1007/s00405-006-0240-6 https://doi.org/10.1007/s00405-006-0240-6 http://jlmc.edu.np the efficacy of ketamine gargle in attenuating postoperative sore throat: a randomized control trial ram prashad sharma,a pradip raj vaidya,b,d man bahadur chand.c,d —–————————————————————————————————————————————— abstract: introduction: postoperative sore throat (post) is a common complication of general anesthesia with endotracheal intubation that affects the patient satisfaction after surgery. the aim of the study was to compare the effectiveness of ketamine gargle with placebo in preventing post after endotracheal intubation. methods: sixty eight patients scheduled for elective surgery under general anesthesia were enrolled in this study. patients were randomly allocated into two groups, 33 in study group and 35 in control group. study group patients were asked to gargle with ketamine (50 mg in 1 ml mixed with 29 ml of drinking water) 10 minutes before induction for 30 seconds. controls were made to do so with 30 ml of drinking water. post was graded at one, two, four, and 24 hrs after operation on a four-point scale (0-3). the outcome measures were compared between two groups in terms of occurrence of post and severity of post at one, two, four, and 24 hr to determine the efficacy of ketamine. results: occurrence of post was significantly less in study group at four hours. severity of post was significantly low in study group at one, two and four hours as compared to that in controls. it was comparable at 24 hours. conclusion: ketamine gargle significantly reduced the occurrence and severity of post. keywords: endotracheal • intubation • ketamine • pharyngitis • postoperative ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, department of anesthesiology lumbini medical college teaching hospital, palpa, nepal b assistant professor c professor d department of anesthesiology, national academy of medical sciences, kathmandu, nepal corresponding author: dr. ram prashad sharma e-mail: elixir841@gmail.com how to cite this article: sharma rp, vaidya pr, chand mb. the efficacy of ketamine gargle in attenuating postoperative sore throat: a randomized control trial. journal of lumbini medical college, 2015;3(1):8-11. doi: 10.22502/ jlmc.v3i1.61. ___________________________________________________________________________________ j. lumbini. med. coll. vol 3, no 1, jan-june 2015 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v3i1.61 introduction: postoperative sore throat (post) is rated by patients as the eighth most undesirable outcome in the postoperative period.1 the occurrence of post varies from 6.6% to 90%.2 the occurrence is highest with tracheal tube (45.4%) followed by patients with laryngeal mask airway (17.5%), while patients with facemask have lowest occurrence of sore throat (3.3%).3 the main mechanism of post is postulated to be irritation and inflammation of the airway.4 post might be a consequence of localized trauma to the pharyngeal and tracheal mucosa during laryngoscopy, intubation and endotracheal tube cuff inflation.5 various measures have been used for attenuating post with variable success. among pharmacological methods in use are beclomethasone inhalation, gargling with aspirin and benzydamine, gargling with azulene sulfonate, local spray with lidocaine and intracuff administration of alkalized lignocaine, topical methylprednisolone, diclofenac epolamine patch, transdermal ketoprofen, and application of triamcinolone acetonide paste.6-13 all these techniques have their own limitations and variable success rate. ketamine, an n-methyl-d-aspartate (nmda) receptor antagonist, is proved to be present also in peripheral nervous system.14,15 peripherally administered nmda receptor antagonists are involved with antinociception and anti-inflammatory cascade.16,17 various studies have been done on ketamine gargling for attenuating postoperative sore throat in other parts of world and all of them have shown reduction in occurrence and severity of post.18-21 this study was done to compare the occurrence and severity of post in two groups of 8 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 jlmc.edu.np sharma rp. et al. the efficacy of ketamine gargle in attenuating postoperative sore throat: a randomized control trial. patients, one receiving ketamine and other receiving normal saline for preoperative gargle. methods: this is a hospital based prospective, randomized, placebo-controlled, double-blind study conducted at national academy of medical sciences, bir hospital for the period of three months (nov 2012 – jan 2013) after the approval by hospital’s institutional review committee. based on previous similar study done by rudra et. al,18 we presumed the occurrence of post to be 60% (p1), and would reduce the occurrence to 20% (p2). power analysis with α = 0.05, β = 0.90, p1 = 0.6 and p2 = 0.2 calculates the minimum required sample size in each group to be 33. a list of computer generated random numbers was created. a total of 68 patients were thus randomized into two groups, the first (study group) containing 33 and the second (control group) containing 35 subjects. patients undergoing elective surgery in bir hospital under general anesthesia with endotracheal intubation were enrolled in the study. inclusion criteria were male or female of asa i or ii of age between 18 to 60 years with weight >40 kg and duration of surgery being less than 120 min. exclusion criteria were patients’ refusal and uncooperative patients, anticipated difficult airway, history of preoperative sore throat and asthma, patients of known allergy to the study drug, history of recent anti-inflammatory medication, patients with upper respiratory tract infection, patient requiring more than one attempt for passage of tracheal tube, extubation provoked bucking and patients undergoing nose and throat surgeries. pre-anesthetic checkup was done a day before surgery. informed and written consent were taken from the patients who were enrolled in the study. patients were informed about their right to withdraw from the study at any time. they were informed that there would be no financial burden to them since the drugs under study would be provided free. the patients who were enrolled in the study were kept nil per oral for eight hours before surgery. on the day of operation, when the patient came to operation theater, intravenous access was secured with 18 g cannula on non-dominant forearm. patients were allocated into either of two groups according to the list of random numbers generated earlier. anesthetic assistant provided the control group with drinking water (30 ml) and the study group with one ml (50 mg) of preservative free ketamine mixed in 29 ml of drinking water. patients were asked to gargle with the given preparation for 30 seconds. anesthesia was induced 10 minutes later. investigator was blinded to the study drug used. monitors were attached which include continuous electrocardiogram, non-invasive blood pressure, pulse oximetry. then injection pethidine 0.75 mg/kg was given for analgesia. after preoxygenation with five breaths of 100% oxygen, induction agent propofol was given and titrated till the eye lash reflex get obtunded. the patients were ventilated with tight fitted mask with oxygen. once the possibility of ventilation was confirmed, muscle relaxant vecuronium 0.12 mg/kg was given, then ventilated with oxygen and one percent halothane for three min. then patients were intubated with sterile polyvinyl chloride endotracheal tube (high volume low pressure cuffs) with an internal diameter of seven mm for women and 7.5 mm for men. the tracheal intubation was performed by experienced anesthesiologist. immediately after intubation, cuff of the endotracheal tube was filled with a volume of room air required to prevent an audible air leak. anesthesia was maintained with oxygen, halothane and vecuronium. at the end of the surgery, halothane was stopped, the patients were reversed with neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/ kg after assessing the presence of adequate volume of spontaneous respiration. gentle suctioning of oral cavity was done and extubated when patients were awake. patient was shifted to post-operative ward. the patients were interviewed in a standard fashion by a blinded investigator on arrival in the post anesthesia care unit when patient was able to respond (one hr), and at two, four and 24 hours using four-point post scores (table 1). occurrence and severity of post-operative sore throat was assessed in post-operative care unit at one hr, two hr, four hr, and 24 hr. side effects post score definition 0 no sore throat 1 mild sore throat (complain of sore throat only on asking) 2 moderate sore throat (complain of sore throat on his/her own) 3 severe sore throat (change of voice or hoarseness associated with throat pain) table 1. postoperative sore throat (post) scores 9 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 sharma rp. et al. the efficacy of ketamine gargle in attenuating postoperative sore throat: a randomized control trial. jlmc.edu.np like hallucination, nausea, vomiting, vertigo, and nystagmus were looked for at one hr of extubation in postoperative care unit. data were collected in microsoft excel 2007 and analyzed by statistical software-spss 16. appropriate tests like t-test for difference of mean, chi-square test for categorical data and wilcoxon rank sum test for ordinal data were used. p<0.05 was considered statistically significant. results: a total of 68 patients were included in the study. there were 33 in study group and 35 in control group. there was no difference among the two groups with regard to asa status, age, gender, weight, duration of surgery, duration of anesthesia (table 2). occurrence of sore throat was significantly less in ketamine group at four hr post extubation. though not significant, occurrence was lower in ketamine group at all other times (table 3). the severity of sore throat was significantly less in ketamine group at four hr post extubation (table 4). no local or systemic side effects were observed. variables study group controls statistics number (n) 33 35 gender: m 11 8 x2=1.72, df=1 p=0.19 f 22 27 age (years) m (sd) 39.09 (14.68) 39.97 (12.4) t=-0.27, df=66, p=0.79 weight (kg) m (sd) 54.71 (9.83) 57.21 (8.92) t= -1.1, df=66, p=0.28 asa: i 27 24 x2=1.59, df=1 p=0.21 ii 6 11 duration of surgery in min, m (sd) 64.84 (25.54) 59.53 (26.35) t=0.84, df=66, p=0.4 duration of anesthesia in min, m (sd) 86.06 (26.03) 82.03 (30.02) t=0.59, df=66, p=0.56 table 2: patient characteristics occurrence of post (hr after extubation) study group (n=33) controls (n=35) p 1 hr, n (sd) 5 (15.1%) 12 (34.3%) x2=2.88 p=0.09 2 hr, n (sd) 9 (27%) 18 (51.4%) x2=3 p=0.08 4 hr, n (sd) 4 (12.1%) 15 (42.9%) x2=6.37 p=0.01 24 hr, n (sd) 2 (6%) 8 (22.9%) x2=3.6 p=0.06 table 3: occurrence of sore throat at 1, 2, 4 and 24 hour post extubation discussion: several factors have been attributed to the occurrence of postoperative sore throat like gender, age, size of endotracheal tube, grade of difficulty of intubation, duration of surgery.22,23 in our study, two study groups were not statistically different in terms of gender, age, weight, duration of surgery and duration of intubation. in recent years, studies have shown that ketamine has its anti-inflammatory properties and it plays a protective role against lung injury.4 the effect of nebulized ketamine inhalation on allergeninduced rats have been examined in the study done by zhu et al. and they concluded that ketamine administration by local route appears to inhibit the inflammatory cascade response.17 besides, experimental studies point out that peripherally administered nmda receptor antagonists are implicated with antinociception.24 in our study, the maximum occurrence of post was 51.4% at two hrs in controls. occurrence of post was reduced significantly at four hours in study group compared to controls. it was comparable between two groups at one, two and 24 hours. this reduction in occurrence and severity of post is consistent with the findings of previous studies.18-21 the severity of pain was statistically less in study group at one, two and four hours as compared to controls. however, pain at 24 hours was not significantly different. there are some limitations of our study. we did not measure the plasma level of ketamine. so we cannot rule out the role of systemic effect of ketamine in our results. we had powered our study to the occurrence of sore throat. the power of this study may not be sufficient for the severity of those events. conclusion: in conclusion, ketamine gargle before induction in patients undergoing general anesthesia with endotracheal intubation is effective and safe in reducing the occurrence and severity of postoperative sore throat. it significantly reduces the occurrence and severity of post at four hrs post extubation. conflict of interest declared: none 10 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 sharma rp. et al. the efficacy of ketamine gargle in attenuating postoperative sore throat: a randomized control trial. jlmc.edu.np 1. macario a, weinger m, carney s, kim a. which clinical anesthesia outcomes are important to avoid? the perspective of patients. anesth analg. 1999;89(3):652-8. 2. sumathi pa, shenoy t, ambareesha m, krishna hm. controlled comparison between betamethasone gel and lidocaine jelly applied over tracheal tube to reduce postoperative sore throat, cough, and hoarseness of voice. br j anaesth. 2008;100(2):215-8. 3. higgins pp, chung f, mezei g. postoperative sore throat after ambulatory surgery. br j anaesth. 2002;88(4):582-4. 4. ayoub cm, ghobashy a, koch me, mcgrimley l, pascale v, qadir s, et al. widespread application of topical steroids to decrease sore throat, hoarseness, and cough after tracheal intubation. anesth analg. 1998;87(3):714-6. 5. agarwal a, gupta d, yadav g, goyal p, singh pk, singh u. an evaluation of the efficacy of licorice gargle for attenuating postoperative sore throat: a prospective, randomized, single-blind study. anesth analg. 2009;109(1):77-81. 6. el hakim m. beclomethasone prevents postoperative sore throat. acta anaesthesiol scand. 1993;37(3):250–2. 7. agarwal a, nath ss, goswami d, gupta d, dhiraaj s, singh pk. an evaluation of the efficacy of aspirin and benzydamine hydrochloride gargle for attenuating postoperative sore throat: a prospective, randomized, single–blind study. anesth analg. 2006;103(4):1001–3. 8. ogata j, minami k, horishita t, shiraishi m, okamoto t, terada t. et al. gargling with sodium azulene sulfonate reduces the postoperative sore throat after intubation of the trachea. anesth analg. 2005;101:290–3. 9. estebe jp, dollo g, le corre p, le naoures a, chevanne f, le verge r. et al. alkalinization of intracuff lidocaine improves endotracheal tube-induced emergence phenomena. anesth analg. 2002;94(1):227–30. 10. le´vy b, mouillac f, quilichini d, schmitz j, guadart j, gouin f. topical methylprednisolone vs lidocaine for the prevention of postoperative sore throat. ann fr anesth reanim. 2003;22:595–9. 11. rahimi m, makarem j. effects of diclofenac epolamine patch on postoperative sore throat in partureints after cesarean delivery under endotracheal general anesthesia. acta anaesthesiol taiwan. 2009;47(1):17-21. 12. ozaki m, minami k, sata t, shigematsu a. transdermal ketoprofen mitigates the severity of postoperative sore throat. can j anaesth. 2001;48(11):1080-3. 13. park sy, kim sh, lee sj, chae ws, jin hc, lee js et al. application of triamcinolone acetonide paste to the endotracheal tube reduces postoperative sore throat: a randomized controlled trial. can j anaesth. 2011;58(5):436-42. 14. carlton sm, coggeshall re. inflammation-induced changes in peripheral glutamate receptor populations. brain res. 1999; 820:63–70. 15. carlton sm, zhou s, coggeshall re. evidence for the interaction of glutamate and nk1 receptors in the periphery. brain res. 1998;790:160–9. 16. davidson em, carlton sm. intraplanter injection of dextrorphan, ketamine or memantine attenuates formalin– induced behaviors. brain res. 1998; 785:136–42. 17. zhu mm, zhou qh, zhu mh et al. effects of nebulized ketamine on allergen-induced airway hyper-responsiveness and inflammation in actively sensitized brown –norway rats. j inflam (lond). 2007;4:10–26. 18. rudra a, ray s, chatterjee s, ahmed a, ghosh s. gargling with ketamine attenuates the postoperative sore throat. indian j anaesth. 2009;53:40-3. 19. canbay o, celebi n, sahin a, celiker v, ozgen s, aypar u. ketamine gargle for attenuating postoperative sore throat. br j anesth. 2008;100:490-3. 20. rajkumar g, eshwori l, konyak py, singh ld, singh tr, rani mb. prophylactic ketamine gargle to reduce postoperative sore throat following endotracheal intubation. j med soc. 2012; 26(3):175-9. 21. shrestha sk, bhattarai b, singh j. ketamine gargling and postoperative sore throat. j nepal med assoc. 2010;50(180):282-5. 22. biro p, seifert b, pasch t. complaints of sore throat after tracheal intubation: a prospective evaluation. eur j anaesthesiol. 2005;22(4):307-11. 23. chen kt, tzeng ji, lu cl, liu ks, chen yw, hsu cs et al. risk factors associated with postoperative sore throat after tracheal intubation: an evaluation in the postanesthetic recovery room. acta anaesthesiol taiwan. 2004;42(1):3-8. 24. davidson em, coggesshall re, carlton sm. peripheral nmda and non-nmda glutamate receptors contribute to nociceptive behaviors in the rat formalin test. neuroreport. 1997;8:941-6. references: 11 pattern of dermatological disease and its relation to gender in lumbini medical college teaching hospital pratistha shrestha,a jameel akhthar mikrania —–————————————————————————————————————————————— abstract: introduction: the pattern of skin disease differs in different countries, and within various region of a country depending on socio-economic, racial and environmental factors. many researchers have reported various patterns of skin disease in different countries. this type of study has not been done in this part of country. so, we decided to study, assess and compare the different pattern of dermatological disease in patients visiting our centre. methods: this was retrospective study done from the hospital record of lumbini medical college teaching hospital (lmcth). the study was carried out from september 2014 to december 2014 while the data were accessed from the records of respondents from september 2013 to august 2014. the diagnosis was categorized into 10 groups. the diagnosis which did not fit any category was kept in “others”. the 10 categories include acne, bacterial infection, dermatophytes, eczema, leprosy, pigmentory diseases, psoriasis, scabies, urticaria and viral infection. data was collected based on gender and categorized according to the diagnosis. microsoft excel was used for data entry while all the analysis both descriptive and inferential statistics was done using spss version 21. results: there were a total of 7967 patients visiting dermatology opd. out of the total patient, there were 52.10% female and 47.89% male and this difference was statistically significant. in both gender eczema was the most common skin disease. eczema was significantly more common in male whereas acne was significantly common in female. most of the patients were from age group of 15-30 yrs with eczema being commonest in this age group. conclusion: eczema and dermatophytes are the most common dermatological diseases. eczema is significantly more common in male. acne is significantly more common in female. keywords: acne • dermatologic • disease • eczema • gender ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, department of dermatology and venereology lumbini medical college teaching hospital, palpa, nepal corresponding author: pratistha shrestha e-mail: pratisthashrestha@hotmail.com how to cite this article: shrestha p, mikrani ja. pattern of dermatological disease and its relation to gender in lumbini medical college teaching hospital. journal of lumbini medical college, 2015;3(1):16-8. doi: 10.22502/ jlmc.v3i1.63. ___________________________________________________________________________________ j. lumbini. med. coll. vol 3, no 1, jan-june 2015 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v3i1.63 introduction: dermatological diseases have high morbidity but apparently few mortalities. it is an important part of any major hospital. the pattern of skin diseases varies from one country to another and across different parts within the country. it also varies according to gender.1 skin diseases are also influenced by various factors like climate, custom, religions, languages and socio-economic condition. the annual report of the health services in 2067/2068 ranks skin diseases as the fourth most common problem in patients attending outpatient clinics in the country, and comprises 1.4% of the total in-patient morbidity.2 as the pattern of dermatological diseases varies in different parts of a country and in different gender, we decided to conduct a retrospective study on pattern of skin diseases and its relation to gender, in lumbini medical college teaching hospital. identifying the pattern of dermatoses can help to educate the patients and plan for the community management of the diseases. methods: this was a retrospective analytical study done in lumbini medical college teaching hospital form 1st of october 2014 to 31st of december 2014. during this period, the record of all patients visiting 16 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 jlmc.edu.np shrestha p. et al. pattern of dermatological disease and its relation to gender in lumbini medical college teaching hospital. to outpatient clinic of department of dermatology and venereology from 1st of september 2013 to 31st of august 2014 was reviewed. the patient’s second name, age, sex, address and diagnosis were recorded. all the diagnosis was made only by dermatologist. diagnosis was done by clinical examination in most cases and laboratory investigation was done whenever required. diagnosis was grouped into 10 categories. the diagnosis which does not fit into these categories was kept in "others". the 10 categories include acne, bacterial infection, dermatophytes, eczema, leprosy, pigmentory diseases, psoriasis, scabies, urticaria and viral infection. pattern of diseases according to gender was also recorded. microsoft excel sheet was used to tabulate the data. data analysis was done in spss 21. t-test was used to compare mean; chi-square test was used to compare proportions. p value less than 0.05 was considered significant. results: a total of 7967 patients were included in this study. as shown in table 1, 4151 (52.10%) were female and the rest 3816 (47.89%) were male. this difference was statistically significant. eczema was the most common disease in both gender. acne was the next common disease in female whereas dermatophytes were in male. leprosy was the least common disease in both gender. acne, pigmentary diseases, psoriasis and urticaria were significantly more common in female compared to male. eczema was the only disease diseases male female statistics eczema (n=1737) 958 779 x2=18.45, p<.001 dermatophytes (n=1329) 700 629 x2=3.79, p=.052 acne (n=1128) 386 742 x2=112.36, p<0.001 scabies (n=622) 324 298 x2=1.09, p=.3 pigmentary diseases (n=733) 290 443 x2=31.94, p<.001 bacterial infection (n=422) 217 205 x2=.34, p=.56 urticaria (n=462) 205 257 x2=5.85, p=0.02 viral infection (n=398) 205 193 x2=.36, p=.55 psoriasis (n=309) 130 179 x2=7.77, p=.005 leprosy (n=23) 10 13 x2=.39, p=.53 others (804) 391 413 x2=.6, p=.44 total (n=7967) 3816 4151 x2=14.09, p<.001 table 1: distribution of disease by gender. that was significantly more common in male. dermatophytes, scabies, bacterial infections, viral infections and leprosy were comparable in both gender. diseases age-group (years) <15 15-30 31-45 >45 acne 54 878 193 3 bacterial infection 94 119 98 111 dermatophytes 105 633 399 192 eczema 116 527 564 530 leprosy 0 10 10 3 others 61 310 267 166 pigmentary disease 65 275 301 92 psoriasis 3 72 118 116 scabies 212 254 120 36 urticaria 109 143 130 80 viral infection 31 130 137 100 total 850 3351 2337 1429 table 2: pattern of disease according to age groups table 2 shows the age-group distribution of the diseases. the most commonly affected age group was 15-30 years. discussion: in our study, dermatological disorders were more common in female which was statistically significant. some studies have reported female preponderance,3,4 as in our study, others have reported male preponderance.5 among all the dermatoses, eczema was the commonest (21.8%) with male outnumbering female which was statistically significant. in our country nepal where farming is the main source of income, thus they are prone to develop eczema mainly on hands and feet. shrestha r. et al. had done study on pattern of skin diseases in a rural area of nepal and found that eczema was the commonest dermatoses.4 similar results were in others studies as well.6-10 but study done by poudyal y. et al. showed dermatophytes was the commonest skin disease.11 however, it was the second common disease in our study (16.68%) which was comparable in both gender. it can be due to climatic variation in different region of the country. this reflects the fact that warm and humid climate creates the environment for the development of fungal infection.12 the low incidence of hansen's disease in this study (7.81%) is due to the fact that such patients 17 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 shrestha p. et al. pattern of dermatological disease and its relation to gender in lumbini medical college teaching hospital. jlmc.edu.np mainly attend leprosy center. the most common age group presenting to the opd was 15-30 years. acne was the most common dermatoses in this age-group followed by dermatophytes and eczema. similar result were found in study done by karn d. et al. on prevalence of skin disease in kavre district, nepal.13 this may be due to fact that this is the most active population and the people in this age group are self conscious about their looks, skin and personalities.14 similar result were found in other study as well.11,15 conclusion: eczema, dermatophytes and acne were the most common pattern of dermatological diseases found in this hospital. the patient from age group 1530 years were the most frequent group with female predominance. this study provides a preliminary baseline data for future clinical research. it might also help to assess the changing trends of dermatological diseases. references: 1. williams hc. epidemiology of skin diseases. burns t, breathnach s, cox n, grifths c. (eds). rooks textbook of dermatology. 7th ed. oxford: blackwell science; 2004. p16-21. 2. annual report. department of health services 2067/2068 (2010/2011), nepal. 3. kuruvilla m, sridhar ks, kumar p, rao g. pattern of skin diseases in bantwal taluq, dakshina kannada. indian j dermatol venereol leprol. 2000;66:247-8. 4. shrestha r, kayastha bmm. pattern of skin diseases in rural area of nepal. pmjn. 2012;12(2): 41-44. 5. rao gs, kumar ss, sandhya. pattern of skin diseases in an indian village. indian j med sci 2003;57:108-10. 6. shrestha dp, gurung d, mausooma f, pradhan m, haikal m, parajuli s et al. pattern and prevalence of eczema: a comparative study between out-patients and village community. sixth south asian regional conference and seventh national conference of society of dermatologists, venereologists and leprologists of nepal (sodvelon). november 13-15, souvenir 2009;142. 7. furue m, yamazaki s, jimbow k, tsuchida t, amagai m, tanaka t et al. prevalence of dermatological disorders in japan: a nationwide, cross-sectional, seasonal, multicenter, hospital-based study. j dermatol. 2011; 38(4): 353–63. 8. sk sarkar, akms islam, kg sen, ars ahmed. pattern of skin diseases in patients attending opd of dermatology department at faridpur medical college hospital, bangladesh. faridpur med. coll. j. 2010;5(1):14-6. 9. devi th, bijayanti, zamzachin g. pattern of skin diseases in imphal. indian journal of dermatology 2006;51(2):14950. 10. shrestha r, lama l, gurung d, shrestha dp, rosdahl i. pattern of skin diseases in rural development community of nepal. nepal journal of dermatology, venereology & leprology.2014; 12(1): 41-4. 11. poudyal y, rajbhandari sl. pattern of skin diseases in patients visiting universal college of medical sciences teaching hospital ( ucms-th ) from the three districts of terai region in nepal. joucms 2014; 2(3) : 3-8. 12. hay rj, moore mk. in: burns t, breathnach s, cox n, griffiths c(eds). rook's textbook of dermatology. 7th ed. oxford: blackwell science ltd; 2004.p 23-31. 13. karn d, khatri r, timalsina m. prevalence of skin disease in kavre district, nepal. njdvl 2010;9(1):7-9 14. walker sl, shah m, hubbard vg, pradhan hm, ghimire m. skin disease is common in rural nepal: result of point prevalence study. b j dermatol 2008;158(20:334-8. 15. emmanouil ks, konstantin k, ioannis dk, ioannis k, ioannis l, anastasios p. et al. primary care and pattern of skin diseases in a mediterranean island. bmc family practice. 2006;7(8). 18 adolescent pregnancy among ethnic variants at lumbini medical college subha shrestha,a,c buddhi kumar shresthab,c —–————————————————————————————————————————————— abstract: introduction: adolescent pregnancy is a common social phenomenon that results to both maternal and fetal related health consequences globally. important factors affecting this high risk group of pregnancies are social, cultural, ethnic and racial disparities which may limit the care during pregnancy thereby affecting the perinatal outcome. the main objective of this study was to estimate the maternal and fetal outcome of adolescent pregnancies visiting lumbini medical college among ethnic variants of mid-western region. methods: a retrospective observational study was conducted in lumbini medical college and teaching hospital for one year duration. data was retrieved from the medical records of the admitted adolescent pregnant mothers with hospital delivery after 20 weeks’ gestation. variables of interest were the selective demographic characteristics like place of residence and ethnicity of women, parity, and obstetrical &fetal outcomes. results: the total numbers of admission for deliveries during the study period were 1905, out of which 462 (24.3%) were adolescent pregnancy. a total of 184 (39%) adolescent mothers were at the age of 19 and 334 (72.2%) of them were from palpa district. the highest number of teenagers were from janajati group i.e. 240 (52%). among all, 38 (10%) had preterm delivery and 7 (1.5%) had intrauterine fetal death. while 407 (88.3%) adolescent pregnancies had vaginal deliveries, 54 (11.7%)of them had lower segment cesarean section (lscs). fifty-one (11.4%) neonates had low birth weight (below 2500 gm)and 11 (2.4%) had stillbirths. among the low birth weight, 32 (51%) newborns were admitted to neonatal intensive care unit (nicu). conclusions: adolescent pregnancy is higher common in palpa district of nepal. janajati adolescent girls are becoming pregnant early after marriage. higher numbers of teenagers are 19 years of age and are primigravida. on reaching the tertiary center, obstetrical outcome is better with less maternal morbidity and no mortality and better neonatal survival. keywords: adolescent • ethnic groups • outcome • pregnancy ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, b assistant professor c department of obstetric and gynecology lumbini medical college, palpa, nepal corresponding author: dr. subha shrestha e-mail: subha_sht@hotmail.com how to cite this article: shrestha s, shrestha bk. adolescent pregnancy among ethnic variants at lumbini medical college. journal of lumbini medical college, 2015;3(1):1-4. doi: 10.22502/jlmc.v3i1.59. ___________________________________________________________________________________ j. lumbini. med. coll. vol 3, no 1, jan-june 2015 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v3i1.59 introduction: the period between the ages of 10 and 19 years in which the individual progresses from the initial appearances of secondary sexual characteristics to full sexual maturity; and during which psychological and emotional processes develop from those of a child to an adult, is adolescence.1 adolescent pregnancy is defined as gestation in teenagers before somatic development is reached. for millions of young people around the world, the onset of adolescence brings not only changes to their bodies but also new vulnerabilities to human rights abuses, particularly in the arenas of sexuality, marriage, and childbearing.2 about 16 million girls aged 15 to 19 and some one million girls below 15 give birth every year, most in low and middle socio-economic countries like nepal. complications during pregnancy and childbirth are the second cause of death for 15-19 years old girls globally. babies born to adolescent mothers face a substantially higher risk of dying than those born to women aged 20 to 24.3 to face the events of childbearing in a very young age is considered to be high risk because of the additional impact of reproduction on a body which is 1 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 jlmc.edu.np shrestha s. et al. adolescent pregnancy among ethnic variants at lumbini medical college. still to grow.4 other important factors affecting this high risk group of pregnancies are social, cultural, ethnic and racial disparities which may limit the care during pregnancy thereby affecting the outcome of these adolescent pregnancies. since limited studies has been done to address this particular issue on maternal and child health in our nation, this study was intended to assess the maternal and fetal outcome of adolescent pregnancy visiting lumbini medical college among ethnic variants of mid-western region methods: this was a retrospective observational study conducted at department of obstetrics and gynecology of lumbini medical college teaching hospital (lmcth), palpa from january 2015 to march 2015. during this period, records of last one year i.e. january 2014 to december 2014 were reviewed. records of all the adolescent pregnant girls were studied. the adolescent teenagers, 19 years or below, with period of gestation more than 20 weeks, who were admitted for safe confinement or delivery at lmcth were enrolled in the study. data was retrieved from the case sheets from medical records department of the hospital. data regarding age, place of residence, ethnic groups as per the most populous ethnicity from demographic survey of nepal 2011 were studied. perinatal outcome in terms of pregnancy complications, mode of delivery and maternal and neonatal morbidity and mortality was also noted. data was analyzed using spss version 16. frequency and percent were calculated for categorical data while mean and standard deviation were found for continuous data. results: the total number of admissions during the study period were 1905, out of which 462 (24.3%) were adolescent pregnancy. most pregnancies 184 (39%) were accounted among teenagers of 19 yrs which was followed by 18 yrs i.e. 161 (34%). pregnancy below 15 years of age was not encountered (table 1). our study showed that adolescent teenagers’ delivery was recorded maximum i.e. 334 (72.3%) from respondents of palpa district, where the hospital is situated. the highest number of teenagers were from janajati i.e. 240 (52%) while lowest were from madhesi i.e one. among all of the ethnic groups, most of the respondents were primigravida i.e 428(92.6%).third gravidity in adolescence were seen in dalit only (table 2). complications during pregnancy and delivery outcome among adolescent mothers are shown in table 3. among the admissions, one had molar pregnancy and belonged to the janajati group, three had twin deliveries (one from dalit and two from brahmin/chhetri group) and 10 (2.1%) had breech deliveries (five from janajati, three from brahmin chhetri and one from dalit group). during postpartum period, seven (1.5%) had primary postpartum ethnic variants primigravida second gravida third gravida total dalit n (%) 104 (90%) 9 (7.8%) 2 (2.2%) 115 (25%) janajati n (%) 223 (92.9%) 17 (7.08%) 0 240 (52%) chhetri/brahmins n (%) 96 (94.1%) 6 (5.9%) 0 102 (22%) muslims n (%) 4 0 0 4 madhesi n (%) 1 0 0 1 table 2. distribution of ethnical variants according to gravidity table 3: pregnancy complications and maternal and fetal outcome among adolescent pregnancies variables n(%) pregnancy complications pregnancy induced hypertension 3 (0.6) eclampsia 2 (0.4) intrauterine fetal death 7 (1.5) prelabour rupture of membranes 6 (1.2) urinary tract infection 4(0.8) cholestasis of pregnancy 1(0.2) type of delivery vaginal 408 (88.3%) caesarean section 54 (11.7%) age of teenager (years) n (%) 15 6 1.3 16 24 5.2 17 87 18.8 18 161 34.8 19 184 39.8 total 462 100 table 1: distribution of adolescent pregnancy according to age 2 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 shrestha s. et al. adolescent pregnancy among ethnic variants at lumbini medical college. jlmc.edu.np hemorrhage, seven (1.5%) had retained placenta and two had puerperal sepsis and were managed accordingly. the total numbers of live births were 446 (88.5%) while stillbirths of 11 (2.4%). fifty-one (13.5%) had low birth weight (below 2500 gm) neonates and 395 (88.5%) had normal weight. thirty-two (62 %) newborns were admitted to neonatal intensive care unit (nicu) for prematurity and low birth weight. discussion: although births among adolescents account for 11% of all births worldwide, they account for 23% of the overall burden of disease secondary to pregnancy and childbirth among women of all ages. in low and middle income countries, complications of pregnancy and childbirth are the leading cause of death in women aged 15–19 years. the vast majority of these births (95%) occur in low and middleincome countries. various countries have vast variation ranging from one to 299 births per 1000 girls, with the highest rates in sub-saharan africa.2 first pregnancy at an early age is risky. this is why the prevention of adolescent pregnancy is an effective intervention that contributes to millennium development goal 5 (improve maternal health). deducting adolescent pregnancy is necessary for this goal which focuses on reducing childhood &maternal mortality. prioritization of adolescent pregnancy decrement policies is included in national reproductive health policies of many countries.5 annual report of nepal department of health had mentioned the rate of 17% among adolescence girls, who are either pregnant or a mother of one child before 19 years of age.5-8 our study showed 24.3% rate of adolescent pregnancy among teenagers visiting our hospital, which is higher in numbers compared to other studies. within south east asia, the recorded adolescent pregnancy is highest in bangladesh 35%, followed by nepal 21 % and india 21%. our study result is similar to the study conducted at by sah rb. et al. in nobel medical college showing 34.6 % of adolescence pregnancy, 39% belonging to brahmin /chhetri group and 50.8% in janajati group.7 the incidence of preterm delivery was less (10%) in our study as compared to studies of tripathi m. et al, prianka m. et al, and khooshideh m. et al., whose studies result showed the rate of preterm delivery as 20%, 27%, and 19% respectively.9-11 another comparable results of preterm labor and delivery with our study is the findings by thaker rv. et al. i.e. 17.8%.12 we calculated the lower rate of caesarean section, preterm delivery, intrauterine fetal deathand hypertensive disorders similar to the findings by kayastha s. et al. and pun kd. et al. similar to pun kd. et al, our study showed vaginal deliveries being the commonest route of delivery and perinatal complications were in higher order among adolescent girls with no maternal mortality during study period.13-14 the better predisposition of adolescent pregnant women to have a spontaneous vaginal delivery is due to better myometrial function, greater connective tissue elasticity and lower cervical compliance.15 our study revealed 1.5% intrauterine fetal death, 2.4% stillbirths, 11.4% low birth weight and 62% needing nicu service among the low birth weight. better and timely availability of nicu facilities to resuscitate very low birth weight babies might have been the reason for positive results among admitted neonates higher birth weight of spontaneous vaginal delivery has minimized the overall adverse perinatal outcome apart from prematurity. babies delivered by adolescent mother are likely to be premature, so the incidence of low birth weight ( <2500 grams) is higher in them. low birth weight is an outcome of malnutrition which is an important determinant of childhood mortality. our study revealed less number of low birth weight babies, so it seems maternal nutrition is better in adolescent mothers of palpa district of nepal in comparison to other remote areas of nepal. conclusions: adolescent pregnancy is high in palpa and nearby districts of mid-western region of nepal with greater preponderance among the janajati group. adolescent pregnancy results in adverse maternal and fetal outcome, adding up perinatal morbidity and mortality. overall obstetrical outcome of adolescent pregnancy at lmcth is good with less maternal morbidity, no mortality and high neonatal survival rate. this study shows that we can have a better feto-maternal outcome with institutional deliveries. preventive measures by the government like health education to women and men of all ethnic groups, 3 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 shrestha s. et al. adolescent pregnancy among ethnic variants at lumbini medical college. jlmc.edu.np 1. world health organization. adolescent sexuality and reproductive health: educational and service aspect. report of world health organization meeting in mexico city.1981 28th april2nd may. 2. world health organization. adolescent pregnancy. media center. fact sheets. 2014 sept-nov. 3. who. preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries.2011;195 4. bacci a, manhica gm, machungo f, bugalho a, cuttini m. outcome of teenage pregnancy in maputo, mozambique. int. j gynecolobstet. 1993:40(1);1923. 5. who. early marriages, adolescent and young pregnancies.65th world health assembly.2012 mar; vol13(4). 6. the world bank. children and youth. the world bank, washington dc, 2004. 7. sahrb,, kumar g, baral dd, jha n, pokharel pk. burden of teenage pregnancies in hilly area of eastern region of nepal. j nobel med col. vol3(1):13-9. 8. department of health services (2011). annual report. ministry of health and population, government of nepal. [online]. available from: http://dohs.gov.np/ sites/default/files/1/files/annual_report_2066_67. pdf (accessed may 27, 2013). 9. tripathi m, sherchan a. outcome of teenage pregnancy. j uni col med sci. 2014;2(6):11-4. 10. mukhopadhaya p, chauduri rn, paul b. hospital based perinatal outcomes and complications in teenage pregnancy in india. j health popul nutr. 2010 oct ;28(5):494-500. 11. maryam k, ali s. pregnancy outcome in teenagers in east sauterne of iran. j pak med assoc. 2008 oct;58(10):541-44. 12. thaker rv, panchal mv, vyas cs, shah sr, shah pt, deliwala kj. study of feto-maternal outcome of teenage pregnancy at tertiary care hospital. gujarat med j .2013 dec;68(2):100-3. 13. kayastha s, pradhan a. obstetric outcome of teenage pregnancy. njog. 2012 jul-dec;17(2):29-32 . 14. pun kd, chauhan m. outcome of adolescent pregnancy at kathmandu university hospital, dhulikhel, kavre. kathmandu univ med j. 2011 janmar;9(33):50-3. 15. jolly mc, sebire n, harris j, robinsons s, regan l. obstetric risks of pregnancy in women less than 18 years old. obstet gynecol. 2000;96:962-6. awareness programs at school levels regarding age at marriage, contraceptive methods and risks of teenage pregnancy might reduce the incidence of adolescent pregnancies. conflict of interest declared: none. references: 4 complications of percutaneous nephrolithotomy and their management: experience from a single centre neeraj thapa,a,d sachin shris,a,d nabin pokharel,b,d yg tambay,c,d yr kher,c,d sumnima acharyaa,e —–————————————————————————————————————————————— abstract: introduction: increasing global prevalence of nephrolithiasis has resulted in the development of new minimally invasive techniques and has also led to the resurgence of established methods such as percutaneous nephrolithotomy (pcnl). this procedure is now recommended as the first option for the treatment of single large or multiple renal stones and those in the inferior calyx. this study was done to assess the complications of pcnl and their management, in our centre. methods: medical records of 144 patients who underwent pcnl at lumbini medical college teaching hospital, during the last one year were reviewed. the demographic data, size, tract number and location of the calculi, and intraoperative and postoperative complications were evaluated. the various parameters of the calculi were evaluated. descriptive analysis with frequencies was done. results: complications occurred in 13 (9.02%) patients. post operative bleeding occurred in seven (4.8%) patients, out of which one patient developed pseudoaneurysms and the other developed arteriovenous fistula. one patient developed hypovolemic shock immediately after surgery. frequent blockage of urine, excessive drainage of urine from the drain site, hemothorax and colonic perforation was seen in one patient each. one patient had mortality due to post operative bleeding. complications increased with the number and size of stones and number and site of the tracts. conclusion: percutaneous nephrolithotomy has low complication rate in experienced hands and complications depend upon stone size, history of open stone surgery, tract number, and tract location. keywords: complications • minimally invasive • nephrolithiasis • nephrostomy • percutaneous ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, b associate professor c professor d department of surgery, lumbini medical college, nepal e department of radiodiagnosis, lumbini medical college, nepal corresponding author: dr. neeraj thapa e-mail: drneerajthapa@gmail.com how to cite this article: thapa n. complications of percutaneous nephrolithotomy and their management: experience from a single centre. journal of lumbini medical college. 2015;3(2):30-3. doi: 10.22502/jlmc.v3i2.67. ___________________________________________________________________________________ j. lumbini. med. coll. vol 3, no 2, july-dec 2015 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v3i2.67 introduction: increasing global prevalence of nephrolithiasis continues to burden the healthcare delivery systems of industrialized nations and exact a disproportionate humanitarian toll on populations of the developing world.1 in the united states alone, the prevalence of nephrolithiasis is nearly twice the rate reported in the 1960s.2-5 the subsequent rise in surgical interventions for nephrolithiasis has resulted in the development of new minimally invasive technologies and techniques, but it has also led to the resurgence of established methods such as percutaneous nephrolithotomy (pcnl). percutaneous entry into the renal collecting system was first described in the 1950s, but it was not until later that percutaneous access to the renal collecting system was routinely utilized for the removal of nephrolithiasis.6-8 pcnl was established as a minimally invasive treatment option for removal of kidney stones in the 1970s and was further developed in the ensuing years.9-11 today, this procedure should be the first option for the treatment of single large or multiple renal stones and those in the inferior calyx.12 percutaneous stone removal was suggested as the first line treatment option for the management of staghorn calculi by the american urological association nephrolithiasis clinical guidelines panel.13 30 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 thapa n. et al. complications of percutaneous nephrolithotomy and their management: experience from a single centre. jlmc.edu.np although pcnl initially proved to be an effective technique, the near-concurrent introduction of shockwave lithotripsy (swl) resulted in a rapid and marked decrease in the utilization of pcnl.14 there has been, however, a recent increase in the utilization of pcnl, largely attributed to the limitations of newer swl equipment, an increase in stone prevalence, and the refinement of pcnl indications, techniques, and instrumentation.15-19 although percutaneous renal surgery is less invasive than an open procedure, complications may occur. "percutaneous nephrolithotomy is a successful (> 90%), less invasive surgery at the cost of greater complications (> 10%)".20,21 there are some complications that may be predictable or unpredictable, such as hemorrhage, collecting system injuries, contiguous organ injuries, intra-operative technical complications, hypothermia, fluid overload, sepsis, stricture formation, nephrocutaneous fistula, renal loss, and death.20,22 in this study we evaluated the occurrence and types of complications and their associated factors with special attention to bleeding and adjacent organ injuries. methods: this retrospective descriptive study was done form 1st of june, 2015 to 30th of september, 2015 in lumbini medical college teaching hospital. medical records of all the patients who underwent pcnl from june 2014 to may 2015 were reviewed. ethical approval was granted by the institutional review committee. patients with comorbidities, like hypertension, diabetes mellitus, copd, asthma, coronary artery disease, were excluded from the study. all these parameters were noted from the patients’ medical records along with the demographic data, size of renal calculi, number and location of renal calculi, location and number of tracts, duration of surgery, complications and duration of hospital stay. the collected data were analyzed with spss-13. technique of pcnl: all the patients presenting for pcnl were admitted a night before surgery and following tests were done: hemoglobin, ultrasonography of abdomen and pelvis, x-ray kub and intravenous pyelography. patients underwent standard pcnl. in lithotomy position, ureteric catheter was inserted in the kidney to be punctured. foley catheter was inserted and patient was changed to prone position. in this position, kidney was punctured under c-arm guidance after the retrograde instillation of radiopaque dye through ureteric catheter. commonly, the posteroinferior or the posterosuperior calyx was punctured. stones were fragmented using a pneumatic lithotripter and extracted out using forceps. dj stenting was done in all cases and drain was kept as deemed necessary. drain if kept, was removed on the second post operative day and the patients were usually discharged on the third post-operative day in uneventful cases. dj stent was removed after six weeks. results: a total of 144 patients underwent pcnl, out of which there were 70 (48.6%) men and 74 (51.4%) women. the mean duration of the operation was 40 minutes (sd=9.3). the mean post operative stay was three days (sd=3.7). the affected kidney was right side in 78 (55%) and the left in 66 (45%) cases. no pcnl was done for chronic renal failure and no open conversion was done in any of the patients. complications occurred in 13 (9.02%) patients. post operative bleeding occurred in seven (4.8%) patients and they underwent blood transfusion. one of them developed pseudoaneurysms and was referred to higher centre for angio-embolization. another patient developed arteriovenous fistula and underwent the same. one patient developed hypovolemic shock immediately after surgery and was managed promptly with intravenous fluids and blood transfusion. another patient had frequent blockage of urine and underwent bladder wash along with observation for four days which was sufficient for his recovery. one patient had excessive drainage of urine from the drain site and recovered after three days of observation. one patient developed hemothorax and was managed with the placement of chest tube. one patient had colonic perforation and underwent laparotomy on the sixth postoperative day and recovered completely. one patient had postoperative bleeding in the first day was managed with nephrectomy along with intensive care. on the 3rd postoperative day, the patient expired secondary to the development of disseminated intravascular coagulation and renal failure with metabolic acidosis. other details about the type of cases and complications in each type is presented in table 1. discussion: significant complications in pcnl can be attributed to incorrect patient selection, the lack of adequate equipment and technical errors. the 31 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 jlmc.edu.np thapa n. et al. complications of percutaneous nephrolithotomy and their management: experience from a single centre. disease variables n complications upper calyx 3 1 middle calyx 12 0 lower calyx 21 3 pelvic 78 2 multiple calyx 30 7 stone size <2cm 96 4 >2cm 42 6 staghorn 6 3 hydronephrosis absent 16 1 mild 71 6 moderate 41 5 severe 16 1 history of open stone surgery yes 1 1 no 143 12 tract number one 141 10 two 3 3 tract location supracostal 3 1 infracostal 140 11 both 1 1 table 1: disease variables and complications. percentage of complication in our series is less than the rate of complications found in literatures. lesser number of extravasation could be due to correct dilatation with metallic dilators. the lower rate of haemorrhage could be attributed to ultrasound and radiology guided puncture. although open stone surgery is needed for some specific renal stones, no open conversion occurred in our patients. in a study by lee and colleagues on 500 patients who underwent pcnl, the most common complication was bleeding, with a 12% transfusion rate.23 renal hemorrhage is the most worrisome and frequent complication of pcnl, which has been often addressed.24 however, severe bleeding leading to complications, such as hypovolemic shock or renal failure, may occur in less than 3% of patients.25-27 in our study also the most common complication was bleeding which was about 4.8%. the probability of vascular lesions increases when the nephrostomy tract passes close to the renal hilus or goes directly posteriorly to it. the high pressure system of a lacerated artery will leak into the lower pressure system of a vein or parenchyma leading to arteriovenous fistula or pseudoaneurysm formation, respectively. in our study there were two patients with such vascular complications. excessive bleeding during pcnl can be managed by some maneuvers, like placement of a larger nephrostomy tube, nephrostomy tube clamping, hydration, and balloon tamponade. the bleeding is mainly venous in origin and can be controlled with the above maneuvers. occurrence of vascular lesions depends mainly on the total number of punctures. it would be logical that decreasing the total number of punctures would reduce the risk of damage to the renal vasculature.28,29 the risk of injury to the pleura and lung increases (10%) if the puncture is above the 12th rib.30 if puncture is through the pleura, a chest tube has to be inserted for prevention of hydrothorax or hemothorax. rate of pleural injury in our study was 0.69% i.e one patient, which only occurred with the supracostal access and was controlled with chest tube insertion. several risk factors contribute to the colonic injury during pcnl, such as left-sided procedure, an extremely lateral percutaneous nephrostomy tract, horseshoe kidney, advanced patient’s age, distended colon, an associated colon obstruction, a hypermobile kidney, a retro-renal colon, and extremely thin patients.31,32 perforation of the colon can be seen in less than 1% of subjects.33 in our study colonic perforation was seen in one patient. complications were associated with multiple punctures and tract formation with larger or multiple stones. one patients who was previously operated on the same side, had two stones, each two cm in size. this patient underwent multiple tract formation i.e. both supracostal and infracostal, and had mortality. septicemia may be due to introduction of infection via the access tract to the kidney or due to working on the infected stones. following pcnl, fever is significantly higher and more frequent in patients with infected urinary stones than in those with sterile stones.30,34.therefore, prophylactic antibiotics and drainage of a pyonephrotic kidney is mandatory prior to pcnl.30 antibiotics can be applied as single-dose or short-course with no significant differences between these two regimes in the occurrence of postoperative infections.25,35 the total time of procedure and the amount of irrigation fluid are major risk factors for occurrence of postoperative fever.30,36 it is important to preserve 32 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 thapa n. et al. complications of percutaneous nephrolithotomy and their management: experience from a single centre. jlmc.edu.np low pressure in the collecting system and keep the duration of surgery to minimum (< 90 minutes).30 conclusion: based on our findings, percutaneous nephrolithotomy has a low complication rate in experienced hands and good equipments. pcnl complications are related to stone burden, stone location and the type of access. 1. romero v, akpinar h, assimos dg. kidney stones: a global picture of prevalence, incidence, and associated risk factors. rev urol. 2010;12:86-96. 2. curhan gc, rimm eb, willett wc, et al. regional variation in nephrolithiasis incidence and prevalence among united states men. j urol. 1994;151:838-41. 3. stamatelou kk, francis me, jones ca, et al. time trends in reported prevalence of kidney stones in the united states: 1976-1994. kidney int. 2003;63:1817-23. 4. soucie jm, thun mj, coates rj, mcclellan w, austin h. demographic and geographic variability of kidney stones in the united states. kidney int. 1994;46:893-9. 5. hiatt ra, dales lg, friedman gd, hunkeler em. frequency of urolithiasis in a prepaid medical care program. am j epidemiol. 1982;115:255-65. 6. ogg cs, saxton hm, cameron js. percutaneous needle nephrostomy. br med j. 1969;4:657-60. 7. fernström i, johansson b. percutaneous pyelolithotomy. a new extraction technique. scand j urol nephrol. 1976;10:2579. 8. badlani g, eshghi m, smith ad. percutaneous surgery for ureteropelvic junction obstruction (endopyelotomy): technique and early results. j urol. 1986;135:26-8. 9. alken p, hutschenreiter g, guenther r. percutaneous kidney stone removal. eur urol. 1982;8:304–11. 10. segura jw, patterson de, leroy aj, williams hj jr, barrett dm, benson rc jr,. percutaneous removal of kidney stones: review of 1,000 cases. j urol. 1985;134:1077–81. 11. rassweiler j, gumpinger r, miller k, ho¨lzermann f, eisenberger f. multimodal treatment (extracorporeal shock wave lithotripsy and endourology) of complicated renal stone disease. eur urol. 1986;12:294–304. 12. lingeman je, newmark jr, wong my. classification and management of staghorn calculi. smith ad, ed. controversies in endourology. philadelphia: saunders; 1995:136-44. 13. liatsikos en, kapoor r, lee b, jabbour m, barbalias g, smith ad. “angular percutaneous renal access”.multiple tracts through a single incision for staghorn calculous treatment in a single session. eur urol. 2005;48:832-7. 14. auge bk, preminger gm. update on shock wave lithotripsy technology. curr opin urol. 2002;12:287-90. 15. aboumarzouk om, kata sg, keeley fx, nabi g. extracorporeal shock wave lithotripsy (eswl) versus ureteroscopic management for ureteric calculi. cochrane database syst rev. 2012;5:cd006029. 16. rassweiler j, sentker l, seemann o, hatzinger m, stock c, frede t. heilbronn laparoscopic radical prostatectomy. technique and results after 100 cases. eur urol. 2001 jul;40(1):54-64. 17. morris ds, wei jt, taub da, dunn rl, wolf js jr, hollenbeck bk . temporal trends in the use of percutaneous nephrolithotomy. j urol. 2006 may;175(5):1731-6. 18. alivizatos g, skolarikos a. is there still a role for open surgery in the management of renal stones? curr opin urol. 2006 mar;16(2):106-11. 19. skolarikos a, alivizatos g, de la rosette jj. percutaneous nephrolithotomy and its legacy. eur urol. 2005 jan;47(1):22-8. 20. turna b, nazli o, demiryoguran s, mammadov r, cal c. percutaneous nephrolithotomy: variables that influence hemorrhage. urology. 2007 apr;69(4):603-7. 21. fuchs gj, yurkanin jp. endoscopic surgery for renal calculi. curr opin urol. 2003 may;13(3):243-7. 22. assimos dg. complications of stone removal. in: marshall l, stoller md, smith ad (eds). smith’s textbook of endourology. st. louis: quality medical publishing; 1996:p.298-308. 23. lee wj, smith ad, cubelli v, vernace fm. percutaneous nephrolithotomy: analysis of 500 consecutive cases urol radiol. 1986;8(2):61-6. 24. srivastava a, singh kj, suri a, dubey d, kumar a, kapoor r, et al. vascular complications after percutaneous nephrolithotomy: are there any predictive factors? urology. 2005 jul;66(1):38-40. 25. gallucci m, fortunato p, schettini m, vincenzoni a. management of hemorrhage after percutaneous renal surgery j endourol. 1998 dec;12(6):509-12. 26. carson cc, brown mw, weinerth jl. vascular complications of percutaneous renal surgery j endourol. 2009 mar;1(3):1817. doi:10.1089/end.1987.1.181. 27. osman m, wendt nordahl g, heger k, michel ms, alken p, knoll t. percutaneous nephrolithotomy with ultrasonographyguided renal access: experience from over 300 cases. bju int. 2005;96(6):875-8. 28. patterson de, segura jw, leroy aj, benson rc jr, may g. the etiology and treatment of delayed bleeding following percutaneous lithotripsy. j urol. 1985 mar;133(3):447-51. 29. kessaris dn, bellman gc, pardalidis np, smith ag. management of hemorrhage after percutaneous renal surgery. j urol. 1995 mar;153(3 pt 1):604-8. 30. michel ms, trojan l, rassweiler jj. complications in percutaneous nephrolithotomy. eur urol. 2007 apr;51(4):899906. 31. juan ys, huang ch, chuang sm, shen jt, li cc, wang cj, et al. colon perforation: a rare complication during percutaneous nephrolithotomy. kaohsiung j med sci. 2006 feb;22(2):99-102. 32. el-nahas ar, shokeir aa, el-assmy am, shoma am, eraky i, el-kenawy mr, et al. colonic perforation during percutaneous nephrolithotomy: study of risk factors. urology. 2006 may;67(5):937-41. 33. vallancien g, capdeville r, veillon b, charton m,brisset jm. colonic perforation during percutaneous nephrolithotomy. j urol. 1985 dec;134(6):1185-7. 34. takeuchi h, ueda m, nonomura m, hida s, oishi k, higashi y, et al. [fever attack in percutaneous nephrolithotomy and transurethral ureterolithotripsy]. hinyokika kiyo. 1987;33:1357-63. 35. moslemi mk, movahed sm, heidari a, saghafi h, abedinzadeh m. comparative evaluation of prophylactic single-dose intravenous antibiotic with postoperative antibiotics in elective urologic surgery. ther clin risk manag. 2010;6:551-6. 36. dogan hs, sahin a, cetinkaya y, akdogan b, ozden e, kendi s. antibiotic prophylaxis in percutaneous nephrolithotomy: prospective study in 81 patients. j endourol. 2002;16:649-53. references: 33 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 kamble vk, et al. unilateral phthiriasis palpebrarum infestation: a rare presentationkamble vk, et al. unilateral phthiriasis palpebrarum infestation: a rare presentation 281 jlmc.edu.np ___________________________________________________________________________________ submitted: 20 august, 2020 accepted: 21 december, 2020 published: 29 december, 2020 a consultant ophthalmologist, b optometrist, c sagarmatha choudhary eye hospital, lahan, siraha, nepal. corresponding author: vinit kumar kamble e-mail: dr.vinitkumarkamble@gmail.com orcid: https://orcid.org/0000-0003-4170-0954_______________________________________________________ abstract: introduction: phthiriasis palpebrarum is an uncommon eyelid infestation mainly caused by phthirus pubis also known as crab lice. case report: a 16 years male presented with redness, itching and watering of the right eye for one week. on slit-lamp biomicroscopic examination lice and nits anchored to the eyelashes along with seborrheic material accumulation was noted. lice, partial nits along with matted eyelashes were removed and sent to laboratory for microscopic examination. on follow up visit remaining nits were expunged. conclusion: meticulous slit lamp biomicroscopic examination should be done in all patients presenting with itching of the eyelids in conjunction with clinical findings resembling seborrhea and evidence for phthiriasis palpebrarum should be looked for. keywords: crab louse, nits, phthiriasis palpebrarum, pruritus, seborrheic case reporthttps://doi.org/10.22502/jlmc.v8i2.398 vinit kumar kamble,a,c sharad gupta,a,c reena yadav,a,c sanjay kumar singh,a,c bipin bista,a,c nirajan sahb,c unilateral phthiriasis palpebrarum infestation: a rare presentation how to cite this article:how to cite this article: kamble vk, gupta s, yadav r, singh sk, bista b, sah n. unilateral kamble vk, gupta s, yadav r, singh sk, bista b, sah n. unilateral phthiriasis palpebrarum infestation: a rare presentation. journal phthiriasis palpebrarum infestation: a rare presentation. journal of lumbini medical college. 2020;8(2):281-283. doi: of lumbini medical college. 2020;8(2):281-283. doi: https://doi. org/10.22502/jlmc.v8i2.398. epub: 2020 december 29. epub: 2020 december 29. introduction: phthiriasis palpebrarum is a rare type of eyelid infestation caused by phthiriasis pubis, commonly known as crab lice.[1] it mainly infests the hair of pubic and inguinal regions, but rarely infests the eye lashes and eyelids.[1] the condition is commonly seen in developing countries and is associated with poor hygiene and overcrowding. [2] these conditions may sometimes be mistaken as blepharitis or blepharo-conjunctivitis due to similarities in the signs and symptoms.[3] various treatment options with varying efficacy are available. few literatures reported that mode of transmission of lice are from one hair bearing area to another and found that any hair bearing area may become infested.[4] here we report an unusual case of phthiriasis palpebrarum infestation of the right upper eyelid. case report: a 16-years-old male presented to our outpatient department with chief complaints of itching and watering of the right eye for one week. on examination the best corrected visual acuity was 6/6 in both eyes. slit lamp bio-microscopic examination of the right upper eyelid showed numerous, translucent, white nits along with multiple mobile, semi-transparent lice of different sizes adherent at the base of eyelashes (fig. 1a and b) whereas lower eyelid and eyelashes were unremarkable. the left eye was normal. he did not give history of similar illness to his family members. he was a student from poor socio-economic background. the pubic and inguinal regions were also examined where no signs of lice infestation were noted. eyelashes, lice and partial removal of nits were done with use of forceps and the specimens were sent for microscopic examination where the lice of phthiriasis pubis and nits were confirmed (fig. 2). complete removal of nits was not attempted due to the risk of bleeding. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 kamble vk, et al. unilateral phthiriasis palpebrarum infestation: a rare presentationkamble vk, et al. unilateral phthiriasis palpebrarum infestation: a rare presentation 282 jlmc.edu.np the patient was advised to apply pilocarpine 4% gel twice daily over the lid margins and asked to review after seven days. the dermatological consultations for the patient and family members were advised but they refused. on follow up all signs and symptoms had resolved and the remaining nits were removed. the recurrence was not seen in six months follow up period. he was advised to maintain eyelid hygiene (figure 3). discussion: phthiriasis palpebrarum is an uncommon cause for pruritus still seen in developing countries with poor personal hygiene. pthiriasis palpebrarum is characterized by infestation of eyelashes with pthirus pubis also considered as a sexually transmitted disease (std).[5] the primary habitat of phthiriasis pubis is pubic hair but in severe infestations, the hair of axilla, chest, eyebrow and eyelashes are also involved.[1,6,7,8] phthiriasis pubis is a member of hematophagous ectoparasites. [2,9] it belongs to the phylum arthropoda, the class insecta and the order phthiraptera. beside this, other two species of lice known to infest humans are pediculus humanus capitis (head louse) and pediculus humanus corporis (body louse).[10] pthirus pubis is an entirely different species with a distinctive morphology and habitat. adult pubic louse is wingless, approximately 1–2 mm in size with a broad, flat and oval translucent body through which freshly ingested blood can be visualised. the body is crab-like which is divided into the head, thorax and abdomen, with three pairs of short, stout legs and powerful claws, which enable them to grasp hair shafts tightly.[11] clinically patient infested with phthiriasis palpebrarum present with pruritus, conjunctival hyperemia and preauricular lymphadenopathy due to secondary infection at the site of louse bites.[1] there are multiple treatment options available like trimming of eyelashes or mechanical removal, 4% pilocarpine gel, oral fig.1. a: magnified view of multiple nits in right upper eyelid figure. b: magnified view of crab louse. fig.3. complete removal of lice and nits. fig.2. microscopic appearance of crab louse and nits j. lumbini. med. coll. vol 8, no 2, july-dec 2020 kamble vk, et al. unilateral phthiriasis palpebrarum infestation: a rare presentationkamble vk, et al. unilateral phthiriasis palpebrarum infestation: a rare presentation 283 jlmc.edu.np ivermectin, 20% fluorescein eye drops, argon laser or cryotherapy.[1,3,12] in our report eyelashes, lice and partial removal of nits were done with forceps and advised to apply 4% pilocarpine gel over lid margins. on follow up, all the signs and symptoms had resolved and the remaining nits were removed. conclusion: phthiriasis palpebrarum infestation is an unusual cause of pruritus. it is mandatory to do meticulous slit lamp biomicroscopic examination in all patients presenting with itching of the eyelids along with clinical findings resembling seborrhea accumulation on the eyelashes to avoid misdiagnosis in cases where blepharitis is considered. a clinical follow up of every patient is recommended to rule out residual parasitic infestation and clinical response to therapy. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. references: 1. anane s, malek i, kamoun r, chtourou o. phthiriasis palpebrarum: diagnosis and treatment. j fr ophthalmol. 2013;36(10);815-9. pmid: 24157356. doi: https://doi.org/10.1016/j. jfo.2013.03.018 2. ryan mf. phthiriasis palpebrarum infection: a concern for child abuse. j emerg med. 2014;46(6):e15962. pmid: 24556565. doi: https://doi.org/10.1016/j.jemermed.2013.11.090 3. yi jw, li l, luo da w. phthiriasis palpebrarum misdiagnosed as allergic blepharoconjunctivitis in a 6-year-old girl. niger j clin pract. 2014;17(4):537-9. pmid: 24909484. doi: https://doi.org/10.4103/1119-3077.134063 4. lacarrubba f, micali g: the not-so-naked eye: phthiriasis palpebrarum. the american journal of medicine. 2013;126(11):960-1. doi: http:// dx.doi.org/10.1016/j.amjmed.2013.08.002 5. charfi f, ben zina z, maazoun m, kharrat w, sellami d, makni f, et al. [phthiriasis pubis palpebrarum in children. diagnosis and treatment]. j fr ophtalmol. 2005;28 (7):765-8. pmid: 16208228. doi: https://doi.org/10.1016/ s0181-5512(05)80990-8 6. dohvoma va, ebana mvogo sr, atangana pja, nyasse p, epee e, ebana mvogo c. phthirus pubis infestation of the eyelids presenting as chronic blepharoconjunctivitis in a 6-year-old girl: a case report. case rep ophthalmol. 2018;9(1):30-34. pmid: 29643778. doi: https://doi.org/10.1159/000485738 7. le guyader f, charpentier p. [phthiriasis palpebrarum in a 52-year-old woman]. j fr ophtalmol. 2018;41(2):196198. pmid: 29426762. doi: https://doi. org/10.1016/j.jfo.2017.08.005 8. gupta m, gupta a. phthiriasis palpebrarum masquerading as seborrheic blepharitis. australas jtol. 2016;57(4):e139-e140. pmid: 29896824. doi: https://doi.org/10.1111/ajd.12378 9. padhi tr, das s, sharma s, rath s, rath s, tripathy d, et al. ocular parasitoses: a comprehensive review. surv ophthalmol. 2017;62(2):161-89. pmid: 27720858. doi: https://doi.org/10.1016/j. survophthal.2016.09.005 10. karabela y, yardimci g, yildirim i, atalay e, kerabela sn. treatment of phthiriasis palpebrarum and crab louse: petrolatum jelly and 1% permethrin shampoo. case reports in medicine. 2015;2015:article id 287906. doi: https://doi.org/10.1155/2015/287906 11. sundu c, dinç e, kurtuluş uc, yıldırım ö. common blepharitis related to phthiriasis palpebrarum: argon laser phototherapy. turkiye parazitol derg. 2015;39(3):252-4. pmid: 26470938. doi: https://doi.org/10.5152/ tpd.2015.3861 12. elston dm. drugs used in the treatment of pediculosis. j drugs dermatol. 2005;4(2):20711. pmid: 15776778 j. lumbini. med. coll. vol 9, no 1, jan-june 2021 tuladhar lr, et al. comparative study on effects of 2% lidocaine hydrochloride with adrenaline (1:200000) on blood pressure among controlled hypertensive and non-hypertensive patients during dental anesthesia jlmc.edu.np ___________________________________________________________________________________ submitted: 22 january, 2021 accepted: 19 april, 2021 published: 02 may, 2021 aassistant professor, department of pharmacology blecturer, department of oral and maxillo-facial surgery clecturer, department of general surgery dassistant professor, department of biochemistry enepal medical college teaching hospital, kathmandu, nepal. fmaharajgunj medical campus, kathmandu, nepal. corresponding author: lujaw ratna tuladhar e-mail: lujaw3@gmail.com orcid: https://orcid.org/0000-0002-1626-1104_______________________________________________________ abstract: introduction: local anesthetic used for dental extraction is 2% lidocaine hydrochloride with adrenaline (1:200000). lidocaine is cardiac depressant and adrenaline is cardiac stimulant; it decreases or increases blood pressure respectively. methods: a total of 100 patients (50 controlled hypertensive and 50 nonhypertensive) were selected. the study was conducted over a period of 14 months from january 2020 to february 2021. blood pressure was measured for patients who were planned for dental extraction by auscultatory method. following that, 1.5-3 ml (depending upon the nerve block) 2% lidocaine with adrenaline (1:200000) was injected using 3ml syringe (26 gauge). blood pressure was re-recorded after 10 minutes from the time of injection. visual analog scale pain score was obtained during administration of local anesthesia. paired t-test was applied to compare blood pressure change before and after administration of local anesthesia in controlled hypertensive and non-hypertensive patients. results: there was a statistically significant increase in both systolic and diastolic blood pressure in non-hypertensive patients (p = 0.008, p = 0.017). this, however, was not the case with controlled hypertensive patients. there was statistically significant increase in systolic blood pressure (p < 0.001). pain on injection (50% in non-hypertensive and 48% in controlled hypertensive patients) was the only adverse drug reaction that was reported in both groups. conclusion: 2% lidocaine hydrochloride with adrenaline (1:200000) increased systolic but not diastolic blood pressure in controlled hypertensive patients. keywords: adrenaline; adverse drug reaction; anesthesia, dental; hypertension; lidocaine original research articlehttps://doi.org/10.22502/jlmc.v9i1.415 lujaw ratna tuladhar,a,e meen bahadur budhathoki,b,e anjali bhattarai,b,e kushal bimb,b,e nikhil acharya,c,e eans tara tuladhar d,f comparative study on effects of 2% lidocaine hydrochloride with adrenaline (1:200000) on blood pressure among controlled hypertensive and nonhypertensive patients during dental anesthesia how to cite this article:how to cite this article: tuladhar lr, budhathoki mb, bhattarai a, bimb k, acharya n, tuladhar et. comparative study on effects of 2% lidocaine hydrochloride with adrenaline (1:200000) on blood pressure among controlled hypertensive and non-hypertensive patients during dental anesthesia. journal of lumbini medical college. 2021;9(1):6pages. doi: https://doi.org/10.22502/jlmc.v9i1.415. epub: may 2, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: local anesthetics used during tooth extraction are 2% lidocaine hydrochloride with adrenaline (1:200000) and 2% plain lidocaine.[1,2] they decrease the unpleasant feeling of pain, however, studies have reported the use of plain lidocaine to generate more pain compared to lidocaine with adrenaline.[3,4,5] lidocaine has cardiac depressant action whereas adrenaline has cardiac stimulant action that can either decrease or increase blood pressure (bp) respectively.[6,7] bp is an important cardiovascular parameter that is measured prior to dental extraction. [8] the normal bp is ≤120/80 mm of hg and hypertensive patients have bp of greater than 120/80mm of hg.[9] the objective of our study was to observe the effect of 2% lidocaine hydrochloride with adrenaline j. lumbini. med. coll. vol 9, no 1, jan-june 2021 tuladhar lr, et al. comparative study on effects of 2% lidocaine hydrochloride with adrenaline (1:200000) on blood pressure among controlled hypertensive and non-hypertensive patients during dental anesthesia jlmc.edu.np (1:200000) on blood pressure among controlled hypertensive and non-hypertensive patients during dental anesthesia. methods: it was a hospital based cross sectional study conducted in the department of oral and maxillofacial surgery, college of dental science, nepal medical college teaching hospital (nmcth). ethical approval was obtained from institutional review committee of nmcth, kathmandu. the study was commenced from january 2020 to february 2021 for the duration of 14 months. sample size was calculated taking the reference to the study conducted by chaudhry s as follows.[10] sample size (n)= z2σ2/d2 where z (standard normal value at 95% confidence interval) = 1.96; σ2 (variance)= 11.082 = 122.76; d (margin of acceptable error)=136.66-133.33= 3.33[10] n= 42.53 ≈ 43. however, 50 patients were taken in each group. the total estimated sample size for the current study was taken as 100 (50 controlled hypertensive and 50 non-hypertensive patients). patients were explained about the procedure and informed consent was obtained. for participants under the age of 18 years, consent was obtained from accompanying guardian. controlled hypertensive (121-139/81-89 mmhg) and non-hypertensive (≤120/80 mm hg) patients from the age of 16 years and above whose treatment was planned for dental extraction were included in this study. hypertensive patients with uncontrolled blood pressure (≥140/90mm hg) or patients not under anti-hypertensive medication were excluded from the study. patients diagnosed with other co-morbid conditions like hyperthyroidism, angina, myocardial infarction, stroke, epilepsy, diabetes and allergic reaction to lidocaine were also excluded to avoid drug interactions. patients were asked to relax for five minutes in supine position in the dental chair. prior to administration of local anesthetic, blood pressure was measured using conventional validated and calibrated microlife® sphygmomanometer and microlife® stethoscope using auscultatory method. following that, 2% lidocaine with adrenaline (1:200000) (xicaine®) was administered using a disposable aspirating type 3ml single use syringe. anesthetic solution (1.5-3 ml) was deposited slowly at the rate of 1 ml per minute. blood pressure was re-recorded after 10 minutes from the time of injection. visual analog scale pain score rating (0-no hurt, 2-hurt little bit, 4-hurt little more, 6hurt even more, 8hurt whole lot, 10hurt worse) was obtained during administration of local anesthesia. the entire procedure was done by the team of intern doctors under the supervision of the researchers. statistical analysis was done by using statistical package for social sciences (spss) version 16. categorical variables were presented as frequency and age was presented as mean and standard deviation. paired t-test was applied to compare mean of bp changes before and after the administration of local anesthesia in controlled hypertensive and non-hypertensive patients. p value less than 0.05 was considered as statistically significant. results: a total of 100 patients were included in the study; 50 controlled hypertensive patients (male = 13, female = 37) and 50 non-hypertensive patients (male = 29, female = 21). the mean age of the controlled hypertensive group was 59.06 ± 8.45 years and non-hypertensive group was 44.22 ± 15.25 years. fifty percent (28% had grade 2, 12% had grade 4 and 10% had grade 6) of the non-hypertensive patients and forty eight percent (36% had grade 2 and 12% had grade 4) of the controlled hypertensive patients complained of pain during administration of local anesthetic. there was a statistically significant increase in systolic (t = -2.775, df = 49, p = 0.008) and diastolic (t = -2.473, df = 49, p = 0.017) bp after administration of lidocaine with adrenaline in nonhypertensive patients though this was not the case with controlled hypertensive patients. we also observed highly significant increase in systolic blood pressure (t = -3.932, df = 49, p < 0.001) but no change in diastolic blood pressure (t = 0.53, df = 49, p = 0.958) in the controlled hypertensive group as shown in table 1. discussion: j. lumbini. med. coll. vol 9, no 1, jan-june 2021 tuladhar lr, et al. comparative study on effects of 2% lidocaine hydrochloride with adrenaline (1:200000) on blood pressure among controlled hypertensive and non-hypertensive patients during dental anesthesia jlmc.edu.np the aim of this study was to analyze the effect of 2% lidocaine with adrenaline (1:200000) on bp in controlled hypertensive and non-hypertensive patients during dental anesthesia. dental anesthesia minimizes pain and prevents endogenous catecholamine release that can trigger hemodynamic change like alteration in bp and heart rate.[11] the most widely used local anesthetic for dental anesthesia is lidocaine.[12] lidocaine primary acts by blocking voltage gated inactivated sodium channel.[13] it also possesses additional cardiac depressant action which can decrease bp.[14]the benefits of lidocaine with adrenaline combination are: it slows the rate of absorption, lower systemic blood levels, delays cresting of peak blood level, prolongs duration of anesthesia, intensifies depth of anesthesia, provides bloodless field during procedure and reduces incidence of systemic reactions.[7] the onset of action of lidocaine with adrenaline is five minutes.[7] the most preferred concentration of local anesthetic for dental procedure is 2% lidocaine hydrochloride with adrenaline (1:200000).[12] 1 ml of it contains 2 mg lidocaine and 0.005mg adrenaline, a maximum of 3 ml will contain 6mg lidocaine and 0.015 mg adrenaline.[7] studies have shown the maximum recommended dose for lidocaine is 500 mg and maximum dose for adrenaline that can be used 0.04mg.[7] adrenaline has biphasic response i.e. at high concentration it increases bp due to vasoconstriction (α1 receptor stimulation) whereas at low concentration it decreases bp due to vasodilation (β2 receptor stimulation).[15] therefore, lidocaine with adrenaline combination can either increase bp or decrease bp depending on the plasma concentration of the respective drug. there are various methods of measuring bp among which oscillometric and auscultatory methods are considered acceptable.[16] although auscultatory method using mercury sphygmomanometer is regarded as the “gold standard” for blood pressure measurement, wide spread implementation on banning mercury diminished its role by this technique. [17] calibrated aneroid sphygmomanometer has better accuracy than digital and should be used for proper and better management.[18] american college of cardiology/ american heart association (acc/aha) hypertension guideline has categorized blood pressure of 130-139/80-89 as grade 1[19] and american society of anesthesiologists (asa) physical status classification system (asaps) have classified a patient with a mild systemic disease e.g. treated hypertension as asa 2.[20] according to international guideline the use of local anesthetic containing adrenaline is safe in patients with controlled hypertension but there are studies that recommend use of plain lidocaine.[21] pannerselvam e et al. in his study reported that patients who received plain lidocaine perceived less pain during injection of anesthetic solution when compared to patients who received lidocaine with vasoconstrictor. he also reported that post-operative wound healing was better in patients anesthetized by plain lidocaine.[2] in another study conducted by kalra p et al. reported that lidocaine with adrenaline should be used with caution in diabetic patients as adrenaline suppresses the release of insulin leading table 1: mean blood pressure (bp) before and after administration of local anesthetic with adrenaline in controlled hypertensive and non-hypertensive patients. case types of bp mean ± sd of bp before and after administration of la mean difference ± sd 95% confidence interval t-value df p value before after upper lower nonhypertensive patients systolic 117.16 ± 7.62 120.98 ± 10.96 -3.82 ± 9.73 -6.59 -1.05 -2.78 49 0.008 diastolic 75.08 ± 6.55 78.16 ± 10.68 -3.08 ± 8.80 -5.58 -0.577 -2.47 49 0.017 controlled hypertensive patients systolic 133.68 ± 8.34 139.16 ± 9.18 -5.48 ± 9.85 -8.28 -2.68 -3.93 49 <0.001 diastolic 84.60 ± 5.61 84.56 ± 7.27 0.04 ± 5.30 -1.55 1.55 0.53 49 0.958 *la: local anaesthetic, *sd: standard deviation j. lumbini. med. coll. vol 9, no 1, jan-june 2021 tuladhar lr, et al. comparative study on effects of 2% lidocaine hydrochloride with adrenaline (1:200000) on blood pressure among controlled hypertensive and non-hypertensive patients during dental anesthesia jlmc.edu.np to increase in blood glucose level.[22] similarly muntaha s et al. in his study reported that 2% lidocaine with adrenaline is widely used but it should be cautiously used in diabetic patients.[12] a study conducted by chardhry s et al. in hypertensive and non-hypertensive patients reported decrease in systolic and diastolic bp after two and five min of injection. the volume of 2% lidocaine with adrenaline (1:100000) deposited was 3.6 ml that contained 0.036 mg adrenaline.[10] cardiac depressant action of lidocaine and low concentration of adrenaline stimulated beta-2 receptor on the blood vessel leading to vasodilation and drop in blood pressure. the study did not report any adverse drug reaction.[10] a study conducted by karm m et al. observed increase in systolic bp (9.3 ± 7 .3 mm hg) but decrease in diastolic bp (–8.4 ± 6.6 mm hg) with 2% lidocaine with 1:200000 adrenaline. [23] the study also reported that 2% lidocaine with 1:200000 adrenaline has better safety with regard to hemodynamic parameters than 2% lidocaine with 1:80000 adrenaline.[23] another study conducted by kyosaka y et al. observed increase in systolic blood pressure at the end of la injection and decrease in diastolic blood pressure after 5 and 10 minutes of la injection in participants on anti-hypertensive drugs. the local anesthetic used in this study was 2% lidocaine with 1:80000 adrenaline.[24] therefore, different studies have reported different results. this variation in result could be due to difference in volume and concentration of lidocaine and adrenaline, age of patient, co-morbidities, medication and types of nerve block (1.2ml for infraorbital nerve block, 1.8ml for posterior superior alveolar nerve block, 1.8 ml for inferior alveolar nerve block, 0.6ml for greater palatine nerve block, 0.4ml for naso-palatine nerve block).[7] in our study, we observed the effect of 2% lidocaine with 1:200000 adrenaline on bp in nonhypertensive and controlled hypertensive patients. we investigated in 100 patients, 50 of them were nonhypertensive and 50 were controlled hypertensive patients (grade 1, 130-139/80-89). we injected 1.53ml of 2% lidocaine with adrenaline (1:200000) that contained 0.00750.015mg adrenaline. we observed that there was an increase in systolic and diastolic blood pressure in non-hypertensive patients. however, controlled hypertensive patients presented with only increase in systolic blood pressure; we did not observe any significant variation in diastolic blood pressure. it is possible that when bp was measured lidocaine was not absorbed systemically (due to adrenaline) to produce cardiac depressant action and only adrenaline was absorbed which could have led to rise in bp. rise in diastolic bp was not observed in controlled hypertensive patient, this could be due to the action of anti-hypertensive drugs. in our study, pain on injection was the only adverse drug reaction reported. fifty percent (28% had grade 2, 12% had grade 4 and 10% had grade 6) of the non-hypertensive patients and forty eight percent (36% had grade 2 and 12% had grade 4) of the hypertensive patients complained of pain during administration of local anesthetic. this difference could be due to difference in age group of the patients, speed of delivery of anesthesia, volume of anesthetic deposited. in a study conducted by strazar a et al., it was reported that solution selection, topical site preparation with topical anesthetic and procedural technique can be followed to minimize pain on injection.[25] another study conducted by kashyap v et al., reported that alkalinization of local anesthetic solution with sodium bicarbonate can reduce pain on injection.[26] the study did not include patient with bp ≥140/90mm of hg. the uncontrolled hypertensive patients (121-139/81-89 mm of hg) were not included. therefore, safety recommendation may not be applicable for the above group. bp was the only outcome parameter that was monitored. conclusion: 2% lidocaine hydrochloride with adrenaline (1:200000) increased systolic but not diastolic blood pressure in controlled hypertensive patients. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 tuladhar lr, et al. comparative study on effects of 2% lidocaine hydrochloride with adrenaline (1:200000) on blood pressure among controlled hypertensive and non-hypertensive patients during dental anesthesia jlmc.edu.np references: 1. abu-mostafa n, al-showaikhat f, al-shubbar f, al-zawad k, al-banawi f. hemodynamic changes following injection of local anesthetics with different concentrations of epinephrine during simple tooth extraction: a prospective randomized clinical trial. j clin exp dent. 2015;7(4):e471–6. pmid: 26535092 doi: https://doi.org/10.4317/jced.52321. 2. panneerselvam e, 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diabetes undergoing tooth extraction after administration of local anesthesia with or without adrenaline. pakistan oral & dental journal. 2018;38(2):187-90. available from: http://podj.com.pk/archive/ june_2018/podj-9.pdf 13. mcnulty mm, edgerton gb, shah rd, hanck da, fozzard ha, lipkind gm. charge at the lidocaine binding site residue phe-1759 affects permeation in human cardiac voltage-gated sodium channels. the journal of physiology. 2007;581(2):741-55. doi: https://doi. org/10.1113/jphysiol.2007.130161 14. torp kd, metheny e, simon lv. lidocaine toxicity. treasure island(fl): statpearls publishing; 2021. pmid: 29494086 available from: https://pubmed.ncbi.nlm.nih. gov/29494086/ 15. lubberding af, thomsen mb. lowj. lumbini. med. coll. vol 9, no 1, jan-june 2021 tuladhar lr, et al. comparative study on effects of 2% lidocaine hydrochloride with adrenaline (1:200000) on blood pressure among controlled hypertensive and non-hypertensive patients during dental anesthesia jlmc.edu.np dose adrenaline reduces blood pressure acutely in anesthetized pigs through a β2adrenergic pathway. j cardiovasc pharmacol. 2019;74(1):38-43. pmid: 31274841 doi: https://doi.org/10.1097/fjc.0000000000000682 16. muntner p, shimbo d, carey rm, charleston jb, gaillard t, misra s, et al. measurement of blood pressure in humans: a scientific statement from the american heart association. hypertension. 2019;73(5):35-66. doi: https://doi.org/10.1161/ hyp.0000000000000087 17. ogedegbe g, pickering t. principles and techniques of blood pressure measurement. cardiol clin. 2010;28(4):571-86. pmid: 20937442 18. shahbabu b, dasgupta a, sarkar k, sahoo sk. which is more accurate in measuring the blood pressure? a digital or an aneroid sphygmomanometer. j clin diagn res. 2016;10(3):lc11-4. pmid: 27134902 doi: https://doi.org/10.7860/jcdr/2016/14351.7458 19. whelton pk, carey rm, aronow ws, casey de, collins kj, dennison himmelfarb c, et al. 2017 acc/aha/aapa/abc/acpm/ags/ apha/ash/aspc/nma/pcna guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the american college of cardiology/american heart association task f. hypertension. 2018;71(6):1269–324. doi: https://doi. org/10.1161/hyp.0000000000000066 20. doyle dj, goyal a, bansal p, garmon eh. american society of anesthesiologists classification. 2020. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2020. pmid: 28722969 available from: http:// www.ncbi.nlm.nih.gov/pubmed/28722969 21. aubertin ma. the hypertensive patient in dental practice: updated recommendations for classification, prevention, monitoring, and dental management. gen dent. 2004;52(6):54452. pmid: 15636281 22. kalra p, rana as, peravali rk, gupta d, jain g. comparative evaluation of local anaesthesia with adrenaline and without adrenaline on blood glucose concentration in patients undergoing tooth extractions. j maxillofac oral surg. 2011;10(3):230-5. pmid: 22942593 doi: https://doi.org/10.1007/s12663-011-02394. 23. karm mh, park fd, kang m, kim hj, kang jw, kim s, et al. comparison of the efficacy and safety of 2% lidocaine hcl with different epinephrine concentration for local anesthesia in participants undergoing surgical extraction of impacted mandibular third molars: a multicenter, randomized, double-blind, crossover, phase iv trial. 2017;96(21):e6753. pmid: 28538371 doi: https://doi.org/10.1097/md.0000000000006753 24. kyosaka y, owatari t, inokoshi m, kubota k, inoue m, minakuchi s. cardiovascular comparison of 2 types of local anesthesia with vasoconstrictor in older adults: a crossover study. anesth prog. 2019;66(3):133-40. pmid: 31545671 doi: https://doi.org/10.2344/anpr-6602-04 25. strazar ar, leynes pg, lalonde dh. minimizing the pain of local anesthesia injection. plast reconstr surg. 2013;132(3):675-84. pmid: 23985640 doi: https://doi.org/10.1097/ prs.0b013e31829ad1e2. 26. kashyap vm, desai r, reddy pb, menon s. effect of alkalinisation of lignocaine for intraoral nerve block on pain during injection, and speed of onset of anaesthesia. br j oral maxillofac surg. 2011;49(8):e72-5. pmid: 21592633 doi: https://doi.org/10.1016/j.bjoms.2011.04.068. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 bhandari kr, et al. prevalence of refractive error and associated risk factors in school-age children in nepal: a cross-sectional study. jlmc.edu.np ___________________________________________________________________________________ submitted: 30 november, 2020 accepted: 21 april, 2021 published: 24 june, 2021 alecturer, department of community medicine bassociate professor, department of statistics cprofessor & head, department of opthalmology dresident, department of opthalmology elumbini medical college teaching hospital, palpa, nepal. fpatan multiple campus, lalitpur, nepal. corresponding author: keshav raj bhandari e-mail: krbhandari54@gmail.com orcid: https://orcid.org/0000-0002-5083-6493_______________________________________________________ abstract: introduction: the most common visual disorder in school age children is refractive error globally. the present study aimed to know the prevalence of refractive errors and explore the factors associated with the refractive error in school-age children in palpa district of western part of nepal. methods: all the school children were selected between age groups 5 to 18 years from four schools of palpa by multistage sampling method. after the preliminary examination on visual acuity, the children were referred to the department of ophthalmology, lumbini medical college, palpa for confirmation of the refractive errors. results: in school-age children the prevalence of refractive error was 9% of which myopia was the most common (4.05%). females (about 12%) were more likely to have refractive errors than males (about 7%). the refractive error of males was 0.106 (right eye) and 0.564 (left eye) times more likely than females. the refractive errors were statistically found more common in dalit students (14.6%) than brahmin/chhetri (about 12%) and janajati (7.6%). the prevalence of refractive errors among students using smart phone/ laptop (about 12%) was higher than those not using (8.36%). conclusion: sex, ethnicity, and near work activity like using the smart device were the covariates of developing refractive error on the eye. myopia was more among those students who were using smartphone/laptops. near activities stress on eyes of the children and might be one of the causes of developing myopia. keywords: prevalence, refractive error, school children original research articlehttps://doi.org/10.22502/jlmc.v9i1.412 keshav raj bhandari,a,e deepak bahadur pachhai,b,f chet raj pant,c,e ashish jamarkatteld,e prevalence of refractive error and associated risk factors in school-age children in nepal: a cross-sectional study how to cite this article:how to cite this article: bhandari kr, pachhai, db, pant cr, jamarkattel a. prevalence of refractive error and associated risk factors in school-age children in nepal: a cross-sectional study. journal of lumbini medical college. 2021;9(1):6 pages. doi: https://doi.org/10.22502/jlmc. v9i1.412. epub: june 24, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: refractive error is a problem with focusing of light accurately on the retina. the most common types of refractive errors are myopia (near-sightedness), hypermetropia (far-sightedness), astigmatism, and presbyopia.[1] the number of people affected globally with refractive errors has been estimated at one to two billion. rates vary between regions of the world with about 80% of asians and 25% of europeans affected.[2] near-sightedness is the most common disorder.[3] it affects children and adults up to 49%while far-sightedness more commonly affects young children and the elderly.[4,5,6] according to 2013 estimates, 660 million people had uncorrected refractive errors in the world and of these 9.5 million were blind due to the refractive error. it is one of the most common causes of vision loss, the others being cataracts, macular degeneration, and vitamin a deficiency.[6] the most common visual disorders found in school-going children are refractive errors and they are also the leading cause of blindness. it can easily be prevented if proper measures are taken timely. in j. lumbini. med. coll. vol 9, no 1, jan-june 2021 bhandari kr, et al. prevalence of refractive error and associated risk factors in school-age children in nepal: a cross-sectional study. jlmc.edu.np the western part of nepal, no estimates of refractive errors in school children are available. considering the importance of the refractive errors the present study was undertaken in palpa district. methods a cross-sectional school-based study was conducted among 837 students of which 368 students were from two government schools in two rural municipalities and 469 students were from two private schools in one municipality and one rural municipality of palpa district. the multistage sampling method was used for the study and all of the children studying in the selected schools who were available at the time of the survey were included in the study. the study was conducted from december 15, 2019, to january 15, 2020. before conducting the study, written information detailing the purpose of the eye examination was sent to all the schools, and permission was sought. all the parents were requested to be present on the day of the examination. those parents, who could not visit on the day of the examination, were sent a report stating their children’s ocular health status. for further consultation, the parents with their children were called to the hospital. the materials used by the team were internally illuminated e chart (provided by nepal netra jyoti sangh), torch lights, direct ophthalmoscopes (heine beta 200, germany), retinoscopes (heine beta 200, germany), trial set, and universal trial frames (emami). in this study, myopia and hypermetropia were recorded if refractive errors were more than -0.5 dioptre and more than +1 dioptre respectively. astigmatism was recorded if the refractive error was more than 0.5 dioptre. visual acuity in the better eye without glasses or with glasses in case of those who had been wearing the same was called presenting vision. the best-corrected vision was defined as the vision achieved by the subject in the better eye while testing for refraction. amblyopia was diagnosed when eyesight deteriorated 6/9 or more after careful eye examination, including fundoscopy, through retarded vision and non-cyclonic refraction.[8] all data were entered in the statistical package for social studies version 23.0 for evaluation. a chisquare test was performed to assess the risk factors of refractive error and binary logistic regression was performed for the best fit of the model. p-value for a confidence interval of 95% was considered significant at the p < 0.05 level for prevalence estimates. institutional review committee (irc) of the lumbini medical college & teaching hospital ltd. provided ethical clearance [irc-lmc 02-d/020] for this study. results: the total number of children in this study was 837. the maximum age of respondents was 18 years and the minimum age was five years. 53% were male and 47% were female. regarding ethnicity of children, most of them were janajati (63%) and brahmin /chhetri and dalit were respectively 29% and 8%. most of the children were from private schools (56%). the majority of the children’s fathers were literate (97.6%) and 93.8% of children’s mothers were literate. the prevalence of refractive error among the children was 9% (table 1). among them, 4% of the children had myopia, 4% had astigmatism and 1 % had hypermetropia. table 1. demographic profile of refractive error (n= 837). frequency (%) sex male 440 (53%) female 397 (47%) ethnicity brahmin / chhetri 246 (29%) janajati 524 (63%) dalit 67 (8%) school private 469 (56%) public 368 (44%) literacy of father literate 817 (97.6%) illiterate 20 (2.4%) literacy of mother literate 785 (93.8%) illiterate 52 (6.2%) refractive error yes 78(9%) no 759 (91%) sex, ethnicity, and using cellphone were the main risk factors of refractive error in schoolage children (table 2). in sex, females (about 12%) were more likely to have refractive error than males (about 7%) which was statistically significant [p=0.005(re), 0.017(le) <0.05, df=2]. as compared to the brahmin/chhetri and janajati, dalits were more prone to develop refractive error j. lumbini. med. coll. vol 9, no 1, jan-june 2021 bhandari kr, et al. prevalence of refractive error and associated risk factors in school-age children in nepal: a cross-sectional study. jlmc.edu.np (brahmin/chhetri= 12.4% on right and 11.6% on left eye, janajati = 7.6%, dalit=14.9%, p= 0.04). the prevalence of refractive error of students who were using smartphone/laptop (about 12%) was higher than those who were not using (8.36%) which was statistically significant. on average the percent distribution of refractive error in private school (10.5%) was more than government school (8%) but was not statistically significant (p =0.323 re, 0.132 le > 0.05). other factors like academic performance, school type, watching tv, siblings, and refractive error of parents were not likely to have a refractive error in children. table 3: unaided visual acuity of the right and left eyes. visual acuity right eye left eye n (%) n (%) 6/6 765 (91.4) 771 (92.1) 6/9-6/18 62 (7.4) 57 (6.8) 6/24-3/60 10 (1.2) 9 (1.1) among 837 students, a majority, (91.4% for the right eye and 92.1% for the left eye), of students had normal visual acuity. ten students (1.2%) had visual acuity of 6/24 in the right eye and nine (1.1%) students in the left eye (table 3). the percent distribution of myopia, hypermetropia, and astigmatism of females was greater than male, which was statistically significant (p=0.029). the prevalence of myopia of male and female were respectively 41.2 % and 58.8 %. table 5 shows that the covariates ethnicity was highly significant for explaining the refractive error to the school children under study. as compared to the dalit student, brahmin /chhetri and janajati students were 0.783 and 0.453 times more likely to have the refractive errors. on the other hand, the male student had about 0.505 more odds of having refractive error as compared to the female student. next, as compared to the students who were not using a cellphone, the odd of having refractive errors were 0.682 times more among those who were using cellphones. table 2. association of refractive error with socioeconomic characteristics (n=837). refractive error (n/%) p value (re,le)right eye (re) left eye (le) no yes no yes sex male 410(93.2) 30(6.8) 409(93) 31(7) 0.005,0.017 female 347(87.4) 50(12.6) 350(88.2) 47(11.8) ethnicity brahmin/chhetri 216(87.8) 30(12.2) 218(88.6) 28(11.4) 0.04, 0.042 janajati 484(92.4) 40(7.6) 484(92.4) 40(7.6) dalit 57(85.1) 10(14.9) 57(85.1) 10(14.9) school type private school 420(89.6) 49(10.4) 419(89.3) 50(10.7) 0.323,0.132 public school 337(91.6) 31(8.4) 340(92.4) 28(7.6) school performance excellent 111(91.7) 10(8.3) 111(91.7) 10(8.3) 0.955,0.870 good 251(90) 28(10) 252(90.3) 27(9.7) average 288(90.3) 31(9.7) 291(91.2) 28(8.8) poor 107(90.4) 11(9.3) 105(89) 13(11) watching tv yes 536(90.4) 57(9.6) 539(90.9) 54(9.1) 0.934,0.741 no 221(90.6) 23(9.4) 220(90.2) 24(9.8) using smartphone/ laptop yes 216(87.4) 31(12.6) 218(88.3) 29(11.7) 0.04,0.048 no 541(91.7) 49(8.36) 541(91.7) 49(8.36) siblings 1-2 children 476(90.3) 51(9.7) 478(90.7) 49(9.3) 0.878,0.978 >2 children 281(90.6) 29(9.4) 281(90.6) 29(9.4) refractive error of parents none 607(90.6) 63(9.4) 609(90.9) 61(9.1) one 136(91.3) 13(23.4) 136(91.3) 13(8.7) 0.137,0.125 both 13(76.5) 4(23.5) 13(90.7) 4(23.5) j. lumbini. med. coll. vol 9, no 1, jan-june 2021 bhandari kr, et al. prevalence of refractive error and associated risk factors in school-age children in nepal: a cross-sectional study. jlmc.edu.np the p-value for calculated chi-square is seen as less than 0.05. hence, overall, the model coefficients were significant at a 5% level of significance. the cox and snell r square and nagelkerke r square were obtained as 0.021 and 0.044 respectively. the first one indicates that the 2.1% of the variation in refractive error to the student under study was explained by the covariates used in the fitted model and the second one indicates the 4.4% of the variation in refractive error to the student was explained by the covariates. discussion: in our study children aged 5–18 years at different public and private schools in palpa district were included in the study. four schools among which two private and two government schools were selected by multistage sampling method. the fieldwork was carried out between december 2019 and january 2020. a total of 837 students were examined. in our study, 9% of children had a refractive error of ± 0.5 or worse in one or both eyes and needed glasses. among refractive errors, myopia and astigmatism were the most common (4.1% and 4.2% respectively) followed by hypermetropia (1.3%); this was slightly higher compared with other studies carried out in another district as jhapa 8.6% (3.9% myopia, 1.7% hypermetropia, and 3% astigmatism) and pokhara 6.43% (4.05% myopia, 1.24% hypermetropia, and 1.14% astigmatism).[7,9] the prevalence of refractive error in kathmandu is 11.6% which is greater than our study.[10] however, pradhan n reported a prevalence of 7.0% in which myopia was the most common refractive error 44 (61.9%) followed by astigmatism 16 (24.1%) and hypermetropia (14%) among the children with refractive errors.[1] however, the percentage distribution of refractive errors in our present study was higher than the refractive errors recorded by naidoo et al., (4.7%) in south africa, and schimiti et al., (4.55%) in brazil.[11,12] assefa wy reported refractive errors in either eye were present in 174 (9.4%) children. the myopia of children was detected in 55 (31.6%) in the right and left eyes followed by far-sightedness in 46 (26.4%) and 39 (22.4%) in the right and left eyes respectively.[3] the proportion of refractive errors found in india, chile and zaire was 25.32%, 17.05%, and 16% respectively.[13,14,15] these researches suggested that the proportion of refractive errors was much higher than our results. the wide variations of percentage distribution of refractive errors observed by different authors were naturally likely to be due to: sample size, different geographical situation, ethnic variation, nutritional status and different criteria adopted by different authors. it seems that refractive errors especially in growing children were one of the major health problems in both developed and developing countries. table 4: association of refractive error with sex of the children. refractive error n (%) p value myopia hypermetropia astigmatism plano sex male 14(41.2) 5(45.5) 11(31.4) 410(54.2) 0.029 female 20(58.8) 6(54.5) 24(68.6) 347(45.8) table 5: model summary of associative factors of refractive error. covariates coef. s.e. wald df p value odds ratio model summary cox & snell r square nagelkerke r square sex male (female) -0.684 0.245 7.787 1 0.005 0.505 chi square = 17.47 df = 4 p value = 0.002 0.021 0.44 ethnicity b/c(dalit) janajati (dalit) -0.245 -0.792 0.398 0.385 6.848 0.377 4.242 2 1 1 0.033 0.539 0.039 0.783 0.453 use of cell phones no (yes) -0.383 0.247 2.411 1 0.120 0.682 constant 1.146 0.390 8.848 1 0.003 0.318 variable(s) entered on step 1: sex, ethnicity, cell phone, b/c=brahmin/ chhetri j. lumbini. med. coll. vol 9, no 1, jan-june 2021 bhandari kr, et al. prevalence of refractive error and associated risk factors in school-age children in nepal: a cross-sectional study. jlmc.edu.np in our present study, the percentage of refractive errors in the girls was found more (about 12%) than in the girl’s counterpart (about 7%) which is statistically significant (p<0.05). pradhan n reports the refractive error of female students (7.86%) was affected more than males (6.22%).[1] however, some studies in nepal and chile did not find a gender difference in refractive errors.[13,16] in our study, the percent distribution of refractive error in dalit students was found more (14.9%) followed by brahmin/chhetri, and janajati (7.6%) which is statistically significant [p=0.04(re), 0.042(le)]. in pokhara, the percent distribution of refractive error of dalit students was comparatively less than brahmin/chhetri and janajati.[7] the study compared the refractive error in different ethnic groups (african american, asian, hispanic, and white) in grades 1 to 8 (age, 5-17 years) and found that refractive error was statistically significant with ethnicity.[17] in the context of nepal, most of the dalit community was poor, regarding poor family they could not eat nutritious food, and regular checkup which may be the cause of the refractive error. the percent distribution of refractive error in our study in private school children {10.4% (re),10.7% (le)} was comparatively higher than public school (8.4% re, 7.6% le) which is not statistically significant (p>0.05). but niroula dr reported the refractive errors were found more in private school children (9.29%) than government school children (4.23%), which is statistically significant (p<0.05).[7] in jhapa, refractive error was significantly high in private school (10.3%) than government schools(6.9%) (χ2 = 6.7, df = 1, p < 0.01). [9] a study conducted in gondar town, northwest ethiopia reported private school children were 2.88 times at risk of developing myopia when compared to those who attended government schools,[18] and this finding is similar to a study conducted in china. [19] in our study the prevalence of refractive error using smart phone/laptop (about 12%) was higher than those who were not using (8.36%) which is statistically significant. as compared to the children who had not used those are 0.6 times likely to have refractive error than using smartphone/ laptop. ichhpujani p reported slightly less than half (278, 48.3%) of students used digital devices every day, 24% (138) used them 3–4 times a week, 15.1% (87) used them 1–2 times a week, and 12.7% (73) used these digital devices 5–6 times a week. with increased age, there was a statistically significant association with increased digital device use in a week.[20] this study has a few limitations. this was a school-based cross-sectional study. this study does not consider the environmental and clinical factors which are major contributors to refractive errors. non-cycloplegic refraction was done instead of cycloplegic which may arise some correction on refractive error. the information of the parent’s refractive error was taken by either use of glass or not, so this information may not be adequate. conclusion: the prevalence of refractive error was 9%. myopia, hypermetropia, and astigmatism of females were greater than males, which was statistically significant. interestingly, in the present study, the refractive errors were found significantly higher in dalit children than brahmin/chhetri and janajati. the developing of myopia in student who were using smartphone/laptop was significantly higher than those who were not using because near activities cause stress on eyes of the children and might be one of the causes of developing myopia. only sex, ethnicity, and near work activity like using the smart device were the covariates of developing refractive error on the eye but clinical characteristics for developing refractive error could not be measured in this study. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. references: 1. pradhan n, sachdeva a, goel t, bhola b, jha d. prevalence of refractive errors among school children of 6-12-years of age group and reason for not using spectacles even after correction. international journal of research in medical sciences. 2018;6(3):798-801. doi: https:// dx.doi.org/10.18203/2320-6012.ijrms20180444 2. denniston ako, murray pi. oxford handbook of ophthalmology. 4 ed. oxford university: oxford university press; 2018. 926 p. available from:https://oxfordmedicine.com/ view/10.1093/med/9780198804550.001.0001/ med-9780198804550 3. yared aw, belaynew wt, destaye s, aynaw t, j. lumbini. med. coll. vol 9, no 1, jan-june 2021 bhandari kr, et al. prevalence of refractive error and associated risk factors in school-age children in nepal: a cross-sectional study. jlmc.edu.np zelalem e. prevalence of refractive errors among school children in gondar town, northwest ethiopia. 2012;19(4):372-6. pmid:23248538. doi: https://doi.org/10.4103/0974-9233.102742 4. pan cw, ramamurthy d, saw sm. worldwide prevalence and risk factors for myopia. ophthalmic physiol opt. 2012;32(1):316. pmid: 22150586 doi: https://doi. org/10.1111/j.1475-1313.2011.00884.x 5. farida fmw, farahat hgs, salem mss. refraction errors in school children. menoufia medical journal. 2018;31(1):293-98. available from: https://www.mmj.eg.net/temp/ menoufiamedj311293-2327494_062754.pdf 6. pan cw, dirani m, cheng cy, wong ty, saw sm. the age-specific prevalence of myopia in asia: a meta-analysis. optom vis sci. 2015;92(3):258-66. pmid: 25611765 doi: https://doi.org/10.1097/opx.0000000000000516 7. niroula dr, saha cg. study on the refractive errors of school going children of pokhara city in nepal. kathmandu univ med j (kumj). 2009;7(25):67-72. pmid: 19483457 doi: https://doi.org/10.3126/kumj.v7i1.1769 8. nepal bp, koirala s, adhikary s, sharma k. ocular morbidity in schoolchildren in kathmandu. br j ophthalmol. 2003;87(5):531-4. pmid: 12714384. doi: https://doi.org/10.1136/ bjo.87.5.531 9. shrestha gs, sujakhu d, joshi p.refractive error among school children in jhapa, nepal. j optom. 2011;4(2):49-55. pmcid: pmc3974394 doi: https://dx.doi.org/10.1016/s18884296(11)70041-3 10. shrestha rk, joshi mr, ghising r, rizyal a. ocular morbidity among children attending government and private schools of kathmandu valley. jnma j nepal med assoc. 2011;51(184):182-8. pmid: 22922898 11. naidoo ks, raghunandan a, mashinge kp, govender p, holden ba, pokharel gp, et al. refractive error and visual impairment in african children in south africa. invest ophthalmol vis sci. 2003;44(9):3764-70. pmid: 12939289 doi: https://doi.org/10.1167/iovs.03-0283 12. schimiti rb, costa vp, gregui mjf, kara-jose n, temporini er. prevalence of refractive error and ocular disorders in preschool and school children of ibiporapr, brazil (19891996). arquivosbrasileiros de oftalmologia. 2001;64(0):379-84. available from: http://www. scielo.br/pdf/abo/v64n5/8353.pdf 13. maul e, barroso s, munoz sr, sperduto rd, ellwein lb. refractive error study in children: results from la florida, chile. am j ophthalomol. 2000;129(4):445-54. pmid: 10764851. doi: https://doi.org/10.1016/s00029394(99)00454-7 14. shrestha rk, joshi mr, ghising r, rizyal a. ocular morbidity among children attending government and private schools of kathmandu valley. journal of nepal medical association. 2011;51(184):182-88. doi: https://doi. org/10.31729/jnma.21 15. sethi s, kartha gp. prevalence of refractive errors in schools children (12 17 years) of ahmedabad city. indian journal of community medicine. 2000;25(4):181-3. available from: https://www.ijcm.org.in/backissues.asp 16. pokharel gp, negrel ad, munoz sr, ellwein lb. refractive error study in children: results from mechi zone, nepal. am j ophthalmol. 2000;129(4):436-44. pmid: 10764850. doi: https://doi.org/10.1016/s0002-9394(99)00453-5 17. kleinstein rn, jones la, hullett s, kwon s, lee rj, friedman ne, et al. refractive error and ethnicity in children. arch ophthalmol. 2003;121(8):1141-7. pmid: 12912692 doi: https://doi.org/10.1001/archopht.121.8.1141 18. belete gt, anbesse dh, tsegaye at, hussen ms. prevalence and associated factors of myopia among high school students in gondar town, northwest ethiopia,2016.clin optom (auckl). 2017;9(0):11-18. pmid: 30214355 doi: https:// doi.org/10.2147/opto.s120485 19. khader ys, batayha wq, abdul-aziz smi, alshiekh khalil mi. prevalence and risk indicators of myopia among schoolchildren in amman, jordan. east mediterr health j. 2006;12(34):434-9. pmid: 17037714 20. ichhpujani p, singh rb, foulsham w, thakur s, lamba as. visual implications of digital device usage in school children: a cross-sectional study. bmc ophthalmology. 2019;19(0):76. pmid: 30866885 doi: https://doi.org/10.1186/s12886019-1082-5 initial experiences of laparoscopic surgery at nobel medical college teaching hospital: a learning curve shanti subedi,a,c narayan gc,b,c sabina lamichhane,b,c manisha chhetrib,c —–————————————————————————————————————————————— abstract: introduction: the field of minimal invasive surgery has flowered explosively in the recent past. modern endoscopy has changed the approach to diagnosis as well as the operative procedure. this study was done with the aim of sharing the experiences of gynecological laparoscopic procedures done at nobel medical college and teaching hospital, nepal. methods: a descriptive study was done in the department of obstetrics and gynecology, nobel medical college from 1st february 2015 to 30th january 2016. all the patients undergoing laparoscopic procedures were analyzed for the indication, type of procedures and their complications. results: during the study period, 100 patients underwent laparoscopic procedures including 25 cases of diagnostic and 75 cases of therapeutic procedures. fifty-three patients with an ovarian mass underwent laparoscopic cystectomy. laparoscopic salpingectomy was done in 11 patients with ectopic pregnancy. laparoscopy assisted vaginal hysterectomy (lavh) was done in eight cases and laparoscopic sterilization in two cases. one patient underwent successful myomectomy. one patient undergoing laparoscopic cystectomy and one case of lavh had conversion to laparotomy because of dense adhesion and vault bleeding respectively. no other major complication noted apart from port side bleeding, infection and vault hematoma. conclusion: laparoscopy is a safe and feasible alternative to open gynecological surgeries though it has a long learning curve and a lot of expertise is necessary. keywords: cystectomy • hysterectomy • laparoscopy • learning • minimally invasive surgical procedures ——————————————————————————————————————————————— ___________________________________________________________________________________ a assistant professor b lecturer c department of obstetric and gynecology, nobel medical college teaching hospital, biratnagar, nepal corresponding author: dr. shanti subedi e-mail: subedi007@gmail.com how to cite this article: subedi s, narayan gc, lamichhane s, chhetry m. initial experiences of laparoscopic surgery at nobel medical college teaching hospital: a learning curve. journal of lumbini medical college. 2016;4(1):203. doi: 10.22502/jlmc.v4i1.77. ___________________________________________________________________________________ j. lumbini. med. coll. vol 4, no 1, jan-june 2016 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v4i1.77 introduction: laparoscopy is a revolution in gynecological surgery as it is safe and less invasive. it was first performed by jacobeus in sweden in 1910.1,2 history shows that in gynecological endoscopy surgery, there was massive enthusiasm in the beginning but its growth was not as expected. the major hurdle for this is the learning curve for endoscopy surgeries.3 in developing countries like nepal, we are still in a crawling phase, the major reason for this being lack of expertise. another reason is that the unit is incorporated along with obstetrics, where workload is high and hence time factor is another barrier. the field of minimal invasive surgery has gained popularity in the recent past. it has revolutionized all surgical fields all over the world. initially, its use in gynecology was restricted to diagnostic purpose specially in cases of infertility and few sterilization procedures. gradually its use expanded from diagnostic to therapeutic modalities in different gynecological problems.4-6 there are definite advantages of laparoscopy over laparotomy with the benefit of shorter hospital stay, less postoperative pain, cosmesis, faster return 20 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 subedi s. et al. initial experiences of laparoscopic surgery at nobel medical college teaching hospital. jlmc.edu.np to normal activity and less chance of adhesion formation. despite these advantages, there are potential limitations like limited exposure of the operative field, small instruments which can be used only through fixed ports and thus limited manipulation of pelvic viscera.7 this study was done to share the initial experiences of laparoscopic surgeries in nobel medical college teaching hospital. methods: this prospective study was done at nobel medical college teaching hospital, nepal from 1st february 2015 to 30th january 2016. all patients requiring laparoscopic surgeries like benign adnexal pathology, infertility, uterine pathology with uterus size less than 12 weeks, haemodynamically stable case of ectopic pregnancy and patient selected for laparoscopic tubal sterilization were enrolled in the study. ethical approval was taken from the ethical review board of the institute. informed consent was taken from the patients after explaining the type of procedure, its duration, complications and need of conversion to laparotomy if required. a routine preoperative assessment was done which included detailed history, clinical examination, complete blood examination, pelvic ultrasonography, tumor markers and computed tomogram of abdomen and pelvis whenever required. all the procedures were done after bowel preparation and under general anesthesia. during the procedure, the patient was placed in lithotomy trendelenburg position. abdomen was opened with either closed or open technique using a veress needle or a hasson cannula respectively. a one cm infraumbilical incision was given and pneumoperitoneum was created. diagnostic laparoscopy was done by the standard method. ovarian cystectomy was done either by enucleation of the cyst or with oophorectomy or by deroofing and aspiration of the cyst followed by removal of the cyst wall. laparoscopy assisted vaginal hysterectomy (lavh) was done according to the standard procedure. all the patients were given antibiotics for seven days and the patients of diagnostic laparoscopy were discharged after 24 hours and operative laparoscopy were discharged after 72 hours. results: total 100 cases were operated during the study period including 25 cases of diagnostic and the rest 75 cases of operative laparoscopy. major indication of diagnostic laparoscopy was infertility in 20 cases and chronic pelvic pain in five cases. there were a total of 53 cases of adnexal pathology. type of the surgeries performed and type of adnexal pathology are given in table 1 and 2 respectively. dysfunctional uterine bleeding was the most common indication of lavh. the other indications are given in table 3. table 4 shows the complications of various laparoscopic procedures. the conversion to laparotomy was done in two cases that ultimately required abdominal hysterectomy due to hemorrhage in one case and adhesion in one. vault hematoma occurred in one case that was type of procedure n (%) diagnostic laparoscopy 25 (25) adnexal pathology 53 (53) ectopic pregnancy 11 (11) lavh 8 (8) subserosal myomectomy 1 (1) sterilization 2 (2) total 100 (100) table 1: type of surgeries performed. adnexal pathology n (%) ovarian cyst ( hemorrhagic/serous) 35 (66.03) endometriotic cyst 15 (28.30) dermoid cyst 3 (5.67) total 53 (100) table 2: type of adnexal pathology operated on indications n (%) dysfunctional uterine bleeding 4 (50) fibroid 2 (25) chronic pelvic pain 2 (25) total 8 table 3: indications of lavh type of complications n (%) port site bleeding 1 (20) port site infection 1 (20) conversion to laparotomy 2 (40) vault hematoma 1(20) total 5 (100) table 4: complications of laparoscopic surgeries 21 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 jlmc.edu.np subedi s. et al. initial experiences of laparoscopic surgery at nobel medical college teaching hospital. managed conservatively with injectable antibiotics and tranexamic acid. port site bleeding was present in one case which was managed with extra sutures and compression bandage. discussion: laparoscopy in the recent years has gained popularity for diagnostic as well as therapeutic purposes, even for minor to major oncologic procedures. surgeons all over the world are striving hard to embark on the voyage of laparoscopy surgery but we are still in an early crawling phase. a total of 100 cases were performed successfully in the study period. we started our journey with diagnostic laparoscopy as all beginners do. the main indications were infertility and chronic pelvic pain. nasir et al. also reported infertility as the most common indication of diagnostic laparoscopy.8,9 a total of 53 patients with adnexal pathology underwent laparoscopic surgery. the most common ovarian pathology in the study was hemorrhagic cyst and serous cystadenoma (n=35, 66%) followed by chocolate cyst (n=15, 28%). this is in contrast to the study done by shah r. et al. where endometriosis was the commonest ovarian pathology followed by dermoid cyst.9 similar pathology was observed in a study done by yuen et al.10 most of the patients with ovarian cyst underwent oophorectomy (n=38, 71.7%) followed by cystectomy in 10 patients. five of the patients with chocolate cyst underwent deroofing and postoperative hormonal suppressive therapy because of adhesion and in one case we had to do laparotomy followed by total abdominal hysterectomy because of extensive adhesion. conversion was done in another one patient because of hemorrhage. all three cases of dermoid cyst had spillage, but none of them developed chemical peritonitis. ideally, they should have been operated without spillage; vigorous washing was done after tissue retrieval in all the cases.11,12 similar to our study, in a series by shwaki et al., they had a spillage rate of 50% with no case of chemical peritonitis.13 the operative time depends on the experience of the surgeon, size of the tumor and the adhesions present. in the initial period, we took a long operative time especially in cases with endometriosis. the operative time progressively decreased after first 10 cases, and after 40 cases, there was further decline. this is the same as stated by yuen et al. who performed surgeries for ovarian mass.10 regarding ectopic pregnancy, laparoscopic management was done in hemodynamically stable patients. in all the 11 cases, we did total salpingectomy. laparoscopy is the gold standard for surgical management of ectopic pregnancy. out of 11 cases we had two cases of undiagnosed ectopic pregnancy. therefore laparoscopy is a rewarding step to exclude ectopic pregnancy as commented by condos et al. in his case series.14 laparoscopic sterilization is not that popular in our context as government is running a free program with an incentive. lavh was done in eight cases mainly for dysfunctional uterine bleeding, fibroid and chronic pelvic pain. one of the patients in this study had to undergo abdominal hysterectomy due to hemorrhage from the vault. devendra et al., in their series of 42 cases of lavh, did conversion in two cases and concluded that lavh is a safe and feasible alternative to abdominal hysterectomy.15 major complications were seen in none of the patients. most complications occurred in first ten cases in a study by altagassen et al.16 they pointed out that the learning curve of thirty cases of lavh was necessary to reach low level of complications. a study conducted in 1994 has shown that the risk of lavh is same as that of abdominal and vaginal hysterectomy in skilled hands.17 this is similar to another study by ribeiro sc. et al. which showed that the safety of laparoscopic hysterectomy equals abdominal hysterectomy after the procedure is mastered.18 conclusion: the trend of gynecological laparoscopic surgery can be further enhanced by improving the learning curve keeping the patients safety as the priority. our journey has shown that laparoscopy is a safe and useful procedure in gynecological practice. conflict of interest: none declared. references: 1. sharp th, francis si, murphy aa. diagnostic and operative laparoscopy. 10th ed. rock ja, jones hw. eds. te linde’s operative gynecology. philadelphia: lippincott williams & wilkins; 2008. 319-35 p. 22 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 subedi s. et al. initial experiences of laparoscopic surgery at nobel medical college teaching hospital. jlmc.edu.np 2. vecchio r, macfayden bv, palazzo f. history of laparoscopic surgery. panminerva med . 2000 mar;42(1):87-90. 3. khanum z, khanum a, rehman au. gynecological laparoscopic surgery: learning curve. annals. 2015;21(4):253-6. 4. american college of obstetricians and gynecologists. operative laparoscopy, acog educational bulletin no 239, american college of obstetricians and gynecologists, washington, dc, usa, 1997. 5. darzi a, mackay s. recent advances in minimal access surgery. bmj. 2002;324(7328):31-4. 6. pittaway de, takacs p, bauguess p. laparoscopic adnexectomy: a comparison with laparotomy. am j obstet gynecol. 1994;171(2):389-91. 7. berek js, berek dl. gynecologic endoscopy. 15th ed. berek js, berek dl, hengst tc, barile g. (eds). berek's and novak's gynecology. new york : lippincott williams and wilkins; 2012. 740-802 p. 8. nasir s, hassan m, tanau k, abubakar pa, ahmed y, umar ag. experience with gynecological laparoscopy in a tertiary hospital, north-west nigeria. orient j med. 2014;26:48-52. 9. saha r, shrestha ns, thapa m, shrestha j, bajracharya j, karki sc. experiences of gynecological laparoscopic surgeries in a teaching hospital. j nepal health res counc. 2013 jan;11(23);49-52. 10. yuen pm, yu km, yip sk, lau wc, roger ms, chang a. a randomized prospective study of laparoscopy and laparotomy in the management of benign ovarian masses. am j obstet gynecol. 1997 jul;177(1):109-14. 11. mettler l, jacobs vr. review of laparoscopic management of benign ovarian masses. jain n., ed. state of the art atlas of endoscopic surgery in infertility and gynecology. new delhi: jaypee brothers medical publishers (p) ltd; 2004. 132-40 p. 12. kocak m, dilbaz b, ozturk n, dede s, altay m, dilbaz s, et al. laparoscopic management of ovarian dermoid cysts: a review of 47 cases. ann saud med. 2004 sepoct;24(5):357-60. 13. shwaki o, soliman i, ebrashy a, sadek ml, bahnassy a. laparoscopic management of ovarian dermoid cysts. mefsj. 2004:9(1):58-65. 14. condos p. experience with gynecological laparoscopy. anzjog. 1972 aug;12(3):188-93. 15. devendra k, tang sk. laparoscopically assisted vaginal hysterectomy an alternative to abdominal hysterectomy. singapore med j. 2002;43(3):138-42. 16. altagarseen c, miachels w, schneider a. learning laparoscopic hysterectomy. obstet and gynecol. 2004 aug;14(21):308-13. 17. liu c, reich h. complications of total laproscopic hysterectomy in 518 cases. gynecol endosc. 1994;3:203-8. 18. ribeiro sc, ribeiro rm, santos nc, pinotti ja. a randomized study of total abdominal, vaginal and laparoscopic hysterectomy. int j gynaecol obstet. 2003 oct;83(1):37-43. 23 seasonal variation of pediatric dermatoses: a hospital based study in western hilly nepal pratistha shrestha,a jameel akhtar mikrania —–————————————————————————————————————————————— abstract: introduction: skin diseases are common in children; however they differ depending in age, region, socioeconomic status and climate. many studies have been done to study pattern of dermatological disease in pediatric age group but only few studies have been done in its seasonal variation. so we decided to study seasonal variation of pediatric dermatoses. methods: this was a retrospective study done from hospital records of lumbini medical college teaching hospital (lmcth). all children 14 years and below attending the dermatology out-patient clinic with skin diseases between the period of march 2015 to february 2016 were included. demographic, clinical and laboratory details were recorded. data were collected and categorized according to four seasons. microsoft excel was used for data entry while all analysis, both descriptive and inferential, was done using spss version 22. results: there were a total of 987 children visiting dermatology clinic during the study period. of those, 520 (52.7%) were male and the remaining 467 (47.3%) were female with m:f ratio of 1.1:1. most of the disorders were seen between 10-14 years of age. majority of visits were in summer (n=403, 40.8%) followed by spring, autumn and winter. most common dermatosis seen among children during summer was fungal infection (n=91, 9.2%) and during winter was eczema (n=49, 5%). conclusion: in the present setting there is seasonal variation of dermatological diseases in pediatric age group. keywords: seasonal • variation • pediatrics • skin diseases ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, department of dermatology and venereology lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. pratistha shrestha e-mail: pratisthashrestha@hotmail.com how to cite this article: shrestha p, mikrani ja. seasonal variation of pediatric dermatoses: a hospital based study in western hilly nepal. journal of lumbini medical college. 2016;4(1):32-4. doi: 10.22502/jlmc.v4i1.75. ___________________________________________________________________________________ j. lumbini. med. coll. vol 4, no 1, jan-june 2016 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v4i1.75 introduction: seasonal variation in skin disease has been observed and studied since centuries. pediatric dermatoses are common in dermatology clinic and these are directly or indirectly affected by climate. various climatic factors that may determine the incidence of skin diseases are cold, heat, light, sunshine and humidity.1 skin diseases are one of the major health problems in children and are associated with significant morbitity.2 nepal is a himalayan country located 28°n and 84°e in the indian subcontinent.3 having a population of 24.1 million (2001 census), it comprises of the mountains in the north, the central hills, and the southern terai plains, with climate varying from arctic type in the north to tropical type in the south.4 in our country nepal, where there is a wide range of climate and where pediatric population constitutes significant proportion of total population, there is a need to study the seasonal variation of pediatric dermatoses. as only a few study has been done about the seasonal variation of skin disease in pediatric age-group, we decided to conduct this study. methods: this was a retrospective study conducted in department of dermatology at lumbini medical college teaching hospital (lmcth), nepal. ethical clearance was taken from the institutional review committee of lmcth. demographic, clinical and laboratory details of all the new cases aged 0 to 14 years, between march 2015 to february 32 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 shrestha p. et al. seasonal variation of pediatric dermatoses. jlmc.edu.np 2016, were collected from the records of the out patient clinic of lmcth. the data obtained were divided into four seasons comprising of spring (march to may), summer (june to august), autumn (september to november), and winter (december to february). the age group of children, included in the study was divided into less than one year (infants), 1-5 years (toddlers and preschool children), 6-10 (school children), and 11-14 years (adolescent). the dermatoses were divided into different groups and their frequency with respect to age and season was noted. microsoft excel was used for data entry while all analysis both descriptive and inferential was done using spss version 22. p value of 0.05 was considered as significant. result: there were a total of 987 children with skin diseases visiting the out-patient clinic during the study period. of those, 520 (52.7%) were male and the remaining 467 (47.3%) were female with m:f ratio of 1.1:1. mean age of male was 7.8 yr (sd=4.55) and that of female was 7.7 yr (sd=4.3) and the difference was not statistically significant (t=0.52, df=985, p=0.6). most of dermatoses was seen in summer (n=403, 40.80%), followed by spring (n=250, 25.30%), autumn (n=168, 17%), and winter (n=166, 16.80%). the majority of dermatoses belonged to fungal infection (n=154, 15.6%) followed by eczema (n=120, 12.2%), and scabies (n=118, 12%). fungal infection being most common in summer and least in winter. eczema was most commonly seen in winter followed by summer. similarly scabies was commonly seen in summer and spring (table 1). out of the total 987 patients, 405 (41%) belonged to 11-14 age group followed by 294 (29.8%) to 6-10 age group, 206 (20.9%) to 1-5 age group and 82 (8.3%) to infant age group. fungal infection was a single most common dermatoses in adolescent (11-14 yr) followed by acne and scabies. in 6-10 age group, eczema was the most common followed by fungal infection and bacterial infection. in 1-5 age group, scabies and fungal infection were the most common followed by viral infection. in infants, eczema was the most common followed by milaria and bacterial infection (table 2). discussion: the pattern of skin diseases in pediatric age group vary from one country to another and within the same country from one region to another due diagnosis su m m er w in te r sp ri ng a ut um n n % bacterial infection 50 6 39 10 105 10.6 hair disorder 10 28 3 26 67 6.8 milaria 43 3 28 4 78 7.9 scabies 45 16 39 18 118 12 eczema 47 49 24 0 120 12.2 fungal infection 91 7 34 22 154 15.6 pigmentary disorder 16 6 12 18 52 5.3 urticaria 14 21 12 26 73 7.4 viral infection 18 13 24 16 71 7.2 acne 48 4 20 16 88 8.9 papulosquamous disorder 3 4 0 3 10 1.0 drug rx 2 6 3 4 15 1.5 others 16 3 12 5 36 3.6 total 403 166 250 168 987 100 percentage 40.8 16.8 25.3 17 100 table 1: seasonal trend of different dematoses diagnosis age-group (years) n <1 15 610 11 -1 4 bacterial infection 13 23 33 36 105 hair disorder 8 15 18 26 67 milaria 14 21 28 15 78 scabies 6 29 34 49 118 eczema 18 16 39 47 120 fungal infection 11 29 38 76 154 pigmentary disorder 0 12 16 24 52 urticaria 0 25 22 26 73 viral infection 0 28 27 16 71 acne 0 0 24 64 88 papulosquamous disorder 0 0 4 6 10 drug rx 0 0 5 10 15 others 12 8 6 10 36 total 82 206 294 405 987 percentage 8.3 20.9 29.8 41 100 table 2: distribution of dermatoses in different age group to various climatic, cultural and socio-economic factors.5 epidemiological data on pediatric dermatoses provides a tool to assess the quality of child health care and build community based health care strategies.6 the high male to female ratio in our study is 33 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 jlmc.edu.np shrestha p. et al. seasonal variation of pediatric dermatoses. comparable with recent study done by sharma s. et al. and patel jk. et al.7,8 similarly, rather sr. et al. reported high frequency in male, with m:f ratio of 1.63:1.9 the study done by poudyal et al. found that the frequency of male children was more common (54.7%) than female.10 there was a wide variation of dermatoses in various season with fungal infection being commonest in summer and eczema being commonest in winter in our study. this was supported by various other studies.7,10 but, in a study done by shrestha et al. and banerjee et al., impetigo was the commonest skin problem with more prevalence in the summer.11,12 a study done by sayal et al. also showed fungal infection to be more common than bacterial and viral infection.13 it can be due to climatic variation in different region of the country. this reflects the fact that warm and humid climate creates the environment for development of fungal infection.14 distribution of pediatric dermatoses in different age group is also important where fungal infection is most common in 11-14 yrs of age in our study. similar result was seen in study done by poudyal et al.10 but in studies done by rather sr. et al. and gul u. et al., acne vulgaris was the single most common dermatoses in adolescents unlike other age group.9,15 milaria was most commonly seen in summer with highest prevalence in 6-10 years age group. as milaria occurs commonly in hot, humid environments, it explains high prevalence in summer in our study. this was supported in study done by shrestha et al. with highest incidence in infants.11 similarly study done by rather sr. et al. also showed highest incidence of milaria in summer.9 study done by banerjee s. et al. revealed that milaria was second most common disease in under five children.12 conclusion: this study provides important data on frequency of dermatological diseases in pediatric patients and its seasonal variation with fungal infection being commonest in summer and eczema in winter. in order to plan for better health care management in children, it is mandatory to have idea about pediatric dermatosis. in the present study we have attempted to acquire sufficient information regarding seasonal variation of pediatric dermatosis. data can be useful in planning of better health programs for children. more survey are required to study the pattern of pediatric dermatology and its seasonal variation in different region of country. references: 1. handa h, handa s, handa r. environmental factors and the skin. 2nd ed. valia rg, valia ar, eds. iadvl textbook and atlas of dermatology. mumbai, india: bhalani; 2001. 82-92 p. 2. ananthakrishnan s, pani sp, nalini p. a comprehensive study of morbidity in school age children. indian pediatr. 2001 sep;38(9):1009-17. 3. encyclopedia. geography of nepal. url:http://www. nationmaster.com 4. pradhan r, shrestha a. ethnic and caste diversity: implications for development. working paper, series no. 4: nepal resident mission, asian development bank, june; 2005. 5. balai m, khare ak, gupta lk, mittal a, kuldeep cm. pattern of pediatric dermatoses in tertiary care centre of south west rajasthan. indian j dermatol. 2012 jul;57(4):275-8. 6. el-khateeb ea, imam aa, sallam ma. pattern of skin diseases in cairo, egypt. int j dermatol. 2011 jul;50(7):844-53. 7. sharma s, bassi r, sodhi mk. epidemiology of dermatoses in children and adolescents in punjab, india. j pak med assoc. 2012;22(3):224-9. 8. patel jk, vyas ap, berman b, vierra m. incidence of childhood dermatosis in india. skinmed. 2010 mayjun;8(3):136-142. 9. rather sr, dogra d, gupta v. study of pattern of pediatric dermatoses in a tertiary care centre in jammu division of jammu and kashmir. int j health sci res. 2015;5(5):124-33. 10. poudyal y, ranjit a, pathak s, chaudhary n. pattern of pediatric dermatoses in a tertiary care hospital of western nepal. dermatol res pract. 2016;2:1-5. 11. shrestha s, jha ak, thapa dp, bhattarai ck. seasonal variation of common skin diseases in pediatric age group: a retrospective study conducted in a medical college of nepal. journal of ucms. 2014;2(1):7-11. 12. banerjee s, gangopadhyay dn, jana s, chanda m. seasonal variation in pediatric dermatoses. indian j dermatol. 2010;55(1):44-6. 13. sayal sk, bal as, gupta cm. pattern of skin diseases in paediatric age group and adolescents. indian j dermatol. 1997;64(3):117-9. 14. hay rj, moore mk. mycology. 7th ed. burns t, breathnach s, cox n, griffiths c, eds. rook's textbook of dermatology. oxford: blackwell science ltd; 2004. 23-31 p. 15. gul u, cakmak sk, gonul m, kilic a, bilgili s. pediatric skin disorders encountered in a dermatology outpatient clinic in turkey. pediatr dermatol. 2008;25:277-8. 34 upper gastrointestinal endoscopy in lumbini medical college and teaching hospital: a retrospective study of two years bishal kc,a,c ms paudel,a,c nabin pokharel,b,d sahadev prashad dhungana,a,c anuj paudel,a,e shamsuddina,c —–————————————————————————————————————————————— abstract: introduction: upper gastrointestinal (ugi) endoscopy includes visualization of the oropharynx, esophagus, stomach, and proximal duodenum, with real time assessment and interpretation of the findings encountered. an upper endoscopy is indicated in the diagnostic evaluation of signs and symptoms of a wide variety of gastrointestinal disorders. besides there are some therapeutic implication of the endoscopy. this study was conducted to study the spectrum of diseases found during the upper gastrointestinal endoscopy in patient presenting in lumbini medical college and teaching hospital (lmcth). methods: this was a retrospective observational study carried out in lmcth. the endoscopic record book of the patients who underwent ugi endoscopy for various reasons from february 2011 to 2013 was analysed. the risk factor of smoking and alcohol was also included and analysed in the study. results: all together 550 upper gi endoscopy was performed in the two years. there were 290 males (52.72%) and females were 260 (47.38%). the mean age was 45.7 years (sd=17.9). most of the patient belonged to the age group 41 to 80 years (71%). among total patients, 209 (38%) of them were found to be macroscopically normal. of those who had positive endoscopic findings; 165 (48.4%) had gastritis and 36 (10.6%) had duodenal ulcer, esophageal varices was in 30 (8.8%), gastric carcinoma in nine (2.6%) of cases. cigarette smoking was significantly associated with the presence of peptic ulcer disease (p=0.01) and malignancy of gastrointestinal tract (p=0.03). alcohol intake was non-significantly related to peptic ulceration (p=0.07) and malignancy of gastrointestinal tract (p=0.09). conclusion: upper gastrointestinal endoscopy is a safe and useful procedure for investigating patients with gastrointestinal complains. gastritis was the most common finding among the patients who had abnormal endoscopy followed by duodenal ulcer and esophageal varices. keywords: endoscopy • gastritis • peptic ulcer disease • varices ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer b assistant professor c department of medicine, lumbini medical college d department of surgery, lumbini medical college e department of pathology, lumbini medical college corresponding author: dr. bishal kc e-mail: bishalk@gmail.com how to cite this article: kc bishal, paudel ms, pokharel n, dhungana sp, paudel a, shamsuddin. upper gastrointestinal endoscopy in lumbini medical college and teaching hospital: a retrospective study of two years. journal of lumbini medical college. 2013;1(1):7-9. doi:10.22502/ jlmc.v1i1.3. ___________________________________________________________________________________ j. lumbini. med. coll. vol 1, no 1, jan-june 2013 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v1i1.3 introduction: upper gastrointestinal diseases are major causes of morbidity and mortality.1,2 upper gastrointestinal endoscopy (ugie) has become a corner stone in the diagnosis and treatment of many of gastrointestinal disorders.3 the direct visualization of the entire esophagus, stomach and duodenum with the facility to obtain material for analysis and to perform various therapeutic measures, make endoscopy superior to other diagnostic procedures.4,5 upper endoscopy, also referred to as esophagogastro-duodenoscopy (egd), is performed by passing a flexible endoscope through the mouth into the esophagus, stomach, bulb, and second duodenum. the procedure is the best method of examining the upper gastrointestinal mucosa.6 7 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np kc b. et al. upper gastrointestinal endoscopy in lumbini medical college and teaching hospital. methods: patients with various complaints presenting in lumbini medical college and teaching hospital (lmcth) were retrospectively analyzed. the endoscopic record book was reviewed from february 2011 to 2013, total duration of two years. all clinico-epidemiological data were reviewed and analyzed. all patients were subjected for upper gi endoscopy after taking prior consent. premedication was given with lidocaine mouth wash. fujinon video endoscope was used to visualize the upper gi tract. it was disinfected with 2% glutaraldehyde solution before and after the procedure. esophageal, gastric and duodenal mucosa was carefully examined for evidence of inflammation, ulceration, erosions. mucosal biopsy, followed by histopathological examination was done if mucosal abnormality was found. data were analyzed using software spss 21 version. results: a total of 550 upper gi endoscopy was performed in two years from february 2011 to 2013. there were 290 males (52.72%) and 260 females (47.27%). the male to female ratio was 1.1:1. the age range was from 13 to 90 years. the mean age was 45 year (sd=17.9). majority were in the age group 41-80 years. regarding the endoscopic findings, the majority of the patients had gastritis 165 (48.4%). duodenal ulcer was found among 36(10.6%) patients, duodenitis 33 (9.7%), esophageal varices 30 (8.8%), gastric ulcer 23(6.7%). discussion: nepal is a country with varying environmental regions and the inhabitants belong to wide ethnic diversities with different cultures and social habits. there are few hospital based studies regarding the findings of the upper gastrointestinal endoscopy. the procedure is done in various hospitals of nepal and there are few published data regarding the findings of the procedure. so, this study was done to address those lacking data of the people of nepal in this part of the country. this study is based on the retrospective analysis of the patients presenting with various complaints. the procedure was safe and there was no any major complication among the patients. majority of the patient who underwent endoscopy were male 290 (52.72%) and the majority belonged to the age group 41-80 which was similar to the studies done before.7 the most frequent disorder diagnosed by upper gastrointestinal endoscopy is gastritis 165 (48.4%). the finding is consistent with the previous review done by kamiya et al, who performed a large review done in six different countries to investigate the situation on endoscopic diagnosis and treatment of gastrointestinal disorders in east asian countries. they found that the gastritis was the most frequently occurring diagnosis in all asian countries.8 one reason of this result is that the prevalence of helicobacter pylori infection is still high in east asian countries. in addition, these patients of gastritis probably include functional dyspepsia patients, who have chronic upper gastrointestinal symptoms with no mucosal lesion on endoscopy. gastritis will be on the decline with the improvement of hygiene and decrease in helicobacter pylori prevalence in future. duodenal ulcer was quite high 36 (10.6%) which might be related to high rate of h. pylori infection in this part of the world. h. pylori is implicated in the occurrence of duodenal ulcer and it is more common in the developing countries, and nepal is not an exception.9-11 gastric ulcer was found in 23 (6.7%) of the patients which was similar to the studies done by groenen et al.12 esophageal varices was quiet common in our study which turned out to be 30 (8.8%). this might be due to high rate of alcohol in this part of nepal. alcohol is one of the risk factors for the cirrhosis of liver and esophageal varices is a common occurrence in presence of cirrhosis of liver.13 we also analyzed the frequent occurrence of gastrointestinal malignancy and peptic ulcer disease among smokers and alcohol consumer. in our study, we found there was a statistically significant relation of smoking to the occurrence of gastrointestinal malignancy. the findings are consistent with the studies done in the other part of the world showing the higher occurrence of gi malignancies among the smokers.14-17 regarding the alcohol intake it was related but not statistically significant. in some of the previous studies, consistent association between alcohol consumption and the risk of gastric cancer has not been demonstrated.18,19 interestingly, a study from europe even suggested that daily intake of wine may be protective.18 cigarette smoking was significantly related to the occurrence peptic ulcer disease in this study. studies primarily performed 8 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 kc b. et al. upper gastrointestinal endoscopy in lumbini medical college and teaching hospital. jlmc.edu.np in the pre h. pylori era found that smoking had an important facilitative role for peptic ulcer disease.20-23 regarding alcohol there was non-significant relation with the occurrence of peptic ulcer disease alcohol in high concentrations damages the gastric mucosal barrier to hydrogen ions and is associated with acute gastric mucosal lesions characterized by mucosal hemorrhages. alcohol also stimulates acid secretion.24 the contents of alcoholic beverages other than alcohol are also strong stimulants of acid secretion. despite these acute effects, there is no evidence that alcohol intake causes or exacerbates chronic peptic ulcer disease.25,26 modest alcohol consumption may even promote ulcer healing.27,28 in contrast, alcohol abuse interferes with patient compliance and ulcer healing.29 retrospective nature of the study is the main limitation. due to this, we could not follow up the outcome of those patients with the various diagnoses. a further prospective study with detail clinical evaluation is required to verify or refute the findings in our study results. conclusion: gastritis is still the most common endoscopic finding in our study. however peptic ulcer disease and the esophageal varices are also common. references: 1. spiller r. abc of the upper gastrointestinal tract (clinical review). anorexia, nausea, vomiting and pain. bmj. 2001;323:1354-7. 2. kolk h. evaluation of symptom presentation in dyspeptic patients referred for uppergastrointestinal endoscopy in estonia. croat med j. 2004;45:592-8. 3. editorial. endoscopy in general practice. bmj. 1995;310:816-7. 4. axon atr, bell gd, jones rh et al. guidelines on appropriate gastrointestinal endoscopy. bmj. 1995;310:853-6. 5. agbakwuru ea, fatusi ao, ndububa da et al. pattern and validity of clinical diagnosis of upper gastrointestinal diseases in south-west nigeria. afr health sci. 2006;6:98-103. 6. loius m, wong ks, mark k. gastrointestinal endoscopy. technology status evaluation report. 2007;66:872-80. 7. suleiman si, salih sy, ahmed ze, kimora k. upper gastrointestinal fibreoptic endoscopy in khartoum. sud med j. 1977;15:19-24. 8. kamiya t, joh t et al. consensus of the present and prospects on endoscopic diagnosis and treatment in east asian countries. diagnostic and therapeutic endoscopy. 012:808365.9 pages. doi: 10.1155/2012/808365. 9. t. ytgat g, langenberg w, rauws e, rietra p. campylobacter like organism (clo) in the human stomach. gastroenterol. 1985;88:1620-4. 10. borody tj, george ll, brandl s et al. helicobacter pylorinegative duodenal ulcer. am j gastroenterol. 1991;86:1154-7. 11. li z, zou d, ma x et al. epidemiology of peptic ulcer disease: endoscopic results of the systematic investigation of gastrointestinal disease in china. am j gastroenterol. 2010;105:2570-7. 12. groenen mj, kuipers ej, hansen be, ouwendijk rj. incidence of duodenal ulcers and gastric ulcers in a western population: back to where it started. can j gastroenterol. 2009 september;23(9):604–8. 13. dufour mc: alcoholic liver disease. in giepidemiology. 1st edition. edited by talley nj, locke iii gr, saito y. malden, massachusetts: blackwell publishing, inc; 2007:231-7. 14. trédaniel j, boffetta p, buiatt e et al. tobacco smoking and gastric cancer: review and meta-analysis. int j cancer. 1997;72:565-73. 15. gonzález ca, pera g, agudo a et al. smoking and the risk of gastric cancer in the european prospective investigation into cancer and nutrition (epic). int j cancer. 2003;107:629-34. 16. barstad b, sørensen ti, tjønneland a, et al. intake of wine, beer and spirits and risk of gastric cancer. eur j cancer prev. 2005;14:239-43. 17. freedman nd, abnet cc, leitzmann mf et al. a prospective study of tobacco, alcohol, and the risk of esophageal and gastric cancer subtypes. am j epidemiol. 2007;165:1424-33. 18. barstad b, sørensen ti, tjønneland a et al. intake of wine, beer and spirits and risk of gastric cancer. eur j cancer prev. 2005;14:239-43. 19. d’avanzo b, la vecchia c, franceschi s. alcohol consumption and the risk of gastric cancer. nutr cancer. 1994;22:57-64. 20. martin df, montgomery e, dobek as et al . campylobacter pylori, nsaids, and smoking: risk factors for peptic ulcer disease. am j gastroenterol. 1989;84:1268-72. 21. anda rf, williamson df, escobedo lg, remington pl. smoking and the risk of peptic ulcer disease among women in the united states. arch intern med. 1990;150:1437-41. 22. korman mg, hansky j, eaves er, schmidt gt. influence of cigarette smoking on healing and relapse in duodenal ulcer disease. gastroenterol. 1983;85:871-4. 23. rosenstock s, jørgensen t, bonnevie o, andersen l. risk factors for pepc ulcer disease: a populaon based prospective cohort study comprising 2416 danish adults. gut. 2003;52:186-93. 24. peterson wl, barne c, walsh jh. effect of intragastric infusions of ethanol and wine on serum gastrin concentration and gastric acid secretion. gastroenterology. 1986;91:1390-5. 25. aldoori wh, giovannucci el, stampfer mj et al. a prospective study of alcohol, smoking, caffeine, and the risk of duodenal ulcer in men. epidemiol. 1997;8:420-4. 26. armstrong d, arnold r, classen m et al. ruder—a prospective, two-year, multi-center study of risk factors for duodenal ulcer relapse during maintenance therapy with ranitidine. ruder study group. dig dis sci. 1994;39:1425-33. 27. sonnenberg a, müller-lissner sa, vogel e et al. predictors of duodenal ulcer healing and relapse. gastroenterol. 1981;81:1061-7. 28. baaglia b, di mario f, doo p, naccarato r. alcohol intake and acute duodenal ulcer healing. am j gastroenterol. 1990;85:1198-200. 29. reynolds jc. famodine therapy for active duodenal ulcers. a multi-variate analysis of factors affecting early healing. ann intern med. 1989;111:742-6. 9 j. lumbini. med. coll. vol 9, no 2, july-dec 2021 pradhan n, et al. effect of anemia in pregnancy and its perinatal outcome: a prospective cohort study jlmc.edu.np ___________________________________________________________________________________ submitted: 26 may, 2021 accepted: 06 october, 2021 published: 17 november, 2021 alecturer, department of obstetrics and gynaecology bprofessor & head, department of obstetrics and gynaecology csenior consultant pediatrician, department of neonatology ddhulikhel hospital, nepal. e-.paropakar maternity and women’s hospital, kathmandu, nepal. corresponding author: noora pradhan e-mail: mailto:drnoorapradhan@gmail.com orcid: https://orcid.org/0000-0001-6076-967x_______________________________________________________ abstract: introduction: anemia is a major risk factor for poor maternal health status. anemia during pregnancy leads to poor birth outcomes such as fetal anemia, low birth weight, preterm birth, stillbirth, and neonatal mortality. this study aimed to assess the effect of anemia in pregnancy and its perinatal outcome. methods: a prospective study was conducted among 370 pregnant women in dhulikhel hospital, kavre from june 2017 to december 2017. descriptive statistics were used to represent the socio-clinical characteristics. bivariate analysis was performed to analyze the effect of anemia. results: the study found that all the participants were anemic out of which mild anemia was observed in 352 (95.4%), moderate anemia in 17 (4.6%), and severe anemia in one (0.3%) participants respectively. women aged 17 to 24 years and multiparous women had higher odds of having moderate anemia (hb 7.0-8.9 g/dl). women with moderate anemia had more odds of having neonates with less apgar scores. women with moderate anemia had nine times higher odds of having newborn mortality. conclusion: anemia during pregnancy not only affects the health status of the mother but also impacts the birth outcomes. this study highlighted the emphasis on the active participation of governmental and non-governmental organizations to prevent adverse effects of anemia during pregnancy and birth outcomes. keywords: anemia; birth outcomes; mortality; perinatal; pregnancy original research articlehttps://doi.org/10.22502/jlmc.v9i2.445 noora pradhan,a,d suman raj tamrakar,b,d shailendra bir karmacharya c,e effect of anemia in pregnancy and its perinatal outcome: a prospective cohort study how to cite this article:how to cite this article: pradhan n, tamrakar sr, karmacharya sb. effect of anemia in pregnancy and its perinatal outcome: a prospective cohort study.. journal of lumbini medical college. 2021;9(2):6 pages. doi: https:// doi.org/10.22502/jlmc.v9i2.445. epub: november 17, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: anemia is a critical public health problem affecting the developed as well as developing world. [1] anemia is the condition in which the number of red blood cells or their oxygen-carrying capacity is inadequate to meet the physiologic needs. anemia in pregnancy has been defined by world health organization (who) as the hemoglobin (hb) concentration less than 11 g/dl where hb less than 9.0-10.9 g/dl is mild anemia, 7.0-8.9 g/dl is moderate anemia and hb less than 7.0 g/dl is severe anemia.[2] as per who, it has been estimated that globally 40% of pregnant women are anemic.[3] iron deficiency anemia during pregnancy is one of the major public health problems.[4] there are multifactorial causes of anemia during pregnancy that include, micronutrient deficiencies of iron, folate due to parasitic infections such as malaria and hookworm, or chronic infections like tb and hiv. [5] studies have shown that 56% of pregnant women globally belong to low and middle-income countries (lmic).[6] southeast asia has a 48% of prevalence of anemia after sub-saharan africa (ssa). anemia prevalence during pregnancy is highest in india (87%), bangladesh (77%), nepal (65%), sri-lanka (60%), and bhutan (59%).[7] j. lumbini. med. coll. vol 9, no 2, july-dec 2021 pradhan n, et al. effect of anemia in pregnancy and its perinatal outcome: a prospective cohort study jlmc.edu.np as per nepal demographic health survey (ndhs, 2016), 41% of the women aged 15 to 49 years are anemic. even though the prevalence of anemia among pregnant women had slightly declined from 48 % to 46% it is still a public health problem in context of nepal.[8] anemia during pregnancy leads to a burden in maternal morbidity, mortality, and poor birth outcomes such as fetal anemia, low birth weight (lbw), preterm birth, and stillbirth. [9,10] very few studies have been conducted in dhulikhel hospital to identify the incidence and outcome of anemia during pregnancy. the outcomes of this study would help to focus on educating people for the need or correction of anemia before pregnancy. methods: a prospective cohort study was conducted from june 2017 to december 2017 to identify the perinatal outcome of anemia during pregnancy. the study was conducted among pregnant women who attended the dhulikhel hospital out-patient department (opd), labor room, and emergency after the approval of institutional review committee (irc) (approval number:97/17). pregnant women who were identified with anemia, aged between 17– 35 years with singleton pregnancy and gravida three or less were included in this study. classification of anemia was done according to world health organisation (who) definition of anemia as the hemoglobin (hb) concentration less than 11 g/dl where hb less than 9.0-10.9 g/dl is mild anemia, 7.0 -8.9 g/dl is moderate anemia and hb less than 7.0 g/ dl is severe anemia. the sample size of this study was determined by the cochran formula, with the proportion (prevalence of anemia during pregnancy) 46%, 5% precision, and 95% confidence interval, which was calculated as 339. the final sample size with a 10% non-response rate was 370. all the patients fulfilling the inclusion criteria were included in the sample. the hematological examination of the pregnant women was conducted in third trimester and followed till delivery. the patient was provided with informed consent before enrolling the patient in the study. the hematological analysis was done in the lab of dhulikhel hospital. data were collected and analyzed after the irc clearance was obtained for the research. the collected data was entered on microsoft excel and exported and analyzed in spss. descriptive statistics were used to summarize data while bivariate logistic regression analysis was performed to analyze the effect of anemia. the association between anemia during pregnancy and independent variables such as adverse perinatal outcomes were assessed by calculating the odds ratio (or) at 95% confidence interval (ci). here, p-value < 0.05 was considered as statistically significant. results: a total of 467 pregnant women were identified with anemia during the study among 1864 pregnant women who visited opd, labor room and emergency room of dhulikhel hospital between june to december 2017. out of them 370 mothers were selected as per the sample size and inclusion criteria. table 1 socio-clinical characteristics of study participants (n=370). variable name n (%) age in years(n=352)* (mean±sd) 24.9±4.61 17 to 24 203 (57.7%) 25 to 35 149 (42.3%) parity* nullipara 222(60.2%) primipara 109(29.5%) multipara 38 (10.3%) booking* unbooked 148 (41.2%) booked 217 (58.8%) anemia severe(<7g/dl) 1 (0.3%) moderate(7-8.9 g/dl) 17 (4.6%) mild (9-10.9 g/dl) 352 (95.1%) risk factor* no 347 (88.5%) yes 22 (6.3%) mode of delivery* vaginal 258 (69.9%) lscs 111 (30.1%) *variables with missing information j. lumbini. med. coll. vol 9, no 2, july-dec 2021 pradhan n, et al. effect of anemia in pregnancy and its perinatal outcome: a prospective cohort study jlmc.edu.np table 2 association between socio-clinical characteristics with the severity of anemia. variable name severity of anemia p-value moderate mild maternal age (n=352) 17 to 24 years 10(58.8%) 193(57.6%) 0.921 25 to 35 years 7(41.2%) 142(42.4%) parity nullipara 8(47.1%) 214(60.8%) 0.17 primipara 5(29.4%) 104(29.5%) multipara 4(23.5%) 34(9.7%) registration status booked 8(47.1%) 209(59.4%) 0.314 unbooked 9(52.9%) 143(40.6%) mode of delivery normal 9(52.90%) 249(70.70%) 0.118 lscs 8(47.1%) 103(29.3%) birth weight (grams) less than 2500 4(23.5%) 51(14.5%) 0.303 2500-3500 13(76.5%) 270(76.7%) more than 3500 0(0.0% 31(8.8%) preterm no 14(82.4%) 310(88.1%) 0.482 yes 3(17.6%) 42(11.9%) apgar score < 6 at 1 minute no 13(76.5%) 344(97.7%) <0.001 yes 4(23.5%) 8(2.3%) apgar score < 6 at 5 minute no 15(88.23%) 348(98.86%) <0.001 yes 2(11.76)% 4(1.13)% nicu stay no 16(94.1%) 339(96.3%) 0.644 yes 1(5.9% 13(3.7%) newborn mortality no 15(88.2%) 347(98.6%) 0.002 yes 2(11.8%) 5(1.4%) chi-square test table 3. social and clinical characteristics associated with anemia in pregnancy (n=369) variables moderate anemia (hb 7.8-9.0 g/dl) n(%) mild anemia (hb 9.0-10.9g/dl) n(%) unadjusted or (95% ci) p-value age (years) 25 to 35 7(41.2%) 142(42.4%) 1 0.921 17 to 24 10(58.8%) 193(57.6%) 1.05(0.39-2.82) parity primipara 5(29.4%) 104(29.5%) 1 nullipara 8(47.1%) 214(60.8%) 0.77(0.24-2.43) 0.666 multipara 4(23.5%) 34(9.7%) 2.44 (0.62-9.63) 0.201 booking* unbooked 8(50.0%) 140(40.1%) 1 0.318 booked 8(50/0%) 209(59.9%) 0.60(0.22-1.61) *variable with missing values j. lumbini. med. coll. vol 9, no 2, july-dec 2021 pradhan n, et al. effect of anemia in pregnancy and its perinatal outcome: a prospective cohort study jlmc.edu.np table 1 shows that mild anemia was observed in 352 (95.4%) participants followed by moderate 17 (4.6%) and severe one (0.3%) respectively. out of the total participants, a few 22 (5.9%) had the presence of risk factors such as pre-eclampsia and hypothyroidism. the majority of the participants 258 (69.9%) had vaginal delivery followed by lscs 111 (30.1%). table 2 shows that moderate anemia was seen more among the age group of 17 to 24 years but the association was not statistically significant. it was observed that moderate anemia was more in participants with apgar score < 6 at 1 minute and this association was statistically significant (p<0.001). similarly, moderate anemia was observed more in participants with apgar score < 6 at 5 minutes which was also statistically significant (p=0.01). the moderate anemia was also observed more in participants with newborn mortality and this association was statistically significant (p=0.002). other factors like parity, registration status, mode of delivery, birth weight, preterm birth, and nicu stay were assessed but no association was found between severity of anemia during pregnancy. table 3 shows an association between anemia and the predictor variables. women aged 17 to 24 had 5% higher odds of having moderate anemia. multiparous women had 2.5 times higher odds of having moderate anemia (or; 2.44; 95% ci 0.62-9.63) in comparison to primipara. the women who had booked the services at dhulikhel hospital had 40% fewer odds of having moderate anemia (or; 0.60; 95% ci 0.22-1.61). however all of the mentioned association was not statistically significant. birth outcomes associated with anemia during pregnancy women delivering a baby with apgar <6 at 1 minute had 13 times higher odds of having moderate anemia (or: 13.23, 95% ci: 3.52-49.61) with significance (p=0.001). women delivering a baby with apgar <6 at 5 minutes had 11 times more odds of having moderate anemia (or: 11.60, 95% ci: 1.96-68.39) with significance (p=0.007). women having moderate anemia during pregnancy had 9.25 times higher odds of having neonatal mortality (or: 9.25, 95% ci: 1.65-51.64) with a significance of (p=0.011). other factors like mode of delivery, preterm birth, low birth weight, and nicu stay were assessed but no association was found between mild and moderate anemia during pregnancy. discussion: anemia is a common issue in pregnant women in lower middle-income countries like nepal. many similar studies have been conducted to observe the pregnancy outcomes in anemic pregnant women.[5,11,12] our study was conducted among table 4. birth outcomes associated with anemia during pregnancy (n=369) variables moderate anemia n(%) mild anemia n(%) unadjusted or (95% ci) p value mode of delivery vaginal 9(52.9%) 249(69.9%) 1 0.126 lscs 8(47.1%) 103(29.3%) 2.14(0.80-5.72) preterm no 14(82.4%) 310(88.1%) 1 0.485 yes 3(17.6%) 42(11.9%) 1.58(0.43-5.73) low birth weight no 13(76.5%) 301(85.5%) 1 0.313 yes 4(23.5%) 51(14.5%) 1.81(0.57-5.78) apgar <6 at 1 minute no 13(76.5%) 344(97.7%) 1 0.0001 yes 4(23.5%) 8(2.3%) 13.23(3.52-49.61) apgar <6 at 5 minute no 15(88.2%) 348(98.9%) 1 0.007 yes 2(11.8%) 4(1.1%) 11.60(1.96-68.39) nicu stay no 16(94.1%) 339(96.3%) 1 0.648 yes 1(5.9%) 13(3.7%) 1.63(0.20-13.24) newborn mortality no 15(88.2%) 347(98.6%) 1 0.011 yes 2(11.8%) 5(1.4%) 9.25(1.65-51.64) j. lumbini. med. coll. vol 9, no 2, july-dec 2021 pradhan n, et al. effect of anemia in pregnancy and its perinatal outcome: a prospective cohort study jlmc.edu.np participants in the third trimester. the present study findings showed that all the participants were anemic. while the majority of them were mild anemic, only one was severely anemic. a study by mulepati et al. found that anemia was highly prevalent in women in the third trimester while another study showed that prevalence was higher in pregnant women in the second trimester. [12,13] a study by lamichhane et al. presented that the majority of participants were moderately anemic while no severe cases of anemia were identified.[14] this was also consistent with the study by ahmad & kalsoom.[15] however, it should be noted that all the participants of the present study were found anemic. this difference might be due to difference in the sample size and study settings. our study found that the severity of anemia prevalence was more in participants aged 17 to 24 years which can be due to majority of the participants belonged to the same age group. similar findings were presented in the study by sharma et al, which showed that low-aged women were more anemic.[16] in the present study, 58% of the women were booked cases which were similar to the study by upadhyay et al.[11] the same study showed that anemia during pregnancy was more common in multipara women which was contrasted in the present study because the mild anemia was more common in nullipara women which can be due to more participants between the age of 17 to 24 years in the study. similar findings observed in another study showed 1.3 times more odds of having anemia.[5] such similar result can be due to the similar representation of age group of participants. the current study showed an association between anemia and birth outcomes such as apgar scores and newborn mortality. association between anemia and apgar score of less than six at 1 minute was observed in another study.[15] cakmak et al. depicted that the low apgar scores were significantly more prevalent among women with abnormal hb levels in third trimesters of pregnancy which was similar to the present study with low apgar scores highest in women having moderate anemia.[17] a study by lone et al. showed women having moderate anemia had 1.8 times increased risk of having apgar score less than 5 at 1 min while women in the present study had 13.23 times higher risk of having apgar score of less than 6 at 1 min.[18] also, in present study anemia and mode of delivery were not statistically significant. but findings presented in another study, cesarean delivery showed 4.8 times higher risk of anemia.[19] a high incidence of the birth outcome in the form of low birth weight, preterm births, and nicu stay was seen in the present study but these outcomes were not statistically significant with anemia in our study. these outcomes were also not found to be statistically associated with anemia in the study by stephen et al.[5] conclusion: the high prevalence of anemia during pregnancy in this study implies that maternal anemia is a important public health problem in middle-income countries like nepal. anemia during pregnancy not only affects the health status of the mother but also impacts birth outcomes. this study highlighted the emphasis on the active participation of governmental and non-governmental organizations to prevent adverse effects of anemia during pregnancy and birth outcomes. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. references: 1. chaparro cm, suchdev ps. anemia epidemiology, pathophysiology, and etiology in lowand middle-income countries. ann n y acad sci. 2019;1450(1):15-31. pmid: 31008520 doi: https://doi.org/10.1111/nyas.14092 2. world health organization. iron deficiency anemia: assessment, prevention and control [internet]. world health organization. report number: who/nhd/01.3, 2001. https:// www.who.int/nutrition/publications/en/ida_ assessment_prevention_control.pdf 3. world health organization. anaemia [internet]. geneva: who; 2021. available from: https:// www.who.int/health-topics/anaemia [accessed 28 march, 2021] 4. black re, victora cg, walker sp, bhutta za, christian p, de onis m, et al. maternal and child undernutrition and overweight in low-income j. lumbini. med. coll. vol 9, no 2, july-dec 2021 pradhan n, et al. effect of anemia in pregnancy and its perinatal outcome: a prospective cohort study jlmc.edu.np and middle-income countries. the lancet. 2013;382(9890):427-51. doi: https://doi. org/10.1016/s0140-6736(13)60937-x 5. stephen g, mgongo m, hussein hashim t, katanga j, stray-pedersen b, msuya se. anaemia in pregnancy: prevalence, risk factors, and adverse perinatal outcomes in northern tanzania. anemia. 2018;2018(0):1846280. pmid: 29854446 doi: https://doi. org/10.1155/2018/1846280 6. osman mo, nour ty, bashir hm, roble ak, nur am, abdilahi ao. risk factors for anemia among pregnant women attending the antenatal care unit in selected jigjiga public health facilities, somali region, east ethiopia 2019: unmatched case-control study. j. multidiscip healthc. 2020;13(0):769-777. pmid: 32848406 doi: https://doi.org/10.2147/jmdh.s260398 7. sukrat b, wilasrusmee c, siribumrungwong b, mcevoy m, okascharoen c, attia j, et al. hemoglobin concentration and pregnancy outcomes: a systematic review and metaanalysis. biomed res int. 2013;2013(0):769057. doi: https://doi.org/10.1155/2013/769057 8. ministry of health nepal, new era, icf. nepal demographic health survey 2016. ministry of health, nepal: kathmandu, nepal; 2017. available from: https://www.dhsprogram.com/ pubs/pdf/fr336/fr336.pdf 9. helmy me, elkhouly n, ghalab ra. maternal anemia with pregnancy and its adverse effects. 2018;31(1):7-11. available from: https://www. mmj.eg.net/text.asp?2018/31/1/7/234258 10. kumari s, garg n, kumar a, guru pki, ansari s, anwar s, et al. maternal and severe anaemia in delivering women is associated with risk of preterm and low birth weight: a cross sectional study from jharkhand, india. one health. 2019;8(0):100098. pmid: 31485474 doi: https://doi.org/10.1016/j.onehlt.2019.100098 11. upadhyay c, upadhyay n. effect of anemia on pregnancy outcome: a prospective study at tertiary care hospital. international journal of reproduction, contraception, obstetrics and gynecology. 2017;6(12):5379-83. doi: https:// dx.doi.org/10.18203/2320-1770.ijrcog20175246 12. mulepati s, chaudhary tk. determinants of anemia among pregnant women attending in a tertiary level hospital, kathmandu. med phoenix. 2017;2(1):24-33. doi: https:// www.jnmc.com.np/index.php/jnmc/article/ download/20/17/93 13. ghimire n, pandey n. knowledge and practice of mothers regarding the prevention of anemia during pregnancy, in teaching hospital, kathmandu. journal of chitwan medical college. 2013;3(5):14-17. doi: https://doi. org/10.3126/jcmc.v3i3.8631 14. lamichhane a, gurung s, panthee k, shrestha d. prevalence of maternal anemia in a tertiary care hospital in western nepal. j nepal med assoc. 2019;57(218):238-42. pmid: 32323654 15. ahmad mo, kalsoom u. effect of maternal anaemia on apgar score of newborn. journal of rawalpindi medical college. 2015;19(3):23942. https://www.journalrmc.com/index.php/ jrmc/article/view/246 16. sharma d, amgain k, panta pp, pokhrel b. hemoglobin levels and anemia evaluation among pregnant women in the remote and rural high lands of mid-western nepal: a hospital based study. bmc pregnancy childbirth. 2020;20(0):182. doi: https://doi.org/10.1186/ s12884-020-02870-7 17. cakmak bd, turker ua, oztas s, arik m, ustunyurt e. the effect of first trimester hemoglobin levels on pregnancy outcomes. turk j obstet gynecol. 2018;15(3):165-170. pmid: 30202626 doi: https://doi.org/10.4274/ tjod.87269 18. lone fw, qureshi rn, emanuel f. maternal anaemia and its impact on perinatal outcome. tropical medicine & international health. 2004;9(4):486-90. doi: https://doi.org/10.1111/ j.1365-3156.2004.01222.x 19. malhotra m, sharma jb, batra s, sharma s, murthy ns, arora r. maternal and perinatal outcome in varying degrees of anemia. int j gynaecol obstet. 2002;79(2):93-100. pmid: 12427391 doi: https://doi.org/10.1016/s00207292(02)00225-4 outcome of eclamptic mothers attending tertiary care centre from home and those referred from primary heath care site: a comparative study upendra pandit,a,d chittaranjan das,b,d farhat banu,c,d shakil ahamadc,e —–————————————————————————————————————————————— abstract: introduction: magnesium sulphate (mgso4) is an effective and safe drug which stabilizes the patient within few hours of eclampsia and terminates subsequent seizures if it is given on time. the aim of this study was to compare maternal and fetal outcome between a group of eclamptic mothers who came to the tertiary care hospital directly without receiving mgso4 (group 1) and those referred from primary care centers after receiving loading dose of mgso4 (group 2). methods: this is a retrospective cohort study of eclamptic mothers who were admitted and managed from the period of 1st january 2012 to 31st march 2016 at nepalgunj medical college teaching hospital, nepal. sociodemographic characters and maternal and fetal outcome was compared between the two groups. results: among 92 cases, 57 (62%) were from group 1 and 35 (38%) were from group 2. most of the mothers attended from banke district (n=52, 56.5%) followed by bardia district (n=17, 18.5%). brahmin and chhetri were 20 (35%) and 10 (29%); muslim 16 (28%) and four (11%); janajati from terai 16 (28%) and eight (23%); janajati from hilly region four (7%) and five (14%); and chaudhari one (2%) and eight (23%) in group 1 and group 2 respectively. more (n=26, 74%) mothers had baby with good apgar score in group 2 than in group 1 (n=33, 58%). there were 14 (15.2%) still births; nine (16%) in group 1 and five (14%) in group 2. complication rate was observed more in group 1 (n=16, 28%) than in group 2 (n=7, 20%) and the most common complication in both groups was wound infection. the mean days of hospital stay was 5.96 (sd=3.32) and 5.91 (sd=3.38) in group 1 and group 2 respectively. conclusion: the group receiving magnesium sulphate in primary care centre have good fetal outcome and less maternal complications compared to those who were admitted directly in tertiary care centre and receive the treatment there. keywords: eclampsia • magnesium sulphate • seizure • treatment outcome ——————————————————————————————————————————————— ___________________________________________________________________________________ a assistant professor b professor c lecturer d department of obstetric and gynecology nepalgunj medical college teaching hospital, nepal e department of pediatrics, nepalgunj medical college teaching hospital, nepal corresponding author: dr. upendra pandit e-mail: drupandit@gmail.com how to cite this article: pandit u, das cr, banu f, ahmad s. outcome of eclamptic mothers attending tertiary care centre from home and those referred from primary heath care site: a comparative study. journal of lumbini medical college. 2016;4(1):24-7. doi: 10.22502/jlmc.v4i1.79. ___________________________________________________________________________________ j. lumbini. med. coll. vol 4, no 1, jan-june 2016 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v4i1.79 introduction: eclampsia alone accounts for 30% of maternal deaths in nepal.1 the challenge behind it is the prevention and early detection of pre-eclamptic state in an antenatal mother. the management depends on the maternal conditions, gestational age, fetal wellbeing, cervical status and previous obstetric history. foremost management approach is stabilization of an eclamptic mother and termination of the seizures and pregnancy. magnesium sulphate (mgso4) is an effective and safe drug which stabilizes the patient within few hours of eclampsia and controls subsequent seizures if given on time.2 it is of utmost help if it can be given as soon as seizure develops. the number of seizures is one of the strongest determinants of poor feto-maternal outcomes.3 a hospital study found that the majority of women had the first fit at home (70.21%), whereas 24 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 pandit u. et al. outcome of eclamptic mothers attending tertiary care centre. jlmc.edu.np approximately one fourth of them had it while already in the hospital (25.53%).4 ministry of heath, nepal, has made the provision of availability of mgso4 in primary health care centre. although there are different barriers in health care systems for the availability and utilization of magnesium sulfate for eclampsia,5 we have assumed that the eclamptic patients who are referred from primary care centre after receiving loading dose of mgso4 on time i.e. immediately after first fit have better maternal and fetal outcomes than those patients who are brought directly to the referral centre without mgso4 treatment. so the objective of this study was to compare the fetomaternal outcomes between these two groups. methods: this is a retrospective cohort study of eclamptic mothers who were admitted and managed at nepalgunj medical college teaching hospital (ngmcth) which is a tertiary care hospital situated in nepalgunj city in western nepal. patients from the districts of mid and far western region of the country are referred to this hospital for tertiary care. this hospital has well equipped intensive care facility for the management of obstetric emergencies. ethical approval and clearance were taken from hospital administration of ngmcth and secondary data of all patients with eclampsia were collected from the period of 1st january 2012 to 31st march 2016. the eclamptic mothers who delivered in the hospital were included in this study. cases of postpartum eclampsia were excluded from the study. these cases were divided into two groups. group 1 was a group of eclamptic mothers who came to the tertiary care hospital without receiving mgso4. group 2 consisted of referred cases from primary care centers after receiving a loading dose of mgso4. sociodemographic characters and maternal and fetal outcomes were compared between the two groups. the following variables were recorded: age, date and time of admission, referral card and details, address, gestational age, date, time and place of administration of loading dose of mgso4 and the completion of its maintenance dose. mode and time of delivery, apgar score, birth weight and maternal and fetal morbidity and mortality were also recorded. data were tabulated and analyzed using ibm spss 20. correlations of the variables were observed. a 95% confidence interval and p value of <0.05 were considered as statistically significant. a chi-square test, fisher exact test, and t-test were used to compare proportions and mean. results: patient’s characteristics: among 92 cases, 57 (62%) were brought directly in the tertiary care hospital (group 1) and 35 (38%) were brought from a primary care center (group 2). group 1 received mgso4 only after they reached the hospital. thirty five (38%) patients were referred with a referral note from the primary care centre after receiving loading dose of mgso4. the mean age of all patients was 20.79 yr (sd=3.3). the most common age group was 20-24 yr (n=32, 56% and n=21, 60%) followed by the age group 15-19 yr (n=19, 33% and n=8, 23%) in group 1 and group 2 respectively. there were no significant differences between the two cohorts regarding age, gestational age, and mode of delivery (table 1). the mean gestational age was 37.2 yr (sd=2.2) and 37.2 yr (sd=2.1) in group l and group 2 respectively. table 2 shows the frequency distribution of cases in each group according to the district from where they were brought. most patients were from banke district followed by bardia district. by ethnic group, brahmin and chhetri together were 20 (35%) and 10 (29%); muslim were 16 (28%) and four (11%); janajati from terai were 16 (28%) and eight (23%); janajati from hilly region were four (7%) and five (14%); and chaudhari were one (2%) and eight (23%) in group 1 and group 2 respectively. the most common gravidity of variables group one group two maternal age (years) n (%) n (%) 15-25 19(33) 8(23) x2=1.6 df=2 p=0.46 20-24 32(56) 21(60) 25-above 6(11) 6(17) gestational age <37 25(44) 10(29) x2=2.2 df=1 p=0.19≥37 32(56) 25(71) mode of delivery vaginal delivery 9(16) 5(14) p=1 fet instrumental delivery 4(7) 2(6) cs 44(77) 28(80) table 1.distribution of characteristics of eclamptic mothers 25 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 jlmc.edu.np pandit u. et al. outcome of eclamptic mothers attending tertiary care centre. eclamptic mothers was primary gravida (n=44, 77.1% and n=26, 74.2% in group 1 and two respectively). the other mothers in each group were multi gravida and the difference was statistically not significant (x2 =0.1, df=1, p=0.8). the most common (n=72, 78.3%) mode of delivery in eclamptic mothers was caesarean section (cs). among them, 44 (61.1%) mothers underwent cs in group l and 28 (38.8%) in group 2. there was no significant difference in mode of delivery between the two groups (x2=0.1, df=1, p=0.8). there were 13 (14.1%) still births. most of them (n=8, 61.5%) belonged to group l .the live birth rate in the two groups was 49 (86%) and 30 (86%) respectively and the difference was not statistically significant. table 3 shows that approximately 74% of mothers had a baby with good apgar score in group 2 compared to one (58%) in group 1. maternal outcome, as live, was observed in 56 (98.3%) and 34 (97%) in group 1 and group 2 respectively. there was one maternal death in each group. no significant difference was observed maternal mortality in both the groups. table 4 shows that the maternal complication rate was observed more in group l (n=16, 28%) than in group 2 (n=7, 20%). though not statistically significant (x2=0.75, df=1, p=0.46). the most common complication was wound infection in both groups. the mean days of hospital stay were 5.96 days (sd=3.32) and 5.91 days (sd= 3.38) in group l and group 2 respectively. no significant difference was observed in terms of hospital stay in the two groups (t=.07, df=90, p=0.94). discussion: eclamptic mothers attending tertiary care centre directly from home (group l) were higher in number (n=57 , 62%) than referral group (n=35, 38%). amongst them, most cases attended from banke district. banke and bardia are home and neighboring districts respectively from tertiary care centre. it shows that high prevalence of eclampsia diseases occurs in banke district. preventive as well as early detection campaign is needed in those districts as an outreach antenatal care program. most of the mother with eclampsia from muslim and janajati community in bake and bardia districts were admitted directly in tertiary care centre. it may be due to unavailability of the primary care centre or simply the ignorance and unawareness of primary facilities available in the community. variables group l group ll p apgar score n (%) n (%) 0 9(16) 5(14) 1-3 0(0) 1(3) 4-6 15(26) 3(9) >7 33(58) 26(74) maternal outcome p = 1 fet live 56(98.3) 34(97) death 1(1.7) 1(3) table 3: apgar score according to the admission status maternal complications group l n (%) group 2 n (%) present 16(28) 7(20) postpartum hemorrhage 6(10) 2(6) wound infection 8(14) 3(8) pulmonary edema / respiratory failure 1(2) 2(6) acute renal failure 1(2) 0 absent 41(72) 28(80) table 4: maternal complications according to the admission status the rate of still birth was observed more in group 1 than in group 2. the still birth rate is slightly higher compared to the findings in ethiopia by eshetu s. et al.6 out of 14 still births, 7 (53.8%) were from banke district from where majority of mother attended hospital directly from home for the treatment of eclampsia. cs was the commonest mode of delivery in both the groups, 44 (77.1%) mothers underwent cs in group l and 28 (80%) in group 2 respectively. districts group 1n (%) group 2 n (%) banke 45 (79) 7 (20) bardiya 3 (5.3) 14 (40) kailali 3 (5.3) 5 (14) dang 3 (5.3) 5 (14) salyan 0 2 (6) others 3 (5.3) 2 (6) total 57(100) 35 (100) table 2: distribution of eclamptic patients according to address. 26 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 pandit u. et al. outcome of eclamptic mothers attending tertiary care centre. jlmc.edu.np the cs rate was slightly higher in group 2 and the overall cs rate is high compared to the cs rate of 45.8% among eclampsia patients in one of the retrospective study done by abate m. et al.7 there was no significant difference in the mode of delivery in both groups (p=0.79).the mode of delivery did not differ in patients who received mgso4. if immediate caesarean delivery is conducted, the maternal and fetal outcome is good in eclampsia.8 approximately 74.2% of mothers had a baby with good apgar score in group 2 compared to that in group 1 (57.8%). there were 14 (15.2%) still births in total and majority of them (n=9, 61.5%) were from group l. this suggests that the mothers who attended the hospital directly were probably unable to receive mgso4 in time, so the better fetal outcome was observed in referred mothers. complication rate was observed more in group l (28%) than in group 2 (20%). the case fatality rate collectively in both groups was observed at 17.3% which is higher compared to the tertiary care hospitals in tanzania (7.7%).9,10 we recommend encouragement and promotion of the use of mgso4 in a primary care centre, especially in banke and bardia districts, to mothers with eclampsia immediately after fits. conclusion: mothers with eclampsia who received mgso4 in primary care centre have good fetal outcome and less maternal complications compared to those that attend tertiary care centre directly and receive the treatment there. loading dose of mgso4 if given immediately after initial convulsion at a primary health facility before referral, is beneficial to improve the maternal and fetal outcome. disclosure: no conflict of interest declared. no violation of human rights and safety. no fund available for this study. references: 1. ministry of health and population (mohp) [nepal]. annual report of the department of health services kathmandu, government of nepal; 2014. 2. cipolla mj, kraig rp. seizures in women with preeclampsia: mechanisms and management. fetal matern med rev. 2011 may; 22(02):91–108. doi: 10.1017/ s0965539511000040. 3. the eclampsia trial collaborative group. which anticonvulsant for women with eclampsia? evidence from the collaborative eclampsia trial. lancet. 1995;345:1455–63. 4. choudhary p. eclampsia: a hospital based retrospective study. katmandu univ med j (kumj). 2003;1(4):237-41. 5. lotufo fa, parpinelli ma, osis mj, surita fg, costa ml, cecatti jg. situational analysis of facilitators and barriers to availability and utilization of magnesium sulfate for eclampsia and severe preeclampsia in the public health system in brazil. bmc pregnancy childbirth. 2016;16(1): 254. doi:10.1186/s12884-016-1055-0. 6. eshetu s, mubarak a, million t, netsanet f, maternal and fetal outcome of pregnancy related hypertension in mettu karl referrel hospital, ethiopia. journal of ovarian research. 2015;8:10. doi 10.1186/s13048-015-0135-5. 7. abate m, lakew z. eclamsia a 5 years retrospective review of 216 cases managed in two teaching hospitals in addis ababa. ethiopian medical journal. 2006;44(1):27-31. 8. coppage kh, polzin wj. severe preeclampsia and delivery outcomes: is immediate cesarean delivery beneficial? am j obstet gynecol. 2002 may;186(5):921-3. 9. kidanto hl, mogren i, massawe sn, lindmark g, nystrom l. criteria based audit on management of eclampsia patients at a tertiary hosital in dar es salaam, tanzania. bmc pregnancy and childbirth. 2009;9(13):1-9. 10. jido ta. eclampsia: maternal and fetal outcome. afr health sci. 2012 jun;12(2):148-52. 27 status of scar in repeat cesarean section in a tertiary hospital subha shrestha,a,d raju shakya,b buddhi kumar shrestha,c,d narinder kaur,a,d babita thapaa,d —–————————————————————————————————————————————— abstract: introduction: in modern obstetrics, with rising trends of primary cesarean section (cs) for fetal and maternal interests, pregnancy over the scarred uterus is a challenge to all treating obstetricians. despite the method of suturing of the cesarean scar, its fate in next pregnancy is still not measurable. objective of this study was to evaluate the status of previous cesarean scar during repeat cesarean section (rcs) and calculate the maternal morbidity in those cases in a tertiary hospital. methods: it was a descriptive, retrospective study conducted at department of obstetrics of lumbini medical college teaching hospital. the study was conducted from 15th july 2014 to 14th july 2015. the data were retrieved from the department of medical records. women undergoing rcs were enrolled. the status of scar was evaluated in terms of intact scar, scar rupture, scar dehiscence, thin lower uterine segment, scar placenta previa, and adhesions as indicator of scar integrity. results: there were 534 (25.4%) cs among 2,098 deliveries during the study period. ninety one (17.04%) of them were rcs. elective rcs were 73.6% (n=67), and emergency rcs were 26.4% (n=24). eighty two (90.1%) women had rcs once and nine (9.9%) had rcs for second time. scar was intact in 22 (91.6%), scar dehiscence in one (8.3%), scar with adhesions in one (8.3%) among emergency rcs and intact in 53 (91.3%) and scar with adhesions in five (8.7%) among elective rcs. there was no scar dehiscence and no scar rupture in two rcs women. adhesions were documented twice higher in women whose primary cs was undertaken outside our hospital. placenta previa and placenta accreta each were found in two cases. conclusion: most of the scars of repeat cesarean section were healthy with no scar rupture. we can consider trial of labor for scarred uterus with strict vigilance and in need, cs is always an option. keywords: maternal mortality • repeat cesarean section • uterine rupture ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer b consultant family physician, lumbini medical college c assistant professor d department of obstetrics and gynecology lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. subha shrestha e-mail: subha_sht@hotmail.com how to cite this article: shrestha s, shakya r, shrestha bk, kaur n, thapa b. status of scar in repeat cesarean section in a tertiary hospital. journal of lumbini medical college. 2016;4(1):42-5. doi: 10.22502/jlmc.v4i1.84. ___________________________________________________________________________________ j. lumbini. med. coll. vol 4, no 1, jan-june 2016 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v4i1.84 introduction: along with rising trends of primary cesarean section (cs) from 5-7% in 1970 to 25-30% in 2003, the rate of pregnancy over the scarred uterus is also ascending up.1 a century ago, edward b. craginoft quoted dictum 'once cesarean, always cesarean' was justifiable for classical uterine incision.2 with invent of kerr low transverse incision, it has been revised and trial of labor after cesarean has outbursten on practice as vaginal birth after cesarean (vbac). when repeat cesarean section has no alternatives i.e. recurrent causes for cesarean, unmet criteria for vbac, failure vbac, prior more than one repeat section, a parturient has to pass through hanging bridge. due to unsettled issues on mode of delivery among women with prior cs, we have not advanced from flamm dictum 'once cesarean, always a controversy' for past two decades.3 in asian countries like ours, the decision making for mode of delivery depends on how we, obstetricians, counsel the client rather than on demand, 42 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 shrestha s. et al. status of scar in repeat cesarean section in a tertiary hospital. jlmc.edu.np medico-legal issue, or health insurance concern unlike in developed countries. repeat cesarean section (rcs) rate is higher despite explaining the option and benefits of vbac in suitable candidates. it is due to various factors like, lady attending the hospital as unbooked case, dilemma on decision making, and fear of harm to baby and self from subjective part apart from contraindication to trial of labor after cesarean (tolac). obstetricians fear for maternal morbidity and mortality as well as perinatal morbidity and mortality due to limited methods to judge the fetal jeopardy, and proven known risks secondary to delay in decision making like scar rupture, scar dehiscence, tear extensions, atonicity, postpartum hemorrhage, need for blood transfusion, cesarean hysterectomy, etc.4,5,6,7,8 it is utmost important to judge the scar integrity by evaluating previous operative details and excluding factors predisposing potentially weak scar formation in subsequent repeat pregnancy.9,10 so, we have conducted this study to evaluate the scar integrity and its status during present repeat cesarean and to rate the maternal morbidity secondary to rcs. methods: this retrospective, observational study was conducted at department of obstetrics of lumbini medical college teaching hospital, nepal. ninety one women undergoing repeat sesarean section (rcs) from 15th july 2014 to 14th july 2015 were enrolled. women who had undergone abdominal or pelvic surgeries and uterine surgeries in addition to cesarean section (cs) were excluded. women who had documented co-morbidities likely to complicate present pregnancy e.g. idiopathic thrombocytopenic purpura, bleeding disorders, genital and abdominal tuberculosis, connective tissue disorders, malignancy etc. were also excluded. medical records were retrieved from medical record section and required information were collected and plotted in the master chart. the status of scar was evaluated in terms of intact scar, scar rupture, scar dehiscence, thin lower uterine segment, scar placenta previa, adhesions (bladder, obscuring field of vision during surgery, etc) as indicator of scar integrity. results: there were total 534 cesarean section (cs) including 91 repeat cesarean section (rcs) out of 2,098 deliveries during the study period. eighty two (90%) had first rcs and nine (10%) had second rcs. there were 67 (73.6%) elective rcs and 24 (26.4%) emergency rcs. mean age of the women was 26.4 yr (sd=4.37) with most of them (n=78, 85.7%) belonging to 2030 years age-group. most women (n=56, 68.2%) of first rcs were between 37-40 weeks of gestation. among women with two rcs, seven (77.8%) were between 37-40 weeks of gestation and one (11.1%) were <36 weeks and >40 weeks of gestation each. all of the women had prior lower segment cesarean section (lscs). there were intact scar in 22 (91.6%), scar dehiscence in one (8.3%), and scar with adhesions in one (8.3%) among emergency rcs. there were 53 (91.3%) intact scar and five (8.7%) scar adhesions among elective rcs. the lower uterine segment was well formed in 13 (54.2%), moderately formed in one (4.1%), thinned out in eight (33.4%) women. three (12.5%) women had placenta previa over previous scar who had emergency rcs. among nine women who had two rcs, three (37.5%) had thin scar, five (62.5%) had well formed scar, seven (87.5%) had intact scar, and one (12.5%) had adhesions among elective rcs group. there was one intact scar, no scar dehiscence, and no scar rupture in women with two repeat cs. adhesions were documented twice higher in women whose primary cs was undertaken outside (n=49) compared to that inside our hospital (n=33) in first rcs (i.e. 15 (30.6%) versus seven (21.2%)). in our study, prior cesarean section was performed with various indications. among them, fetal distress and primigravida with breech presentation accounted for 21 (25.6%) and 14 (17%) cases respectively, followed by non-progress of labor (n=8, 9.7%), feto-pelvic disproportion (n=7, 8.5%), oligohydamnios (n=7, 8.5%), failed induction (n=6, 7.3%), malpresentation other than breech (n=5, 6%), and bad obstetric history (boh), pregnancy induced hypertension (pih), and multiple gestation each <5% among one rcs. indications of second repeat section were fetal distress and non-progress of labor in two (22.2%) cases each and boh, pih, and not in labor till 40 weeks in one (11.1%) case each. indications for the present cesarean section were recurrent causes in 12 (14.6%), not in labor 43 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 jlmc.edu.np shrestha s. et al. status of scar in repeat cesarean section in a tertiary hospital. in 15 (18.2%), short spacing in nine (10.9%), scar tenderness in six (7.3%), fetal distress in six (7.3%), failed vbac in five (6%), on request in six (7.3%), oligohydramnios in four (0.8%), malpresentation in six (7.3%), boh in eight (9.7%), iugr in two (2.4%), pih in one (1.2%), obstructed labor in one (1.2%), polyhydramnios in one (1.25) in one rcs group. in previous two cs women, eight (88.8%) had elective repeat cs and one (11.2%) had rcs in labor. the maternal morbidity variables encountered in our study were post partum hemorrhage (pph) in seven (8.5%), placenta previa over previous scar in three (3.6%), blood transfusion in seven (8.5%), aph in one (1.2%), wound gap in one (1.2%), hematuric urine in three (3.6%) among first rcs women. placenta accreta was encountered in one women who had pph and needed blood transfusion. hematuria was seen in women who had emergency rcs and had adhesions of bladder over lower uterine segment. pregnancy with anemia was encountered in 28 (34.1%) women with first rcs and in four (44.4%) women with second rcs. placenta accreta was diagnosed intra-operatively in a woman who had second rcs and she also had primary pph needing blood transfusion. eight women needed blood transfusion due to postpartum hemorrhage. discussion: in our study, the rate of repeat cesarean section (rcs) was 17.04 % among 534 cesarean sections. primary cesarean section rate is rising, so is the rate of repeat cesarean following.2 the study done in nobel medical college of biratnagar by subedi s. among 2011 women resulted 21.2% rate of cs for previous cs.4 enkin et al found 20.1% of repeat cs in a study of 8899 women, which is similar to our study.11 the common indications of repeat cs in our study were 'not in labor' till 40 weeks (n=15, 18.2%), recurrent cause where vbac is contraindicated in 14.6%, fetal distress 7.3%, malpresentation 7.3% among others. this is similar to the study of karim f. et al. in 778 women where fetal distress were 8.3%, malpresentation 5.8%, pih 3.4%, breech presentation 10%, and oligohydramnios 14%.12 there is increased risk of uterine rupture, intra-operative bleeding, and higher maternal morbidity with high order cesarean section, specially where the cases are unbooked and land up in emergency with previous recurrent cause for cs.13 we took all previous two repeat cesarean women to rcs (eight elective and one emergency) because they were unbooked case, with history of prior cs in periphery and no definite documentation of previous surgery and indication. the maternal morbidity included hemorrhage (8.5%), blood transfusion (7.3%), hematuria (3.6%), wound gap (1.2%), scar placenta previa (3.6%), scar dehiscence (1.2%) in first repeat cs. placenta accreta resulted in one women of second repeat cs. these results are similar to the study done by mafatlal sj. and co-workers at gujarat among 385 women, and nargis n. et al. among 570 women at dhaka.14,15 in our study, rcs was done in six women where no scar dehiscence or rupture was noted similar to the study from ludhiana, india by puri p. and co-workers.16 there was high risk of morbidly adherent placenta in women with low lying placenta and previous section, so planned antepartum and intrapartum assessment is mandatory to prevent maternal mortality and morbidity. the preparedness for blood transfusion and management of antecedent complications has to be considered beforehand.9,10 in a pregnant woman with two past caesarean sections, elective rcs is indicated in a weak scar, a recurrent indication, an obstetric complication in the current pregnancy, or a scenario where a safe vaginal delivery is not feasible.17 conclusion: most of the scar of pregnant women undergoing repeat cesarean section were healthy. we can offer them a trial of labor with strict vigilance and a readily available backup facility of cesarean section. conflict of interest: none declared. fund available: none. references: 1. christilaw je. cesarean section by choice: constructing a reproductive rights framework for the debate. int j gynecol obstet. 2006;94:262-8. 2. cragin eb. conservatism in obstetrics. ny med j. 1916;104:1–3. 44 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 shrestha s. et al. status of scar in repeat cesarean section in a tertiary hospital. jlmc.edu.np 3. williams jw. prior cesarean delivery. 24th ed. cunningham fg, leveno kj, bloom sl, spong cy, dashe js, hoffman bl, et al., editors. williams obstetrics. usa: mcgraw hill companies; 2014. 609-21 p. 4. subedi s. rising rate of cesarean sectiona year review. journal of nobel college. 2012;1(2):72-6. 5. mcmahon mj, luther er, bowes wa jr, olshan af. comparison of trial of labor with and elective second cesarean section. n eng j med. 1996 sep;335(10):689-95. 6. mansoor m. to study uterine rupture and fetal distress in patients with previous lscs. pak j mhs. 2010 aprjun;4(2):105-8. 7. shamshad. factors leading to increased cesarean section rate. gomal j med sci. 2008 jan-jun;6(1):1-5. 8. krishna u, daftary s. induction of labor. 5th ed. krishna u, shah d, salvi v, editors. pregnancy at risk: a practical approach to high risk pregnancy and delivery. the federation of obstetric and gynecological societies of india. jaypee brothers publication; 2010. 581 p. 9. dewhurst j. obstetrics emergencies. 8th ed. edmonds k, editor. dewhurst’s textbook of obstetrics and gynecology. uk: wiley & blackwell; 2012. 300 p. 10. paterson-brown s, singh c. developing a care bundle for the management of suspected placenta accreta. obstet and gynecol. 2010;12:21-27. 11. enkin m. labour and delivery following previous cesarean section. edkin m, keirs mj, chalmers i, editors. elective care in pregnancy and childbirth. oxford: oxford university press, 1989. 1196-1215 p. 12. karim f, ghazi a, ali t, aslam r, afreen u, farhat r. trends and determinants of cesarean section. j surg pak. 2011 jan-mar;16(1):22-7. 13. birth after previous cesarean birth. green-top guideline no.45. rcog. 2015 oct. 2-31 p. 14. mafatlal sj, narendrabhai mm. analysis of mode of delivery in women with previous one cesarean section. j obstet gynecol india. 2009 mar-apr;59(2):136-9. 15. nargis n, al-mahmood ak, akhter d. evaluation of uterine scar on repeat second cesarean section in patients with previous cesarean section. akmmc j. 2012;3(1):16-9. 16. puri p, abraham m, grover s. vaginal birth after one previous lower segment cesarean section. j k sci. 2011octdec;13(4):179-81. 17. wijesinghe ps, ekanaake cd. twice a cesarean, always a cesarean: fact or fiction? sri-lanka j obstet gynecol. 2012; 34:131-34. 45 intraperitoneal hydrocortisone plus bupivacaine versus bupivacaine alone for pain relief after laparoscopic cholecystectomy: a randomized controlled trial mahesh sharma,a,c kalpana kharbuja,a,c nil raj sharmab,c —–————————————————————————————————————————————— abstract: introduction: laparoscopic cholecystectomy has been the gold standard in the treatment of gallstones since last decades. beside several benefits of laparoscopic cholecystectomy compared with open surgery, postoperative pain is still a frequent melancholy. hence, pain management is utmost regarding patients' comfort. the main objective of the study was to compare the effect of intraperitoneal hydrocortisone plus bupivacaine with bupivacaine alone on pain relief following laparoscopic cholecystectomy. methods: a randomized study was conducted from december 2015 to august 2015 that included 100 patients aged 20 to 60 years of both genders who were found to have symptomatic gallstones and were scheduled for elective laparoscopic cholecystectomy at lumbini medical college. patients randomly received 100 mg hydrocortisone plus 100 mg bupivacaine in 200 ml normal saline (group a) or 100 mg bupivacaine in 200 ml normal saline (group b) into the peritoneum. post-operative abdominal and shoulder pain were evaluated using visual analog score (vas). the patients were also followed up for postoperative analgesic requirements, and recovery variables. data were collected, tabulated and analyzed statistically using spss version 19. results: total number of patients in this study were 100. age and gender among both groups were comparable. vas scores for pain was significantly lower for group a as compared to group b at 0, 2, 4, 6, 12, and 24 hours. time of oral intake in hrs for liquids and solids was statistically significant in group a compared to group b. rescue analgesic requirement was also significantly low in group a compared to group b. hospital stay in both group were comparable. conclusion: combination of hydrocortisone plus bupivacaine can relieve pain after laparoscopic cholecystectomy better compared to bupivacaine alone when administered intraperitoneally. keywords: bupivacaine • cholecystectomy • hydrocortisone • intraperitoneal • pain ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, b professor and head c department of anesthesiology and critical care, lumbini medical college, palpa, nepal corresponding author: dr. mahesh sharma e-mail: maheshsharmalmc2@gmail.com how to cite this article: shrama m, kharbuja k, sharma nr. intraperitoneal hydrocortisone plus bupivacaine versus bupivacaine alone for pain relief after laparoscopic cholecystectomy: a randomized control trial. journal of lumbini medical college. 2015;3(2):41-4. doi: 10.22502/jlmc. v3i2.71. ___________________________________________________________________________________ j. lumbini. med. coll. vol 3, no 2, july-dec 2015 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v3i2.71 introduction: laparoscopic cholecystectomy (lc) is the most common, minimally invasive and gold standard methods in treatment for symptomatic cholelithiasis.1 less post-operative pain, early oral intake after surgery, shorter hospital stay, early resumption of normal activities and improved cosmesis have been well recognized advantages of lc.2,3 although pain is less intense than following open cholecystectomy, some patients still experience considerable discomfort during the first 24 to 72 postoperative hours, which can delay discharge.4 various modalities have been proposed to relieve pain after laparoscopic cholecystectomy like usage of non-steroidal anti-inflammatory drugs (nsaids), opioids, intraperitoneal local anesthetics, port site infiltration of local anesthetic etc.5 therefore, preoperative decision for pain relief after laparoscopy is an important aspect of planning laparoscopic cholecystectomy. since there is a paucity of data on comparison of intraperitoneal efficacy of 41 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 jlmc.edu.np sharma m. et al. intraperitoneal hydrocortisone plus bupivacaine versus bupivacaine alone for pain relief after laparoscopic cholecystectomy. steroids and local anesthesia combination with local anesthetics alone for pain relief after laparoscopic cholecystectomy, the present study was conducted to compare the pain relief with intraperitoneal hydrocortisone with bupivacaine and bupivacaine alone following laparoscopic cholecystectomy additional objectives of our analysis included features like, requirement of rescue analgesia, duration of hospital stay and oral intake time after laparoscopic cholecystectomy under general anesthesia. methods: the present study was a hospital-based experimental study conducted in the department of anesthesia and critical care, lumbini medical college teaching hospital, lumbini, nepal from 1st december 2015 to 30th august 2015. the study was approved by the institutional review committed of lumbini medical college. a total of 100 patients with american society of anesthesiologists (asa) physical status i and ii, aged 20-60 years, both genders, having symptomatic gallstones, and scheduled for laparoscopic cholecystectomy were included in the study. a detailed history was taken and thorough clinical examinations of all the patients were performed. information about age, sex, weight and height of the patients was noted. the selected patients were then explained about the procedure and written informed consent was taken. patients with the following criteria were excluded from this study: (i) associated chronic diseases like diabetes mellitus, significant cardiac, renal or pulmonary diseases; (ii) hepato-biliary malignancies; (iii) positive history of pregnancy or previous abdominal surgery; (iv) allergy to hydrocortisone and bupivacaine; (v) converted to open cholecystectomy, and (vi) presence of acute cholecystitis, choledocholithiasis or portal hypertension. all the patients were pre-medicated with diazepam 10 mg night before surgery and on the morning of the surgery. the randomization of patients was done on patient's arrival at the operation theatre according to a list of computer generated random numbers. operative procedure: on operating table, patient was preloaded with 10 ml/kg ringer lactate solution, pre-oxygenated with 100% oxygen for five minutes. two milligram per kilogram of fentanyl and two mg/kg of propofol was given followed by 0.1 mg/kg of vecuronium to aid endotracheal intubation. after conforming the endotracheal tube, ventilation was adjusted to maintain eco2 at 35 to 40 mm hg. anesthesia was maintained with oxygen, isoflurane and intermittent dose of vecuronium 0.01 mg/kg and fentanyl l mg/kg. after receiving anesthesia and before insufflations of co2, instillation of 100 mg hydrocortisone plus 100 mg bupivacaine in 200 ml normal saline (group a) or 100 mg bupivacaine in 200 ml normal saline (group b) was done into the peritoneum by a surgical scrub nurse who was blind to the study. following this, the patients were rotated into trendelenburg, anti-trendelenburg, left and right lateral positions (each for 2 minutes), and finally brought to supine position. all surgical procedures were performed by the same surgical team. during procedure, intra-abdominal pressure was maintained at 14 mm hg. manual compression of abdomen by open trocars was done to evacuate co2 at the end of procedure. ten milliliters of 0.25% bupivacaine were injected in laparoscopic port entering site. muscle relaxant was reversed at the end of surgery using 0.05 mg/kg of neostigmine and 0.005 mg/kg of glycopyrrolate. post-operatively, patients were assessed for pain using visual analogue scale (vas) in the recovery room (0 hr), and at 2, 4, 6, 12, and 24 hours based on a 0-10 scale (with zero meaning no pain and 10 meaning the most intense pain ever felt). parameters like rescue analgesic requirements, time of oral intake after the surgery and total hospital stay after operation were also recorded. fentanyl 1 mg/ kg and 2 mg/kg was given as rescue analgesia for vas 4 7 and 8 10 respectively. collected data was analyzed using the statistical package for the social sciences, version 19. arithmetic mean and standard deviation values for different variables were calculated. t-test was used to compare mean, chi-square test to compare proportions, and mann–whitney u test for comparing the ordinal values. a value of p <0.05 was considered statistically significant. results: females outnumbered males in both the group with f:m ratio of 7.0 and 5.50 for group a and group b respectively. demographic characteristics of patients in two groups is shown in table 1. there was no significant difference in age or gender in two groups (table 1). 42 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 sharma m. et al. intraperitoneal hydrocortisone plus bupivacaine versus bupivacaine alone for pain relief after laparoscopic cholecystectomy. jlmc.edu.np variable group a (n=48) group b (n=52) statistics age mean (sd) 38.92 (10.78) 42.47(12.52) t= -1.51, df=97, p=0.13 gender n (%) male 6 (12.5) 8 (15.38) x2=0.03, df=1, p=0.86female 42 (87.5) 44 (84.61) table 1: demoghaphic characteristics of patients in two groups all the patients had post-operative pain due to varied reasons like adhesions, diseases of liver, abnormal anatomy of gallbladder and biliary tract, complication during dissection like bleeding, bile duct injury, gallbladder perforation, stone loss visceral injury, and insertion of drain. the abdominal and shoulder pain scores were significantly lower in group a at 0, 2, 4, 6, 12 and 24 hours (table 2). time from recovery (hours) group a (mean rank) group b (mean rank) u= mann whitney’s u value 0 41 58.47 u=1656, p=0.001 2 44.15 55.51 u=1505, p=0.004 4 42.59 56.95 u=1580, p=0.009 6 39.84 59.56 u=1712, p=0.0001 12 41.57 57.93 u=1629, p=0.003 24 41.36 58.13 u=1639, p=0.003 table 2: visual analogue scale (vas) scores for post-operative abdominal pain in two groups rescue analgesia requirement: chi-square test of independence was applied to see relation between rescue analgesia requirement in two groups. those in control group (not receiving hydrocortisone) were statistically more likely to receive rescue analgesia (x2=18.14, df=1, p<0.001). time of oral intake: time for oral intake for liquid and semi-solid post-surgery was significant less for group a compared to group b. however, for normal diet, this was significantly different (table 3). diet group mean time (hr) statistics liquid a 6.01 t= -3.33, df=89.6 p=0.001b 6.20 semi solid a 7.68 t= -3.61, df=56.86 p=0.001b 8.07 normal a 11.80 t= -1.65, df=57.2 p=0.1b 12.05 table 3: time of oral intake after recovery. hospital stay: hospital stay in group a was significantly shorter (t=1.73, df=91, p<0.001). mean hospital stay in group a was 2.15 days (sd=0.36) and in group b was 2.29 days (sd=0.49). discussion: evident benefits of laparoscopic cholecystectomy such as reduction in postoperative disability, cosmesis and early return to work have rendered it the procedure of choice for symptomatic cholelithiasis.6 pain after laparoscopic cholecystectomy is inevitable. pain involves several component (parietal, visceral, and shoulder pain) with different intensities and their own time course.7 there are various mechanism for visceral pain after laparoscopic cholecystectomy like rapid distension of peritoneum which may be associated with traumatic traction of nerves, tearing of blood vessels, and release of inflammatory mediators. other mechanism for pain includes local irritation and inflammation around gall bladder bed, liver, diaphragm or peritoneum, gall bladder removal, and abdominal muscle distension.8-10 shoulder pain may be due to inflammation of peritoneum reflection supplied by phrenic nerves.9 post-operative pain is multi-factorial in origin, and therefore multi-modal therapy may be needed to optimize pain relief. intra-peritoneal administration of various drugs are given along with local anesthetic for pain relief after laparoscopic cholecystectomy like bupivacaine with morphine, bupivacaine with meperidine, bupivacaine with tramadol, bupivacaine with magnesium sulphate, ropivacaine, ropivacaine and gas drain, levobupivacaine with epinephrine, lidocaine with tanoxicam.11 hydrocortisone along with bupivacaine have an additional advantage than bupivacaine alone because steroid decreases the pain through various mechanism like suppression of bradykinin, release of neuropeptides, peripheral suppression of phospholipase enzymes thereby decreasing cyclooxygenase and lipooxygenase pathway of inflammatory pathway, and inhibition of other mediators of inflammation eg, tnf, interleukin 6 and 12.12-15 hydrocortisone was given before surgery and co2 insufflation as the onset of action of hydrocortisone is 1-2 hrs thus allowing time to diffuse across cell membrane and alter gene transcription.16 amene s. et al. assessed the analgesic effect of intra peritoneal injection of hydrocortisone alone before 43 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 sharma m. et al. intraperitoneal hydrocortisone plus bupivacaine versus bupivacaine alone for pain relief after laparoscopic cholecystectomy. jlmc.edu.np gas insufflation in laparoscopic cholecystectomy and concluded that intraperitoneal hydrocortisone can reduce postoperative pain with no significant postoperative adverse effect. on the contrary, we found bupivacaine with hydrocortisone has significantly low vas score at 0, 6, 12, 24 hrs and rescue analgesia requirement was low.11 the study conducted by sabzi sarvestani et al. concluded that the intraperitoneal administration of bupivacaine with hydrocortisone before gas insufflation can reduce post-operative pain similar to intraperitoneal bupivacaine with no significant post-operative adverse effects in laparoscopic cholecystectomy. this finding was in consistent with our study and this might be because the concentration of bupivacaine in which hydrocortisone used was different in our study than that of the previous study.17 zahra asgari et al. studied the effect of hydrocortisone added to intra-peritoneal bupivacaine on post-operative pain after gynecological surgery and concluded that combination to be more effective then bupivacaine alone which is similar to our study.18 limitations: 1. studies with larger sample size are recommended. 2. further studies with a control group and different dose and concentration of the drugs must be carried out to provide maximal benefit in terms of post-operative pain relief with minimal adverse effects after laparoscopic surgery. 3. combined usage of steroid and local anesthetic solution may not be indicated for all patients. for example, diabetic patients may experience hyperglycemia and patients with a long-term infectious process may be destructively affected by the anti-inflammatory effects of steroids. conclusion: intra-peritoneal instillation of hydrocortisone 100 mg with bupivacaine 100 mg in 200 ml normal saline during laparoscopic cholecystectomy significantly reduces post-operative pain and requirement of rescue analgesia then that of bupivacaine 100 mg in 200 ml normal saline alone. 1. ali sa, soomro ag, mohammad at, jarwar m, siddique aj. experience of laparoscopic cholecystectomy during a steep learning curve at a university hospital. j ayub med coll. abbottabad 2012;24(1):27-9. 2. cwik g, skoczylas t, wyroslak-najs j, wallner g. the value of percutaneous ultrasound in predicting conversion from laparoscopic to open cholecystectomy due to acute cholecystitis. surg endosc. 2013;27(7):2561-8. doi: 10.1007/s00464-013-2787-9. 3. jacobs m, verdeja jc, goldstein hs. laparoscopic cholecystectomy in acute cholecystitis. j laparoendoscop surgery. 2009;1(3):175-7. 4. upadya m, pushpavathi sh, seetharam kr. comparison of intra-peritoneal bupivacaine and intravenous paracetamol for postoperative pain relief after laparoscopic cholecystectomy. anesth essays res. 2015;9(1):39-43. doi: 10.4103/0259-1162.150154. 5. jabbour-khoury si, dabbous as, gerges fj, azar ms, ayoub cm, khoury gs. intraperitoneal and intravenous routes for pain relief in laparoscopic cholecystectomy. jsls. 2005;9(3):316-21. 6. kama na, kologlu m, doganay m, reis e, atli m, dolapci m. a risk score for conversion from laparoscopic to open cholecystectomy. am j surg. 2001;181(6):520-5. 7. joris j, thiry e, paris p, weerts j, lamy m. pain after laparoscopic cholecystectomy: characteristics and effect of intraperitoneal bupivacaine. anesth analg. 1995;81(2):379-84. 8. cuschieri a . laparoscopic cholecystectomy. j r coll surg edinb. 1999;44(3):187-92. 9. alexander ji . pain after laparoscopy. br j anaesth. 1997;79(3):369-78. 10. gupta r, bogra j, kothari n, kohli m. postoperative analgesia with intraperitoneal fentanyl and bupivacaine: a randomized control trial. canadian journal on medicine. 2010;1(1):1-11. 11. sarvestani as, amini s, kalhor m, roshanravan r, mohammadi m, lebaschi ah. intraperitoneal hydrocortisone for pain relief after laparoscopic cholecystectomy. saudi j anaesth. 2013;7(1):14-7. doi: 10.4103/1658-354x.109799. 12. fukami y, terasaki m, okamoto y, sakaguchi k, murata t, ohkubo m, et al. efficacy of preoperative dexamethasone in patients with laparoscopic cholecystectomy: a prospective randomized double-blind study. j hepatobiliary pancreat surg. 2009;16(3):367-71. doi: 10.1007/s00534-009-0079-5. 13. callery mp. preoperative steroids for laparoscopic surgery. ann surg. 2003;238(5):661-2. 14. hong d, byers mr, oswald rj. dexamethasone treatment reduces sensory neuropeptides and nerve sprouting reactions in injured teeth. pain. 1993;55(2):171-81. 15. sapolsky rm, romero lm, munck au. how do glucocorticoids influence stress responses? integrating permissive, suppressive, stimulatory, and preparative actions. endocr rev. 2000;21(1):55-89. 16. holte k, kehlet h. perioperative single-dose glucocorticoid administration: pathophysiologic effects and clinical implications. j am coll surg. 2002;195(5):694-712. 17. sarvestani as, amini s. intraperitoneal hydrocortisone plus bupivacaine administration for pain relief after laparoscopic cholecystectomy, a comparison with bupivacaine alone .journal of surgery and trauma. 2014;2(1):6-11. 18. asgari z, mozafar-jalali s, faridi-tazehkand n, sabet s. intraperitoneal dexamethasone as a new method for relieving postoperative shoulder pain after gynecologic laparoscopy. int j feertil steril. 2012;6(1):59-64. references: 44 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 05 september, 2019 accepted: 14 may, 2020 published: 29 may, 2020 a lecturer, department of anatomy b lumbini medical college teaching hospital, palpa, nepal. corresponding author: subina shrestha e-mail: ssubina8@gmail.com orcid: https://orcid.org/0000-0002-0006-4974 _______________________________________________________ —–———————————————————————————————————————————— abstract introduction: height is important for determination of basic energy requirement, standardization and identification. it is also useful for measuring physical capacity and adjusting drug dosages. sometimes the exact height cannot be determined directly because the patient is unable to stand as a result of neuromuscular weakness, deformities of axial skeleton, loss of lower limbs and in case of amputation. forensic investigations of skeletal remains also face the problems. under such circumstances, height can be estimated by hand dimensions.methods: hand dimensions and height were measured on 239 medical students in the department of anatomy using standard instruments. among them 120 were females and 119 were males. correlation between height and hand dimensions was studied. regression equation was derived for estimation of height from hand dimensions.results: the correlations between height and hand dimension were statistically significant in both genders (p<0.05). the pearson correlation between height and hand length was 0.616 and between height and hand breadth was 0.353 in males. those coefficients for females were 0.706 and 0.198 respectively. regression equations were formulated for height with hand length in males and females. conclusion: height can be predicted from hand length. hand length showed moderate (males) to strong (females) positive correlation with statistical significance whereas hand breadth showed weak positive correlation with statistical significance. keywords: anthropometry, hand dimensions, height, linear regression original research articlehttps://doi.org/10.22502/jlmc.v8i1.301 subina shrestha,a,b sudikshya kca,b anthropometric measurement of hand dimension and their correlation with height in undergraduate students of a medical college in nepal how to cite this article:how to cite this article: shrestha s, kc s. anthropometric measurement of hand dimension and their correlation with height in undergraduate students of a medical college in nepal. journal of lumbini medical college. journal of lumbini medical college. 2020;8(1):5 pages doi: 2020;8(1):5 pages doi: https://doi.org/10.22502/jlmc.v8i1.301 epub: 2020 may 29.epub: 2020 may 29. introduction: height is the upright posture which is an important tool of physical identity. it establishes the identity of an individual from mutilated, decomposed and amputated body fragments which become an important necessity in recent times due to natural disasters like earthquakes, tsunamis, cyclones, floods and man-made disasters like terrorist attacks, bomb blasts, mass accidents, wars, plane crashes etc.[1] the hand length was reliable alternative for estimating age-related loss in height. while alive the height is one of the key parameters established in the course of identification of unknown skeletal remains. height helps to determine various features of a population including nutritional health and genetics. height is considered as one of the important parameters for individual identification.[2] for determination of height, anatomical and mathematical methods are generally applied. mathematical methods that forensic anthropologists use for height reconstruction when complete skeletons are not available include regression equation and multiplication factor.[3] in 2018, the study conducted by pandeya et al., calculated the estimation of height from hand length.[4] the present study aimed to investigate the association j. lumbini. med. coll. vol 8, no 1, jan-june 2020 shrestha s, et al. shrestha s, et al. anthropometric measurement of hand dimension and their correlation with heightanthropometric measurement of hand dimension and their correlation with height jlmc.edu.np of hand dimensions (hand length and hand breadth) with height, and derive a linear regression equation between them to show if height could be predicted using hand dimensions. methods: an observational, cross sectional study was carried out from june 2019 to august 2019 among the first, second and third year students of bachelor of medicine and bachelor of surgery and first year students of bachelor of science,nursing in the department of human anatomy, lumbini medical college and teaching hospital, pravas, palpa, nepal. the ethical clearance was obtained from institutional review committee (irc-lmc06-c/019). informed consent was taken from each participant. sample size was calculated by using the formula, n = [(zα+zβ)/c]2+3 where, n=desired sample size zα=1.96(standard value at 95% confidence interval) zβ=0.80 c=0.5 ln {(1+r)/ (1-r)} r =0.32(coefficient of correlation)[5] the calculated minimum sample size was 75 for each gender. we enrolled a total of 119 males and 120 females in the study. for the selection of required participants the procedure was explained verbally and only the interested students were included. those having deformities of axial skeleton and hand were excluded. standing height was measured to the nearest centimetres (cm) using a stadiometer with the participant standing bare footed on a horizontal plane with eyes looking straight forward, the lower margins of the orbits and upper margins of external acoustic meatus lying in the same horizontal plane (frankfurt plane). the height was measured from the sole of feet to the vertex of head. each participant was instructed to place his/ her hands supine on a flat hard horizontal surface with fingers extended and adducted. then the hand length (hl) of both hands, right and left, was measured by a metallic scale from the midpoint of the distal crease of wrist joint to the distal end of the most anterior projecting point that is tip of the middle finger. next, the participants were asked to place their hands in prone position on the flat hard horizontal surface with thumb extended and other fingers in extended and adducted position. then the hand breadth (hb) of both hands was measured on a distance between the radial side of the 2nd metacarpo-phalangeal joint and the ulnar side of the 5th metacarpo-phalangeal joint.[6] data were entered in statistical package for social sciences software (spsstm) version 20. descriptive statistics were presented in terms of mean and standard deviation. linear regression was used to determine relationship between height and hand dimensions. p value <0.05 was considered to be statistically significant. results: a total of 239 participants comprising 119 males and 120 females were taken. their age ranged from 18 to 25 years. the mean (+sd)height, hand length and hand breadth of males and females are shown in table 1. the mean height, hand length and hand breadth of males were found to be greater than those of females and the differences were statistically significant (p<0.001). table 1: comparison of the findings of male and female participants. variables males (n=119) mean ± sd females (n=120) mean ± sd statistics age (years) 20.50 ± 1.51 19.78 ± 1.12 t (237) = 4.136, p<0.001 height (cm) 170.52 ± 5.78 158.78 ± 6.93 t (237) = 14.207, p<0.001 hand length (cm) 18.54 ± 0.98 16.85 ± 0.94 t (237) = 13.519, p<0.001 hand breadth (cm) 8.32 ± 0.44 7.07 ± 0.63 t (237) = 17.819, p<0.001 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 shrestha s, et al. shrestha s, et al. anthropometric measurement of hand dimension and their correlation with heightanthropometric measurement of hand dimension and their correlation with height jlmc.edu.np table 2 shows moderate positive correlation between hand length and height of males which was statistically significant (r=0.616, p<0.001). similarly, correlation between hand length and height of females was strongly positive and statistically significant (r= 0.706, p<0.001). table 2: correlation coefficient of height with hand length and hand breadth hand dimension height male female r p value r p value hand length 0.616 <0.001 0.706 <0.001 hand breadth 0.353 <0.001 0.198 0.030 r= coefficient of correlation there was a weak positive correlation between height and hand breadth of males which was statistically significant (r=0.353, p<0.001). in females there was a weak positive correlation between height and hand breadth which was statistically significant (r=0.198, p=0.03). fig. 1 shows the relationship between height and hand length (hl) of females. the following linear regression equation was obtained to predict height (cm) based on hand length (cm). a significant regression equation was found f(1,118)=117.4, p<0.001 with r2 of 0.49, standard error of the estimate=4.93. female participant’s height is equal to height = 70.992+5.209×hl fig 1: relationship between height and hand length in females fig. 2 shows the relationship between height and hand length of males and the linear regression equation obtained was to predict height (cm) based on hand length (cm). a significant regression equation was found f(1,117)=71.62,p<0.001 with r2 of 0.38, standard error of the estimate=4.56. male participant’s height is equal to height = 103.394+3.621× hl fig 2: relationship between height and hand length in males similarly, the following linear regression equations were obtained to predict height (cm) based on hand breadth (hb in cm) in females and males respectively. for females, a significant regression equation was found f(1,118)=4.83, p = 0.03 with r2 of 0.039, standard error of the estimate=6.82. participant’s height is equal to height = 143.28+2.19×hb male participant’s height is equal to height = 132.21+4.60×hb. where, f(1,117)=16.66, p<0.001 with r2 of 0.125, standard error of the estimate=5.43. linear regression models for estimating height from hand breadth had poor predictability explaining only 3.9 % of the variance in case of females and 12.5 % of the variance in case of males. hence, hand length was more reliable than hand breadth to predict the height. discussion: height is one of the important parameters to insight various features of population including nutritional health and genetics. however, under certain circumstances height cannot be exactly measured and in such conditions hand dimensions can be one of the reliable alternatives.[7] so the j. lumbini. med. coll. vol 8, no 1, jan-june 2020 shrestha s, et al. shrestha s, et al. anthropometric measurement of hand dimension and their correlation with heightanthropometric measurement of hand dimension and their correlation with height jlmc.edu.np present study was an attempt to find out the relation between height and hand dimensions. from this study we found that correlation of height with hand length was stronger than that with hand breadth in both males and females. various studies had been carried out on assessment of height and its correlation with hand length. mean height of both sexes and the correlation coefficients (r) =0.6 (for males) and 0.7 (for females) between height and hand length of our sample were similar to the previous study conducted in delhi population.[8] despite having almost similar heights in population of sri lanka,[9] the correlation coefficients (r=0.5 and 0.5) were slightly smaller. the calculated mean hand length of males in the present study was almost same to the north indian male population, but it was dissimilar in case of female.[10] in the present study the mean height was 170.52 ±5.78 and 158.78 ±6.93 cm in males and females respectively, while a study conducted in north acrot district tamilnadu,[11] mentioned different mean heights. previously the study conducted by pandeya et al., calculated the estimation of height from hand length only and their linear regression equation in male and female respectively were height=95.86+3.76×hl and height=79.41+4.46×hl.[4] there are certain limitations of this study. it was conducted in one of the medical colleges of nepal in a small population. the result obtained from this study might not represent all medical students. further studies have to be carried out to develop the regression formula for the nepalese population with larger sample size. the linear regression equation could have been derived from right and left hand dimension in relation to height. conclusion: linear regression equations were derived in relation of height with hand dimensions. we found that prediction of height can be done more accurately from the hand length than the hand breadth. acknowledgement:mr. keshav raj bhandari conflicts of interest: no competing interests exist. source of funds:no funds were available. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 shrestha s, et al. shrestha s, et al. anthropometric measurement of hand dimension and their correlation with heightanthropometric measurement of hand dimension and their correlation with height jlmc.edu.np references 1. mansur di, haque mk, sharma k, karki rk, khanal k, karna r. estimation of stature from foot length in adult nepalese population and its clinical relevance. kathmandu univ med j. 2012;10(37):16-9. pmid: 22971855. doi: https://doi.org/10.3126/kumj.v10i1.6907 2. krishan k, kanchan t, sharma a. multiplication factor versus regression analysis in stature estimation from hand and foot dimensions. j forensic legal med. 2012;19(4):211-4. pmid: 22520373. doi:https://doi.org/10.1016/j. jflm.2011.12.024 3. venkatachalam ksm, felix ajw. comparison of regression equation with multiplication factor indetermination of stature from hand length in adults. journal of medical science and clinical research. 2019;7(1):188-92. doi: https://dx.doi.org/10.18535/jmscr/v7i1.33 4. pandeya a, atreya a. estimation of stature from percutaneous hand length among the students of a medical college. j nepal med assosc. 2018;56(211):687-690. pmid: 30381766. doi: https://doi.org/10.31729/jnma.3624 5. supare ms, pandit sv, bagul as. estimation of stature from hand length and hand breadth in medical students of maharastra, india. international journal of health & allied sciences. 2015;4(3):154-9. available from:http://www. ijhas.in/text.asp?2015/4/3/154/160875 6. numan ai, idris mo, zirahei jv, amaza ds, dalori mb. prediction of stature from hand anthropometry: a comparative study in the three major ethnic groups in nigeria. british journal of medicine & research. 2013;3(4):1062-73. doi: https://doi. org/10.9734/bjmmr/2013/1932 7. krishan k, sharma a. estimation of stature from dimensions of hands and feet in north indian population. j forensic leg med. 2007;14(6):327-32. pmid: 17239650. doi: https://doi.org/10.1016/j.jcfm.2006.10.008 8. sunil, dikshit pc, aggarwal a, rani m. estimation of stature from hand length. journal of indian academy of forensicmedicine. 2005;27(4):219-21. available from: http:// medind.nic.in/jal/t05/i4/jalt05i4p219.pdf 9. ilayperuma i, nanayakkara g, palahepitiya n. prediction of personal stature based on the hand length. galle medical journal. 2009;14(1):15-8. doi: http://doi.org/10.4038/gmj.v14i1.1165 10. kaur m, singh b, mahajan a, khurana bs, kaur a, batra aps, et al. anthropometric measurements of hand length for estimation of stature in north indians. international journal of applied biology and pharmaceutical technology. 2013;4(2):251-55. available from: http://www.ijabpt.com/volume-4-issue-2.php 11. karthick s, elangovan m. estimation of stature using hand length in the population of north arcot district tamilnadu. global journal for research analysis. 2018;7(5):49-50. doi: https://www.doi.org/10.36106/gjra abstract: introduction: mental health nursing is the practice of promoting mental and caring for people with mental illness. violence towards nurses by the psychiatry patient in clinical setting is an endemic worldwide and a multifaceted problem. method: purposive sampling of thirty sample of nurses from psychiatry ward, emergency room and medicine ward were selected from 1st of august 2013 to 30th of august, 2013. sampling technique was pre-experimental, one group pre-test, posttest design, reliability of the tool (r=0.95) was tested by split half method using karl pearson’s product moment correlation formula and spearman-brown’s prophecy formula. socio-demographic data by using proforma. pretest was done, knowledge score was calculated, self-developed instructional model was introduced and after 7 days’ duration post-test was done. results: pre-test assessment revealed that the highest percentage (53.34) of the nursing personnel had good level of knowledge. the significance of difference between the pre-test and post-test knowledge scores was statistically tested using paired ‘t’ test and was found to be very highly significant (t=11.66, p < 0.05). interpretation: the study revealed that there was very highly significant increase in the knowledge following the administration of self-instructional module. key word: violent patients, nursing personnel, self-instructional module introduction mental health nursing is the practice of promoting mental health as well as caring for people who have mental illness.1 during the course of practice, a mental health nurse has to face violence from acute psychiatric patients. violence towards nurses in workplace is an endemic worldwide and detrimental effect on nurse’s psychological, cognitive, and emotional wellbeing, and negative impact on public healthcare costs and organizations effectiveness.2 usual assaultive event are two assaults per ward; out of these one resulted in major physical injury even sexual harassment and sexual assaults.3 emergency departments and psychiatric departments are always susceptible to violent incidents.4 to overcome the above problems a mental health nurse must possess sound knowledge and skills in management of violent psychiatric patients.5 according to the national patient safety agency survey it was estimated that in england and wales there were 3,00,000 aggression/minor assaults, 50,000 absconding, 45,000 sexual assault/harassment, 25,000 self-harm, 4,500 physical threat, 200 deaths by suicide, 85 unnatural deaths of detained patients and 1.3 homicides by inpatients per year.6 even in the royal college of psychiatrists, london (2004), out of the 1515 reported violent incidents, 766 were found to be major assaults.7 objectives to differentiate between score of pre-test knowledge and post-test knowledge using the same structured questionnaire. hypothesis the mean post-test knowledge score of nursing personnel on management of violent patients will be significantly higher than their mean pre-test knowledge score. results the fig-1 shows that majority 87% of the nursing staff had not attended any in-service education. table-1 shows that only 13.33% of the subjects possessed excellent knowledge, 53.34% of the subjects had good knowledge, 23.33% had satisfactory and 10% had poor knowledge. effectiveness of self instructional model on the management of violent patients among nursing personnel in selected ward of lumbini medical college pokharel b, pokharel a department of psychiatry and college of nursing lumbini medical college original article corresponding author: ms. bandana pokharel, department of psychiatry nursing, college of nursing, lmc-th, pravash, tansen, palpa, nepal; e-mail: bandanapokharel30@yahoo.com fig 1: nursing staffs attending inservice education 105 testing of hypothesis the hypothesis was tested using “paired-t” test. the value of ‘t’ was calculated to analyses the difference in the knowledge of the nursing personnel before and after the administration of self-instructional module. the calculated “t” value was greater than the table value in all sections. therefore, the null hypothesis was rejected and the research hypothesis was accepted. the gain in knowledge score was observed to be highly significant (table-3). table-4 shows that total mean was increased by 7.16 and 23.87% after administration of the self-instructional module. areas mean effectiveness ‘t‘ value table value p value concept of violence, factors causing violence, identification and ititial management 2.56 8.25 1.70 <0.05 table 3: significance of difference between pre-test and post-test knowledge (n=30) discussion the highest percentage (80%) of the sample belonged to the age group of 21-30 years, highest percentage of nurses (90%) were staff nurse, and remaining were nursing officers. the majority (87%) of the nursing personnel did not receive any additional education, only 13% had received some education program this findings is supported by a findings of lin y, liu h.9 the results showed that 44.7% nurses had received training regarding violence; 61% of the nurses reported experiencing verbal and physical threat without formal training.8 the pre-test scores showed that highest percentage (87%) of the nursing personnel had average knowledge regarding management of violent patients, 10% had good knowledge and only 3% of had poor knowledge. this finding is similar to the findings of park de c in which the knowledge score of nursing staff was highest (98%) i.e. good knowledge and only 2% had poor knowledge.9 the mean percentage of the total knowledge score of the pre-test was 68.9% with total mean ± sd of 20.67±4.04. in the area of “concept of violence, factors affecting violence, identification and initial management of violent patients”, the pre test l m coll j 2013; 1(2) percentage of score level of knowledge frequency percentage >70 excellent 4 13.33 60-70 good 16 53.33 50-60 satisfactory 7 23.33 <50 poor 3 10 table 1: distribution of the level of knowledge on pre-test of nursing personnel (n=30) table-2 shows that the highest effectiveness was found for the “violence is associated with substance abuse” (54%) whereas least effectiveness (7%) was found for the items “violence means risk of injury to self and others” and “severe depression with psychotic symptoms causes violence to self. s n item pre-test post-test effectiveness no % no % no % 1 violence means risk of injury to self and others 28 93 30 100 2 7 2 violence is characterized by physical and verbal threat 11 37 21 70 11 33 3 phychological factors responsible for violence are life experience 2 7 8 27 6 20 4 violence is associated with substance abuse 2 7 8 27 6 20 5 violent behavior is commonly seen in psychiatric hospitals in patients with psychosis 10 33 26 87 16 54 6 factors which influence aggravation of violence in psychiatric ward is not caring or showing concern towards patient 27 90 30 100 3 10 7 severe depression with psychotic symptoms causes violence to self 13 45 21 70 8 25 8 an initial symptom which should alert the nurse regarding violence is lun and aggressive speech 25 83 27 90 2 7 9 assessment of motor activity of violent behavior includes clenching and pounding fist 19 63 27 90 8 27 10 assessment of verbal behavior of violent patients includes verbal threats towards real and imagined objects 13 43 24 80 11 37 table 2: effectiveness of self instructional module in pre-test and post-test with regard to concept of violence, factors causing violence, identification of violence and initial management of violence (n=30) 106 knowledge score was only 18.57% (5.57 ± 1.51), whereas the post-test mean knowledge score was 27.1% (8.13± 0.88) showing an increase of 8.53% (2.56 ±0.63) in the mean knowledge score. the overall findings revealed that the mean percentage of post-test score was more on compared to the mean percentage of the pre-test score. the effectiveness of self-instructional module was observed most of the areas, which is also supported by the findings of barlow r, in which education was given to the nurses.10 the difference between the pre-test and post test knowledge score was analyzed using paired ‘t’ test. the difference was found to be highly significant (t = 11.66). a significant increase was observed in the knowledge score after administration of self instructional module. findings suggest that the self instructional module was effective in improving the knowledge which is similar to the findings of udmala v (2002) in which self-instructional module was effective on awareness of aids education package for women’s health groups.11 area max score pre-test(x) mean ±sd mean % post-test(y) mean ±sd mean% effectiveness (y-x) % concept of violence, causative factors, identification and initial management 10 5.75 ±1.51 18.57 8.13 ±0.88 27.10 2.56 ± 0.63 8.53 table 4: effectiveness of self-instructional module with mean, sd and mean percentage of pre-test and post-test knowledge scores. 1. shreevani r. a guide to mental health and psychiatric nursing. new delhi: jaypee brothers medical publishers; 2004; 120. 2. luck l, jackson d, usher k. stamp: components of observable behaviour that indicates potential for patient violence in emergency departments. j adv nurs 2007; 59(1): 11-9. 3. hibbert dp. violence in health care incident analysis. mja 2005; 183. 4. suja js. develop a sim on breast self-examination for degree college students in selected college at mangalore. unpublished m. sc. (n) thesis submitted to rguhs, bangalore. 2002. 5. liu j, wuerker a. biopsychosocial basis of aggressive and violent behaviour implications for nursing students. int j nurs 2005; 42: 229-41. 6. nolan p, dallender j. violence in mental healthcare. the experiences of mental health nurses and psychiatrists. j adv nurs 1999; 30(4): 934-41. 7. grenyer bfs, lllkiw-laville 0, bino p, coleman m. safer at work: development and evaluation of an aggression and violence minimization programme. australian new zealand j psychiatr 2004; 389(10): 804. 8. whittingtom r, shuttleworth s, hill l. violence to staff in a psychiatric hospital setting. j adv nurs 1996; 24: 326-33. 9. lin y, liu h. the impact of workplace violence on nurses in south taiwan. int j nurs 2005; 773-8. 10. barlow r. prevalence and precipitants of aggression in psychiatric inpatient units. australian and new zealand j psychiatr 2000; 34(6): 967. 11. udmala v. a study to evaluate the effectiveness of an aids awareness package for improving women's health groups for aids awareness, action among urban slum dwellers of a selected district of andhra pradesh. unpublished m. phil. thesis submitted to mahe, manipal. 2002. references 107 elastic stable intramedullary nailing for treatment of pediatric tibial fractures sandeep gurung,a,c dipendra kc,a,c roshni khatrib,c —–————————————————————————————————————————————— abstract: introduction: tibia fractures in the skeletally immature patient can usually be treated with above knee cast or patellar tendon bearing cast. the purpose of our study was to evaluate epidemiology and outcome of elastic stable intramedullary nailing fixation of pediatric tibial shaft fractures treated at our institution. methods: over a period of one year, fifty pediatric patients of tibial shaft fractures, with average age of 9.68 yr (sd=2.37), were treated with elastic stable intramedullary nail. demographic data, union and complication rate were evaluated. results: there were 36 closed and 14 open fractures. the average time to union was 11.6 weeks (sd=2.65) for close and 14.3 weeks (sd=2.62) for open fracture. there were no instances of growth arrest, re-manipulations, or re-fracture. conclusion: we conclude that flexible intramedullary fixation is an easy and effective method of management of both open and closed unstable fractures of the tibia in children. keywords: intramedullary fracture fixation • pediatrics • tibial fractures • treatment outcome ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, b medical officer c department of orthopedics and traumatology nepalgunj medical college teaching hospital, nepal. corresponding author: dr. sandeep gurung e-mail: sgurung848@gmail.com how to cite this article: gurung s, kc d, khatri r. elastic stable intramedullary nailing for treatment of pediatric tibial fractures. journal of lumbini medical college. 2016;4(1):11-4. doi: 10.22502/jlmc.v4i1.82. ___________________________________________________________________________________ j. lumbini. med. coll. vol 4, no 1, jan-june 2016 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v4i1.82 introductions: tibial fractures are the second most common reason for orthopedic inpatient admission to children's hospitals.1,2 nearly all diaphyseal fractures of the tibia in children can be successfully treated using closed methods and cast immobilization. others have proposed pins in plaster, external fixation, open reduction with internal fixation, or intramedullary stabilization for those fractures that cannot be successfully managed using closed methods.3 recently, titanium elastic nails have gained popularity for the stabilization of femoral shaft fractures and other long bone fractures in the pediatric population.4-6 elasticity of the implants promotes callus formation by limiting stress shielding and promoting oscillation at the fracture site.4,7 traction forces are transformed into compression forces at the fracture site by two bent nails crossing each other and providing three-point fixation within the medullary canal. proposed advantages of elastic stable intramedullary nailing (esin) include immediate fracture stabilization, early mobilization, little soft tissue disruption, low infection and re-fracture rates, and more rapid return to daily function than conservative treatment with immobilization alone.4,7 current study evaluates epidemiology and outcome of esin fixation of pediatric tibial shaft fractures treated at our institution. methods: this was a prospective, observational study conducted in nepalgunj medical college teaching hospital (ngmcth) from november 2013 to october 2014. there were 50 children with displaced tibial shaft fracture who underwent esin after closed or open reduction. patients' demographic data, mode 11 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 jlmc.edu.np gurung s. et al. elastic stable intramedullary nailing for treatment of pediatric tibial fractures. of injury, union rate, and complication rates were evaluated. our indications for the procedure were polytrauma, open fracture, or failure to achieve a satisfactory closed reduction with informed consent. surgical technique: all patients were operated upon under general anesthesia. the affected limb was cleaned and draped. the appropriate size of nail was determined using the image intensifier. the fracture site and entry point at the level of the metaphysis were marked, taking care to avoid the physis. a two to three cm incision was made on either side of the tibia, proximal to the marked entry point. under fluoroscopic control, the cortex was broached with a drill of larger diameter than the nail to be inserted. two nails of equal diameter were pre-bent so that the apex of the bend would lie at the fracture site on opposite cortices. the tips of the nails were bent to 45˚ in order to facilitate passage along the opposite cortex and to aid in fracture reduction. the pre-bent nail was placed on an inserter and inserted from the side opposite the distal displacement in an antegrade fashion. under fluoroscopic guidance, it was slid along the opposite cortex until the fracture site was reached. a reduction was performed and the nail was advanced across the fracture site. the nail was embedded in the distal tibial metaphysis without violating the cortex or the physis. the second nail was placed from the other side in a similar fashion. the bent tip of the nails could be rotated after passing the fracture site to achieve an anatomic reduction. care was taken not to distract the fracture site. the nail ends were then bent distally and posteriorly and cut one cm from the cortical surface so that the nail ends would sit deep to the compartment fascia but be proud enough for easy retrieval. the wounds were closed with an absorbable fascial and subcuticular stitch. after surgery, all the patients were placed in a short-leg cast and mobilized, non-weight-bearing for four to six weeks. weight-bearing in a walking plaster was permitted when adequate callus was seen at the fracture site. fractures were considered to be united when tri-cortical callus was visible on the radiographs and there was no tenderness at the fracture site on clinical examination. final outcome was graded as excellent, satisfactory, or poor based on criteria described by flynn and colleagues (table 1).4 excellent satisfactory poor limb length discrepancy <1 cm <2 cm >2 cm mal-alignment up to 5° 5-10° >10° pain none none present complication none minor major table 1: flynn et al. (2001) criterion results: there were 36 boys (72%) and 14 girls (28%) with tibia fractures managed with esin during the study period. the average age of the fifty children was 9.68 year (sd=2.37). twenty four (48%) patients had tibial fracture following rta, followed by fall from height on fourteen cases (28%), sports injury in nine cases (18%), and hit by a stone in three (6%) cases. thirty two patients (64%) were affected on the right tibia and 18 cases (36%) on the left tibia. thirty six (72%) children had closed fracture and fourteen (28%) had open fracture. all the open fractures were managed by open method. of the closed 36 fractures, 32 (88.9%) were managed by closed method and the rest four (11.1%) were managed by open methods. associated injuries were seen in ten (20%) children. four (8%) had head trauma managed conservatively, two (4%) had blunt trauma abdomen which was also managed conservatively, two (4%) had radius fracture which was managed by intramedullary k-wire fixation, and two (4%) had ipsilateral femur fracture which was managed with esin. twenty six (48%) cases which was managed with esin had both bone leg fracture and twenty four (48%) had isolated tibia fracture. classification of open fractures according to gustilo and anderson classification is shown in table 2.8 the average union time for closed fractures was 11.61 weeks (sd=2.65) and open fracture was 14.36 weeks (sd=2.62). grade one open fracture united on 13.38 weeks (sd=3.11) while grade two fracture united in 15.67 weeks (sd=0.82). five mechanism of injury gustilo and anderson totalgrade i open grade ii open grade iii open fall from height 3 1 0 4 rta 5 3 0 8 hit by a stone 0 2 0 2 total 8 6 0 14 table 2: distribution of patients with open fracture according to gustilo and anderson classification. 12 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 gurung s. et al. elastic stable intramedullary nailing for treatment of pediatric tibial fractures. jlmc.edu.np (10%) patient developed superficial bursitis due to prominent nail but there was no wound breakage as nail was buried beneath skin. four (8%) patient had pain at the nail insertion site, two had limb length discrepancy of less than two cm lengthening, and two had superficial infection at the fracture site. out of 50 patients, 46 (92%) had excellent outcome and four (8%) had satisfactory outcome according to flynn et al. criterion.4 discussion: although cast immobilization remains the standard treatment for appropriate fractures of the tibia, pediatric orthopedic surgeons have been trying to minimize the prolonged immobilization necessary after such treatment. fixation is particularly beneficial for children who have sustained multiple injuries from high energy trauma,those with head injuries, open fractures, compartment syndrome and for older children.9 there have been an increasing number of reports demonstrating the effectiveness of surgical treatment of tibial shaft fractures in children. the ideal internal fixation device for such pediatric tibial fractures would be a simple load sharing device that would maintain alignment, allow mobilization until bridging callus forms, not cross the physis, and be both easy to insert and remove. the search for treatment which satisfy most of these criteria has led to an increasing number of surgeons using the elastic intramedullary nails, to treat a variety of pediatric long bone fractures including the tibial shaft.4,6,10 there are several advantages of this technique. three-point fixation within the medullary canal allows maintenance of both alignment and rotation for most fractures. flexible intramedullary nails provide fixation that is stable and elastic. the elastic fixation allows for controlled repetitive motion at the fracture site. this allows for cyclic loading as well as resistance to angular and rotational deforming forces.11 the shear forces that cause displacement are transformed into compression and traction forces.12 the healing, as a result of this elastic stabilization, is by external callus.13 the basic science literature supports that controlled motion at the fracture site results in improved healing in long bones fractures.14,15 there are few articles in the literature on the management of diaphyseal fractures of the tibia in children with intramedullary fixation.11,16,17 o’brien et al. reported 16 fractures of the tibia, fixed internally with intramedullary fixation, which achieved a very good functional outcome.17 they reported one superficial infection, six coronal and seven sagittal angulations, but no functional compromise. one child had a leg-length discrepancy of over 1.5 cm. vrsansky et al. reviewed 308 children with fractured long bones fixed with flexible intramedullary nails, of which 36 involved the tibia. an excellent functional outcome was reported, with all patients mobilizing independently by three to five months.18 qidawi described a retrospective review of 84 fractures of the tibia treated with intramedullary k-wires with a mean time to union of 9.5 weeks.11 more recently, kubiak et al. compared flexible nailing with external fixation, as a method of treating fractures of the tibia in children. this was a retrospective review of clinical and radiographical outcomes for 31 children with fractures of the tibia. of these, 16 had elastic stable intramedullary nailing (esin) and 15 had external fixation. in the external fixation group there were eight children (53%) with an open fracture, compared with five (31%) in the esin group. the mean time to union was 18 weeks in the external fixation group but only seven weeks in the esin group. there were seven bony complications in the external fixation group (two delayed unions, three nonunions, and two malalignments), whilst there was one bony complication in the esin group.19 the authors recommended that esin should be used for the treatment of fractures of the tibia in skeletally immature patients in need of surgical stabilization, including open fractures without segmental bone loss and limited comminution. hasenhuttl reviewed 235 cases and reported good healing in 93% of closed fractures and 66% of open fractures.20 the nonunion rate was 4.4%, as was the rate of deep infection with osteomyelitis. it is difficult from our small sample size to draw any conclusion from this observation. in addition to the satisfactory alignment with which these fractures healed, all of our fractures healed. there were no delayed unions or malunions and there were no re-fractures, probably because these injuries heal with often-abundant callus, thereby reducing the risk of re-fracture. there were no cases of physeal arrest or proximal tibia growth disturbances. conclusions: this study indicates that flexible titanium nails are an effective treatment option for the unstable tibia fracture in skeletally immature 13 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 gurung s. et al. elastic stable intramedullary nailing for treatment of pediatric tibial fractures. jlmc.edu.np patient. we conclude that, where indicated, flexible intramedullary nailing should be done as it is a relatively simple and effective way to stabilize open and closed fractures of the tibia in children with few complications, allowing early mobilization, and an excellent functional outcome. references: 1. setter kj, palomino ke. pediatric tibia fractures: current concepts. curr opin pediatr. 2006;18(1):30-5. 2. galano gj, vitale ma, kessler mw, hyman je, vitale mg. the most frequent traumatic orthopedic injuries from a national pediatric inpatient population. j pediatr orthop. 2005;25(1):39-44. 3. irwin a, gibson p, ashcroft p. open fractures of the tibia in children. injury. 1995;26:21-4. doi: 10.1016/00201383(95)90547-b. 4. flynn jm, hresko t, reynolds ra, blasier rd, davidson r, kasser j. titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. j pediatr orthop. 2001;21(1):4-8. 5. flynn jm, luedtke l, ganley tj, pill sg. titanium elastic nails for pediatric femur fractures: lessons from the learning curve. am j orthop. 2002;31(2):71-4. 6. ligier jn, metaizeau jp, prevot j, lascombes p. elastic stable intramedullary nailing of femoral shaft fractures in children. j bone joint surg br. 1988;70(1):74-7. 7. huber ri, keller hw, huber pm, rehm ke. flexible intramedullary nailing as fracture treatment in children. j pediatr orthop. 1996;16(5):602-5. 8. gustilo rb, anderson jt. prevention of infection in the treatment of one thousand and twenty five open fracture of long bone; retrospecitve and prospective analysis. j bone joint surg am. 1976;58:453-6. 9. tolo vt. external skeletal fixation in children’s fractures. j paediatr orthop. 1983;3(4):435-42. 10. vallamshetla vrp, de silva u, bache ce. flexible intramedullary nails for unstable fractures of the tibia in children. j bone joint surg br. 2006;88:536-40. 11. qidawi sa. intramedullary kirschner wiring for tibia fractures in children. j pediatr orthop. 2001;21:294-7. 12. muller me, nazarian s, koch p, schatzker j. the comprehensive classification of fractures of long bones. berlin: springer-verlag; 1990. 13. barry m, paterson jm. flexible intramedullary nails for fractures in children. j bone joint surg br. 2004;86(7):947-53. 14. baker sp, o’neill b, haddon w jr, long wb. the injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. j trauma. 1974;14(3):187-96. 15. wiss d, segal d, gumbs vl, salter d. flexible medullary nailing of tibial shaft fractures. j trauma. 1986;62(12):1106-12. 16. ligier jn, metaizeau jp, prevot j. closed flexible medullary nailing in pediatric traumatology. chir pediatr. 1983;24(6):383-5. 17. o’brien t, weisman ds, ronchetti p, piller cp, maloney m. flexible titanium nailing for the treatment of the unstable paediatric tibial fracture. j pediatr orthop. 2004;24(6):601-9. 18. vrsansky p, bourdelat d, al faour a. flexible stable intramedullary pinning technique in the treatment of paediatric fractures. j pediatr orthop. 2000;20:23-7. 19. kubiak en, egol ka, scher d, wasserman b, feldman d, koval kj. operative treatment of tibial fractures in children: are elastic stable intramedullary nails an improvement over external fixation? j bone joint surg am. 2005;87(8):1761-8. 20. hasenhuttl k. the treatment of unstable fractures of the tibia and fibula with flexible medullary wires: a review of two hundred and thirty-five fractures. j bone joint surg am. 1981;63(6):921-31. 14 presentation and management of soft-tissue foreign bodies in a teaching hospital of western nepal ruban raj joshi,a rajeev dwivedia —–————————————————————————————————————————————— abstract: introduction: accidental penetrating injuries with foreign bodies are a common presentation in hospital's emergency rooms. if missed, these bodies can remain dormant or result in a wide range of complications. this study evaluated the characteristics of patients, presentation and management who suffered foreign body embedded in soft tissue at a teaching hospital of western nepal. methods: the study was conducted at department of orthopaedics, lumbini medical college teaching hospital from september 2013 to august 2015. all cases confirmed to have a foreign body in soft tissue were enrolled. surgical exploration with removal of foreign body was carried in operating room under tourniquet control. the patient demographics, cause of injury, nature of foreign body, occupation of the patient, diagnostic yield of radioimaging, procedures undertaken for retrieval of foreign body, and complications were recorded. all patients were followed-up up to five months. results: total 28 patients, nine (32.1%) males and 19 females (67.9%) were observed. the mean age was 35.6 yr (sd=11.1). housewives (n=14, 50%) were the common sufferers. most of our patients (n=17, 60.7%) presented two weeks after injury. accidental prick while cutting grass or tree was the common mode (n=13, 46.3%) of injury and among foreign bodies, wooden or vegetative were the commonest (n=19, 67.9%) observed. among the extremities, hand (n=10, 35.7%) and foot (n=5, 17.9%) were commonly affected. all patients had successful surgical exploration and retrieval of the foreign bodies under anesthesia and tourniquet control in operating room. image intensifier was employed in seven cases to locate the foreign bodies per-operatively. wound infection developed in 14.2% (n=4) of patients, all of whom were managed successfully with oral antibiotics. none of the patients required re-hospitalization. all patients were fine at final five months follow up. conclusion: managing foreign body embedded in the soft tissue are challenging. surgical exploration under tourniquet control suffice a definitive management. at times, image intensifier is required to locate the foreign body. keywords: foreign-body • management • presentation • removal • soft tissue ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, department of orthopedics and traumatology, lumbini medical college teaching hospital, palpa, nepal. corresponding author: dr. ruban raj joshi e-mail: rubanjoshi@hotmail.com how to cite this article: joshi rr, dwivedi r. presentation and management of soft tissue foreign bodies in a teaching hospital of western nepal. journal of lumbini medical college. 2015;3(2):50-4. doi: 10.22502/jlmc. v3i2.73. ___________________________________________________________________________________ j. lumbini. med. coll. vol 3, no 2, july-dec 2015 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v3i2.73 introduction: foreign bodies (fbs) are any objects originating outside the body and constitute the flora of our surroundings which enter the human body during accidental injuries such as motor vehicle accidents, explosions and ballistic injuries or can be self-inflicted. the nature and location of the foreign bodies can vary considerably.1 penetrating and impalement injuries are common presentations at the hospital's emergency rooms both in the developed as well as developing countries. foreign body injuries should be suspected in all such cases.2,3 these foreign bodies may be detected incidentally in x-rays or when missed, may present later with an abscess, granulomas, non healing sinuses, lump, or stinging sensation.4 sometimes fb may present away from the site of primary wound because of delayed migration into soft tissues planes.5 radiographs and ultrasound are two commonly available adjuncts for detecting foreign bodies.6 in order to preclude these complications, the foreign bodies are best removed surgically. we frequently encounter patients with soft tissue foreign body in fresh wounds as well as 50 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 joshi rr. et al. presentation and management of soft tissue foreign bodies in a teaching hospital of western nepal. jlmc.edu.np embedded deep in healed wound. the present study was undertaken to evaluate the clinical presentation, diagnosis, and management of soft-tissue foreign bodies in a teaching hospital setting of hilly western region of nepal. methods: this descriptive case series study was carried out at the department of orthopaedic surgery, lumbini medical college teaching hospital from september 2013 to august 2015. all patients of either gender with suspected foreign body in wound were followed and included in the study after the foreign body was confirmed by palpation, radiography, ultrasonography or exploration. informed consent was taken on a proforma before entering the data. the initial assessment was made by detailed history, thorough examination, plain radiographs, and ultrasonography. tetanus prophylaxis was routinely employed if there was no booster dose of tetanus immunization within 10 years. passive immunization with tetanus immunoglobulion was also ensured in patients with contaminated wounds with unknown history of tetanus immunization. antibiotics prophylaxis was given to all patients with cefazoline 500 1000 mg and metronidazole 15 mg/kg. all the cases were admitted in the hospital. cases with history suggestive of embedded foreign bodies with fresh wounds were surgically explored in operating room and careful retrieval, under regional or local anesthesia and tourniquet control was undertaken under aseptic precautions. digital x-rays with markers at puncture site and ultrasonography were performed in cases where it was not palpable. in cases where wound exploration did not identify the foreign body, per operative fluoroscopy was employed. the demographic profile of the patients, cause of injury, occupation of the patient, type of foreign body, diagnostic yield of plain x-rays, type of procedure undertaken for retrieval of foreign body, any complications were all recorded. a follow-up of five months was done. the data were analyzed by spss software (version 19, chicago, il, usa) and various descriptive statistics were used to calculate frequencies, percentages, mean, and standard deviation. the numerical data such as age were expressed as mean and standard deviation while the categorical data such as the causes and types of foreign bodies were expressed as frequency and percentages. results: a total 32 cases presented to department of orthopeadic surgery, lumbini medical college teaching hospital with foreign bodies embedded in soft tissues. only 28 patients were included in the data analysis as the rest either refused or left before the completion of the proforma. there were nine (32.1%) males and 19 (67.9%) females with m:f ratio of 1:2.1. the mean age was 35.6 yr (sd=11.1) with a range of nine to 55 years while the median was 36 years. housewives were the common sufferers (n=14, 50%). occupations of the remainder of the patients included farmers (n=5, 17.9%), labourer (n=3, 10.7%), and teacher, student and wood workers (n=2, 7.1% each). six cases (21.4%) presented within 24 hours of injury with fresh wounds, five (17.9%) presented within 2 weeks of primary injury and seventeen cases (60.7%) presented after 2 weeks of injury. among the injury causing mechanisms, the commonest were injury sustained during cutting grass and trees (n=13, 46.3%). the remainder included road traffic accidents and fall from height (n=4, 14.3% each), firearm injury, physical assault, playing and sports injury (n=1 each). the extremities commonly affected were hand (n=10, 35.7%), foot (n=5, 17.9%), forearm and knee (n=3, 10.7% each), leg (n=2, 7.1%), and pelvis, buttock, thigh, wrist and arm (n=1 each). among the foreign bodies observed wooden splinters were commonest 19 (67.9%) (table 1). the digital radiography were taken in two views for all cases except where the foreign body was easily palpable or located by ultrasonography. digital roentgenograms were performed in 20 (71.4%) cases while five cases (17.8%) were foreign bodies n(%) wooden 19(67.9) glass 3(10.7) needle 2(7.1) pebbles 2(7.1) metallic 1(3.6) bullet 1(3.6) table 1: the distribution of foreign bodies. 51 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 jlmc.edu.np joshi rr. et al. presentation and management of soft tissue foreign bodies in a teaching hospital of western nepal. operated without x-rays as foreign body was clearly visualized or palpable. in three cases, they were marked preoperatively by ultrasonologist. most of patients had successful surgical exploration and retrieval of the foreign bodies. in seven cases, image intensifier was employed to locate the foreign bodies per-operatively. in one case, foreign body could not be retrieved despite all efforts, and procedure was abandoned due to risk of additional soft tissue injury. wound infection was found in 14.2% (n=4) patients, all of whom were managed successfully with oral antibiotics and secondary closure. none of our patients had hospital readmission. all patients were uneventful at five months follow up. discussion: soft-tissue foreign body are usually under reported as most of the patients are presented to local clinics, emergency departments of non-teaching hospitals and outpatient clinics.7 in our study, we had majority female patients. our finding contrasts to the observation of salati et al. and mohammadi et al. who reported a gender difference in foreign body injury patterns with predominant involvement of males.8,9 the difference is probable due to more frequent involvement of our women in household, farming and cattle grazing activities. majority of our patients were relatively young with a median age 36 yr. other published studies have also reported more frequent involvement of relatively younger patients sustaining injuries.8,9 the time of presentation since the initial injury to emergency department or outpatient clinics is variable in different reports. our observation contrasts to that of levine et al. who reported majority of their patients presenting within 48 hours.10 salati et al. reported that only 10% of his cases attended within 2 weeks of injury, rest of 90% came after two weeks.8 our findings are comparable to that of salati as two third of our patients presented after two weeks of initial injury. wood splinters and foreign bodies with other vegetative nature were most commonly observed. it may be probably due to majority of our female population engagement in cattle grazing and cutting grass activities in difficult terrain of hilly region. or findings contrasts to the observation of saaq m., where needle and metallic fragments were the commonest.4 stones/gravels and glass were observed in cases secondary to road traffic accidents. sewing needles were observed in females probably due to exposure to routine stitching and sewing at home. in our series, we did not find any case of selfinflicted foreign body injury. contrary to this, there is growing appreciation of self-injury characterized by the deliberate destruction or alteration of body tissues without suicidal intent. it is estimated that in the united states, 4% of the general population and 13-23% of the adolescents report a history of nonsuicidal selfinjury.11-13 such self-inflicted injuries with foreign bodies, if any in our part of the world, are yet to be documented in the published literature. the hands and feet were the most vulnerable part for puncturing injuries resulting in foreign bodies embedded in soft tissue.14 upper and lower limbs collectively contributed for majority of our cases and the same is reported in other contemporary articles. metallic foreign bodies, confirmed on surgical exploration, were detected on pre-operative plain x-rays. ultrasonography was advised in all cases where fb was not visible in plain x-rays. the published literature reveals a growing trend towards more frequent use of high frequency ultrasound for both diagnosis and management of hand foreign bodies.15 in our series, there were nineteen cases of wooden foreign bodies; however, none of them could be detected on preoperative x-rays and all of them were confirmed on surgical exploration only. peterson et al., who reported a series of 12 cases of retained foreign bodies, also observed failure of plain x-rays to reveal the diagnosis.16 radiographs may reveal a wooden foreign body in only up to 15% of patients. the wooden foreign bodies are usually radiolucent and associated with gas in the matrix. however, the small size of the foreign body often is not sufficient to create an appreciable radiolucency. wood usually shows a linear hypo-intense signal on mr imaging with gas in the matrix. ct typically shows the retained wood as a linear area of increased attenuation, which is best seen on wide window settings. sonography has proved the most useful modality, easily identifying the retained wood as a linear echogenic focus with marked acoustic shadowing.16-18 ct scan and mri are more informative and precise but are costly and are not performed routinely. most of our patients did not come for a regular follow up which is a common scenario in our part 52 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 joshi rr. et al. presentation and management of soft tissue foreign bodies in a teaching hospital of western nepal. jlmc.edu.np of the country. the wound complication following removal of fb in our study was within acceptable limits. there was one case where small metallic fragments were missed and remained asymptomatic. there were some interesting cases that need mention. a 45 years old lady presented with a wooden fb penetration and localized swellings to her right forearm. on exploration, 6.5 cm x 1.25 cm bamboo splinter was removed from her flexor compartment of forearm along with multiple twigs in extensor aspect (fig 1). another 54 years old gentleman had penetrating tree branch in left calf following fall from a cliff (fig 2). a 12x 2cm of wooden branch was retrieved without any neurovascular injury. a 46 years female presented with a ganglion like fig 1: a. a 45 years lady with penetrating wooden foreign body in right forearm; b. plain radiograph showing a radiolucent shadow at proximal forearm but discrete foreign body is not seen; c. peroperative photo showing bamboo splinter in deep forearm muscles; d. removed bamboo splinter. fig 2: a 54 old male with penetrating injury by wooden foreign body in left calf; b removed wooden foreign body. swelling over posterolateral aspect ankle with acute inflammatory changes. on incision and drainage two pieces of bamboo splinter was removed underneath peroneal vessels along with a serosanguineous fluid (fig 3). lastly, 24 years male had embedded metallic fragments in forearm for 8 months (fig 4). our study had some limitations. it was a single centered study for short duration with small number of cases. another limitation was a lack of long-term follow-up results. we could not evaluate fig 4: a. plain radiographs forearm showing radio opaque metallic foreign bodies; b. per-operative pictures showing incisions to retrieve the foreign bodies; c. extracted metallic foreign bodies. fig 3: a. a 46 years old female with a discharging sinus at posterolateral ankle; b. ultrasonogram revealing echogenic wooden splinter; c. per-operative photo showing wood splinter embedded in soft tissue; d. removed wooden foreign bodies. b 53 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 joshi rr. et al. presentation and management of soft tissue foreign bodies in a teaching hospital of western nepal. jlmc.edu.np whether unexpected complications developed after discharge from the hospital more than five months after the procedure. our study should prompt other similar local studies and hence allow more meaningful comparison of results in our own population in various parts of our country. we recommend the conduct of a multicenter local study to confirm and improve upon our results. also a similar local study may be conducted to evaluate the overall economic and working days lost as a result of such injuries. conclusions: foreign body injuries are severe injuries that may cause significant problems when ignored. majority of the sufferers are middle aged females and present with history of puncturing or penetrating injury that suggest the presumptive diagnosis of foreign bodies. wooden splinters and thorn injuries were most commonly encountered. plain radiographs reliably diagnose and locate metallic, glass, and stony foreign bodies; however, wooden foreign bodies are often not revealed by plain x-rays. surgical exploration in operating room and careful retrieval under anesthesia and tourniquet control suffice as the definitive treatment. in rare instances, intraoperative image intensifier is needed to locate foreign bodies per operatively. conflict of interest: the principal author did not take part in editorial decisions. references: 1. panigrahi r, dash sk, palo n, priyadarshi a, sahu sk, biswal mr. foreign body detection in musculoskeletal injuries: a in vitro blinded study comparing sensitivity among digital radiography, ultrasonography, ct and magnetic resonance imaging. musculoskelet regen. 2015;2:1-7. doi: 10.14800/mr.649. 2. boyse td, fessell dp, jacobson ja, lin j, van holsbeeck mt, hayes cw. us of soft-tissue foreign bodies and associated complications with surgical correlation. radiographics. 2001;21(5):1251-6. 3. lese ab. hand injury, soft tissue [serial online] [2012 oct 23]. available from: url: http:// www.emedicine.com/ emerg/topic225.htm 4. saaiq m. epidemiology and management of foreign bodies in the hand: pakistani perspective. world j plast surg. 2014;3(1):13-17. 5. ozsarac m, demircan a, sener s. glass foreign body in soft tissue: possibility of high morbidity due to delayed migration. j emerg med. 2011 dec;41(6):e125-8. doi: 10.1016/j.jemermed.2008.04.051. 6. horton lk, jacobson ja, powell a, fessell dp, hayes cw. sonography and radiography of soft-tissue foreign bodies. am j roentgenol. 2001;176(5):1155-9. doi: 10.2214/ ajr.176.5.1761155 7. alemdar c, demirtaş a, gem m, özkul e, azboy i, bulut m, et al. orthopedic approach to foreign body stings. journal of clinical and experimental investigations. 2013;4(4):443-8. doi: 0.5799/ahinjs.01.2013.04.0321 8. salati sa, rather a. missed foreign bodies in the hand: an experience from a center in kashmir. libyan j med. 2010;5:1-5. doi: 10.3402/ljm.v5i0.5083 9. mohammadi a, ghasemi-rad m, khodabakhsh m. nonopaque soft tissue foreign body: sonographic findings. bmc med imaging. 2011;11:9. doi: 10.1186/1471-234211-9. 10. levine mr, gorman sm, young cf, courtney dm. clinical characteristics and management of wound foreign bodies in the ed. am j emerg med. 2008;26(8):918-22. doi: 10.1016/j.ajem.2007.11.026. 11. jacobson cm, gould m. the epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review of the literature. arch suicide res. 2007;11(2):129-47. 12. young as, shiels we 2nd, murakami jw, coley bd, hogan mj. self-embedding behavior: radiologic management of self-inserted soft-tissue foreign bodies. radiology. 2010;257(1):233-9. doi: 10.1148/radiol.10091566. epub 2010 sep 7. 13. wraight wm, belcher hj, critchley hd. deliberate selfharm by insertion of foreign bodies into the forearm. j plast reconstr aesthet surg. 2008;61:700-3. 14. halaas gw. management of foreign bodies in the skin. am fam physician. 2007;76(5):683-690. 15. saboo ss, saboo sh, soni ss, adhanev. high-resolution sonography is effective in detection of soft tissue foreign bodies:experience from a rural indian center. j ultrasound med. 2009;28:1245-9. 16. peterson jj, bancroft lw, kransdorf mj. wooden foreign bodies: imaging appearance. am j roentgenol. 2002;178:557-62. 17. monu ju, mcmanus cm, ward wg, haygood tm, pope tl, bohrer sp. soft-tissue masses caused by long-standing foreign bodies in the extremities: mr imaging findings. ajr 1995;165:395-7. 18. shrestha d, sharma uk, mohammad r, dhoju d. the role of ultrasonography in detection and localization of radiolucent foreign body in soft tissues of extremities. j nepal med assoc. 2009;49:5-9. 54 comparison of perinatal outcome of breech presentation between vaginal delivery and cesarean section buddhi kumar shrestha,a,c subha shresthab,c —–————————————————————————————————————————————— abstract: introduction: many times, parturient opt for labour and vaginal breech delivery even after informing increased perinatal risks. vaginal breech deliveries are undertaken with the reasons like avoidance of cesarean section in next pregnancy, null risk of operative and anesthetic hazards, ability to resume early all household works after vaginal birth, etc. the purpose of this study is to compare the perinatal outcome of breech deliveries in singleton breech presentation between vaginal breech delivery and cesarean section. methods: a retrospective study was done in lumbini medical college teaching hospital for the duration of one year (december 2014 to november 2015). data of perinatal outcome of breech deliveries were collected from the hospital records. the records of neonatal examination were also collected. the primary outcomes included were neonatal morbidity and mortality. results: out of 80 selected women with breech presentation, 42 of them had vaginal deliveries and 38 women had undergone caesarean section. the perinatal mortality was 4.8% and morbidity was 2% in vaginal breech deliveries. there was no significant difference of apgar score in the two groups at any time. similarly, there was no significant difference in perinatal morbidity and mortality in the two groups. nulliparous women were more likely to deliver by cesarean section. conclusion: in places where planned vaginal delivery is a common practice and when strict criteria are met before and during labour, planned vaginal breech delivery of singleton fetus in breech presentation remains a safe option that can be offered to women. keywords: breech presentation • cesarean section • perinatal mortality • pregnancy outcome • vaginal birth ——————————————————————————————————————————————— ___________________________________________________________________________________ a assistant professor b lecturer c department of obstetric and gynecology, lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. buddhi kumar shrestha e-mail: drbuddhi205@gmail.com how to cite this article: shrestha bk, shrestha s. comparison of perinatal outcome of breech presentation between vaginal delivery and cesarean section. journal of lumbini medical college. 2016;4(1):4-6. doi: 10.22502/jlmc.v4i1.87. ___________________________________________________________________________________ j. lumbini. med. coll. vol 4, no 1, jan-june 2016 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v4i1.87 introduction: breech presentation is defined as a fetus in longitudinal lie with the buttocks or legs adjacent to the birth canal (cervix) or enters it near term before the head. it occurs in 3-4% of all deliveries.1 predisposing factors for breech presentation includes prematurity, uterine anomalies, fetal hydrocephalus, space occupying lesion in lower pole of uterus, etc. there is a lot of controversy regarding selection of candidate for trial of vaginal breech delivery. american college of obstetricians and gynecologists (acog) and royal college of obstetrician and gynecologists (rcog) recommend that "the decision regarding the mode of delivery should depend on the experience of the health care provider" as a multicenter trial showed that planned cesarean delivery was not associated with a reduction in the rate of death or developmental delay. the perinatal mortality and morbidity increases with breech presentation by 2-4 folds regardless of the mode of deliveries. in short, decision of mode of breech deliveries should be individualized.1 there is no enough evidence regarding the use of planned caesarean delivery for preterm or term babies.2,3 4 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 shrestha bk. et al. comparison of perinatal outcome of breech presentation between vaginal delivery and cesarean section. jlmc.edu.np the current study is an attempt to compare the perinatal outcome between vaginal breech deliveries and caesarean breech deliveries. methods: a retrospective study was done in lumbini medical college teaching hospital for the duration of one year (december 2014 to november 2015) comprising of 80 cases of breech presentation delivered after 28 completed weeks of gestation. all women with breech deliveries and 28 completed weeks of gestation during the period of study were included. following were excluded from the study: congenital anomalies incompatible to vaginal delivery, any breech other than frank and complete breech (footling breech presentation, hyperflexed head), intrauterine fetal death, multiple pregnancies, clinically inadequate pelvis, macrosomia, or intra uterine growth retardation (iugr) baby. outcome measures studied were: neonatal mortality and morbidities (need of nicu, fractures, paralysis, respiratory distress syndrome, cord prolapse and one minute apgar score less than five). data were collected and entered in excel 2007. analysis was done with spss 16. descriptive statistics like mean, standard deviation, frequency, percentage were calculated. pearson chi square test was used for comparison and p value <0.05 was considered significant. results: there were total 3160 deliveries during the study period. among them, 80 women had breech presentation and hence the rate of breech presentation was 2.53%. caesarean section was done in 38 (47.5%) women out of which elective was done in 8 (10%) and emergency in 30 (37.5%) cases. vaginal breech delivery was conducted in 42 (52.5%). of those 80 breech, 48 (60%) were frank breech and the rest 32 (40%) were complete breech. vaginal breech deliveries were common in frank breech (n=36, 75%) and cesarean section was common in complete breech (n=26, 81%) and this difference was statistically significant x2(n=80, df=1) = 24.4, p<0.001. thus, the women with frank breech were more likely to deliver by vaginal route. apgar score of babies at one and five minutes is shown in table 1. there was no significant difference of apgar score in two groups at any time. perinatal morbidity and mortality in the two groups is compared in table 2 and table 3. there is no significant difference in perinatal morbidity and mortality in the two groups. relationship between mode of delivery was compared to parity of the women. there were 46 nulliparous and 34 multipara women. among nulliparous, 30 (65%) delivered by cesarean section whereas among multipara, only eight (24%) delivered by cesarean section. this difference was statistically significant (x2[n=80, df=1] = 13.6, p<0.001). nulliparous women were more likely to deliver by cesarean section. apgar score vaginal delivery (n= 42) cesarean section (n=38) n % n % 1 min <7 3 7.1 3 7.8% p=1 fet > 7 39 92.9 35 92.2% 5 min <7 2 4.7 2 5.3% p=1 fet >7 40 95.3 36 94.7% table 1: apgar score by mode of delivery vaginal delivery (n=42) cesarean section (n=38) morbidity n % n % present 2 2 p=1 fet birth asphyxia 2 4.7 0 meconium aspiration 0 2 5.2 absent 40 36 table 2: perinatal morbidity by mode of delivery table 3: perinatal mortality by mode of delivery vaginal delivery (n= 42) cesarean section (n= 38) death n % n % present 1 2.3 1 2.6 p=1 fetabsent 41 97.7 37 97.4 discussion: there is a risk that reduction in vaginal breech deliveries may lead to less skilled obstetricians and less favorable results in situations where vaginal delivery is unavoidable, such as undiagnosed breech in advanced labor or delivery of second twin. so, a skilled practitioner should be available to conduct 5 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 jlmc.edu.np shrestha bk. et al. comparison of perinatal outcome of breech presentation between vaginal delivery and cesarean section. labour with breech presentation and all vaginal breech deliveries. where such facility is lacking, a lady should be optioned/referred to the better center. practitioner should have appropriate training like advance life support training in obstetrics (also), skilled birth attendant (sba) to supervise labour and delivery of breech and should be readily available.4 planned vaginal delivery of singleton fetuses in breech presentation at term remains a safe option that can be offered to women in places where vaginal delivery is a common practice and when strict criteria are met before and during labor, planned considering the type of breech, pelvic adequacy and estimated fetal weight etc.5 perinatal mortality and morbidity rate reduction is possible when all women begin to value preconception counseling and attendance at antenatal clinics.6 many authors, in their study, had concluded term vaginal breech delivery is associated with significantly increase in perinatal morbidity and mortality (more evident in nullipara women and in neonates with expected birth weight 3500–4000 g), when compared with caesarean breech delivery.7,8,9,10,11 on contrary, our study had resulted similar outcomes on perinatal mortality and morbidity in breech delivery by vaginal route or by cesarean section. haider s., in her study had concluded that there is no firm evidence to support systemic elective cesarean section for all breech presentation at term. to determine whether a potential benefit for the neonates out-weight the increased risk to mother after elective caesarean section, large unbiased studies are needed.12 in countries like ours, women prefer to have vaginal birth due to fear of surgery, physical restrain that has to be maintained post operation, need of repeated sections in future pregnancies, financial status, etc. we could not oblige all parturient for elective cesarean section when many studies and rcog guideline recommend vaginal breech deliveries by trained practitioners. in our institute, practitioners with also training, sba training are conducting vaginal breech deliveries for years under supervision of experienced obstetricians. the premoda trial was conducted in france and belgium and it did not find a significant excess risk associated with vaginal delivery compared with cesarean section. in the light of the premoda study, some obstetricians have been calling for a return to breech vaginal delivery.4 conclusion: with utmost respect to guidelines and evaluation of various factors leading to fetal morbidity and mortality from surgical procedure and anesthetic hazards as well as no difference in outcome of neonates regarding the route of deliveries; we prefer to provide supervised planned vaginal birth to the selected cases of breech presentation. in places where planned vaginal delivery is a common practice and when strict criteria are met before and during labour, planned vaginal breech delivery of singleton fetus in breech presentation remains a safe option that can be offered to women. references: 1. williams jw. breech delivery. 24th ed. cunningham fg, leveno kj, bloom sl, spong cy, dashe js, hoffman bl, et al., editors. williams obstetrics. usa: mcgraw hill companies; 2014. 558 p. 2. alfirevic z, milan sj, livio s. cesarean section versus vaginal delivery for preterm birth in singletons. cochrane database syst rev. 2012;6:cd000078. 3. lindqvist a, norden-lindeberg s, hanson u. perinatal mortality and route of delivery in term breech presentations. br j obstet gynaecol. 1997;104(11):1288-91. 4. royal college of obstetricians and gynaecologists (2006) rcog guideline no. 20b dec. 5. goffinet f1, carayol m, foidart jm, alexander s, uzan s, subtil d et al. is planned vaginal delivery for breech presentation at term still an option? results of an observational prospective survey in france and belgium. am j obstet gynecol. 2006;194:1002–11. 6. al-mejhim fm, al-najashi ss. trends in perinatal mortality at king fahd hospital of the university, al-khobar, saudi arabia: a ten years study. j family community med. 1998; 5(2):31-7. 7. alshaheen h, abd al-karim a. perinatal outcomes of singleton term breech deliveries in basra. emhj. 2010; 16(1):34-9. 8. hannah me, hannah wj, hewson sa, hodnett ed, saigal s, willan ar. planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. term breech trial collaborative group. lancet. 2000;356:1375-83. 9. rietberg cc, elferink-stinkens pm, brand r, van loon aj, van hemel oj, visser gh. term breech presentation in the netherlands from 1995 to 1999: mortality and morbidity in relation to the mode of delivery of 33824 infants. bjog. 2003,110:604-60. 10. rietberg cc, elferink-stinkens pm, visser gh. the effect of the term breech trial on medical intervention behaviour and neonatal outcome in the netherlands: an analysis of 35,453 term breech infants. bjog. 2005;112:205-9. 11. herbst a, kallen k. influence of mode of delivery on neonatal mortality and morbidity in spontaneous preterm breech delivery. eur j obstet gynecol reprod biol. 2007;133: 5-9. 12. herbst a, thorngren-jerneck k. mode of delivery in breech presentation at term: increased neonatal morbidity with vaginal delivery. acta obstet gynecol scand. 2001; 80:731-7. 6 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 30 september, 2019 accepted: 20 may, 2020 published: 06 june, 2020 a lecturer, department of surgery b associate professor, department of surgery c assistant professor, department of surgery d dhulikhel hospital, kathmandu university hospital, dulikhel, nepal. corresponding author: rajan koju e-mail: kojurajan@gmail.com orcid: https://orcid.org/0000-0001-6329-1691 _______________________________________________________ —–———————————————————————————————————————————— abstract introduction: there are various modalities of breaking urinary tract calculus. the aim of this study was to compare outcome between laser and pneumatic lithotripsy in patients with upper ureteric calculus in terms of stone free rate, proximal migration and complication. methods: this was a prospective comparative study done in 210 patients with upper ureteric calculus. the patients were randomized into two groups (laser lithotripsy and pneumatic lithotripsy) from april 2018 to june 2019. the main objective of both the procedures was to break stone into particles less than 3 mm which was confirmed by x-ray kub and ultrasonography of abdomen and pelvis after six weeks and to compare effectiveness in terms of immediate stone free rate, proximal migration, operative duration and post-operative complication. results: there was no difference in age, gender and stone size in both groups. immediate stone free rate was 99.05% in laser lithotripsy and 76.19% in pneumatic lithotripsy (p value<0.001). proximal migration in laser lithotripsy was 0.95% and 23.81% in pneumatic lithotripsy (p<0.001). there was significantly prolonged operative duration in pneumatic lithotripsy (14.7±4.77 min vs 13.31±3.24 in laser lithotripsy, p=0.014). complications were more in pneumatic lithotripsy group, which was statistically significant (p=0.017). conclusion: both pneumatic and laser lithotripsy are effective and safe modalities for treating upper ureteric calculus, however laser has less chances of proximal migration and higher immediate stone free rate with less complication. keywords: laser lithotripsy, pneumatic lithotripsy, ureteric calculus original research articlehttps://doi.org/10.22502/jlmc.v8i1.303 rajan koju,a,d hemnath joshi,b,d sujan makaju shrestha,a,d robin karmacharya,c,d narendra shalike a,d a comparative study between pneumatic and laser lithotripsy for proximal ureteric calculus how to cite this article:how to cite this article: koju r, joshi h, shrestha sm, karmacharya r, shalike n. a comparative study between pneumatic and laser lithotripsy for proximal ureteric calculus. journal of lumbini medical college. 2020;8(1):6 pages doi: 2020;8(1):6 pages doi: https://doi.org/10.22502/jlmc.v8i1.303 epub: 2020 june 06.epub: 2020 june 06. introduction: kidney and ureteric stones are common pathologies dealt in surgical out-patient department (opd).[1] more than 80% of out-patient cases in our department are of stone disease in the renal system. there are different treatment modalities for ureteric calculus depending upon various factors like size, density and location of calculus. available modalities are medical therapy, open surgery, laparoscopic surgery, endoluminal surgery and extracorporeal shock wave lithotripsy (eswl).[2] after the invention of uretero-renoscopy (urs) and eswl in 1980s, there has been a paradigm shift in the treatment modality of ureteric calculus from open surgery to endoluminal and non-invasive method. the main advantage of urs is fragmentation of calculus under vision. there are various modalities for stone fragmentation in urs – electrohydrolic lithotripsy (ehl), pneumatic, ultrasonic, laser and dual energy source (ultrasound+pneumatic) lithotripsy. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 koju r, et al. comparative study between pneumatic and laser lithotripsy for proximal ureteric calculus. jlmc.edu.np [3] there are various types of laser; among which holmium: yttrium aluminium garnet (ho:yag) is the one that is commonly used as tissue penetration of holmium laser is less than two millimetres.[4] both laser lithotripsy (ll) and pneumatic lithotripsy (pl) have favourable outcomes.[2] it works as a ballistic force of the compressed air whereas ho:yag works by creation of microscopic vaporization bubbles and rapid impulsion of the these bubbles at the tip of fibre creates a shock wave that causes breakdown of stones.[5] there are very few published studies on comparison of different modalities of lithotripters for proximal ureteric calculus in our population. the aim of this study was to compare efficacy of pneumatic versus laser lithotripters for proximal ureteric calculus in our population. methods: this was a prospective comparative study done in 210 cases of proximal ureteric calculus (105 in pl and 105 in ll) in dhulikhel hospital, kathmandu university hospital from april 2018 to june 2019. ethical clearance was received from institutional review committee (irc: 10/18) of dhulikhel hospital, kathmandu university school of medical sciences. informed consent was taken from all patients. patients with active urinary tract infection (uti), abnormal renal function, coagulopathy, spine deformity and pregnancy were excluded from our study. urine culture, ultrasonography of abdomen and pelvis and intravenous urography (ivu) or computed tomography (ct) ivu were done in all cases before surgery. a single dose of intravenous (iv) ciprofloxacin was given 30 minutes before surgery. all patients were given spinal anaesthesia and kept in lithotomy position. urs was done by three surgeons of urology unit, dhulikhel hospital. urs was done with 9.5 and 7.5 fr scope (karl storz, germany) semi-rigid scope under direct vision with 0.035 guidewire placement. for pl group, 1 and 1.2mm nidhi lith-probe was passed through working channel of urs. the tip of the probe was rested on the surface of the stone and probe was activated. pressure was set in the range from 2.5-2.7 kg/cm2, frequency of 8 pulse/sec. for ll group, tip of laser fibre was kept 2 mm away from stone. fibre used was of 200 micron and power setting were 8-12 watt with frequency of 8-10 hz. lumenis 20-watt holmium laser was used in our procedure. stones were broken down to particles less than 3 mm. double j (dj) stent was kept in cases with mucosal injury, impacted stone and purulent discharge from collecting system. it was removed after six weeks after confirming stone free status with x-ray kub. no visible radio-opacity of ureteric stone in x-ray kub and no echogenic structure of radiolucent ureteric calculi on sonogram kub region was considered stone free rate. immediate stone free rate was considered as the absence of calculi in the fluoroscopy at the time of surgery. complications related to procedure like mucosal injury, bleeding, perforation, stricture and infection were expected. all data were evaluated by statistical package for social sciences (spsstm) version 20.0. qualitative data was analysed with chi-square test. quantitative data was analysed with mean and standard deviation and student t-test. p-value less than 0.05 was considered statistically significant. results: table 1 demonstrates the distribution of demographic and clinical characteristics between the two groups which include gender, laterality, variables ll (n=105) pl (n=105) statistics mean age ± sd, in years 35.67 ± 12.64 34.68 ± 12.69 t (n = 210) = 0.5664, p = 0.572 gender male 66 (62.9%) 67 (63.8%) x2 (df = 1, n= 210) =0.0205, p = 0.886female 39 (37.1%) 38 (36.2%) stone laterality bilateral 2 (1.9%) 6 (5.7%) x2 (df = 2, n= 210) = 2.2528, p = 0.324left 49 (46.7%) 50 (47.6%) right 54 (51.4%) 49 (46.7%) mean stone size ± sd, in mm 9.50 ± 1.64 9.53 ± 1.86 t (n = 210) = 0.1240, p = 0.902 table 1. comparison of demographic and clinical characteristics. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 koju r, et al. comparative study between pneumatic and laser lithotripsy for proximal ureteric calculus. jlmc.edu.np stone size and age which were comparable in both the groups. there were more bilateral cases in the pneumatic group however it was statistically not significant. table 2 illustrates operative and post-operative status which showed there was significant stone migration and higher re-ursl rate in pl group (p value<0.001), however, there was no significant difference in hospital stay. dj stenting was more in pl group which was statistically significant. stone migration was noted in the cases with stone larger than 12 mm size. in ll group, there was one case of stone migration which was managed with re-ursl after two weeks. in pl group, there were 25 cases of stone migration, 15 underwent reursl and 10 underwent eswl before removal of dj stent (six weeks). in majority of cases dj stenting was done as most of the cases there was impacted stone causing narrowing of lumen. there were two complications in ll group, one case of fever and another of bleeding due to mucosal injury. in pl group there were ten complications, five cases of fever and another five cases of bleeding. complication rates were statistically significant(p=0.017). post-operative fever was managed with analgesics and intravenous antibiotics. no stricture was noted in any patient in three months follow-up period. discussion: urinary calculus is one of the common problems dealt in surgical out-patient department. there are various modalities of treatment for ureteric calculus which depend on location, size, density and obstructive features. stone less than five millimetres can be treated with medical expulsion therapy with alpha-1 antagonist. soft proximal ureteric stone less than one centimetre can be treated noninvasively with extracorporeal shockwave.[6] with advancement in medical science there have been major changes in the modality of treatment for urolithiasis.[7] endoluminal surgery is the choice of treatment for urolithiasis. in endoluminal surgery also there are various sources of energy for breaking stone. pneumatic lithotripsy though cheap and safe one, has certain limitations like stone migration especially in case of proximal ureteric calculus.[8] in such proximal calculus holmium laser is preferred as it produces weak shock wave preventing migration of calculus. it is a reliable source of lithotripter regardless of density and composition of calculus. [9] our study has shown ll is better option than pl in regards to sfr, less stone migration, less rate of dj stenting and decreased rate of re-intervention. razaghi et al. reported 100% immediate sfr in ll arm (n=12) and 42.9% in pl arm (n=14) p=0.001; no migration in ll arm and 57.1% in pl arm for upper ureteric calculus.[8] bapat et al. reported high sfr in ll arm (97.01 vs 86.01%) and less auxiliary procedure in ll arm (1.99 vs 13.98%) for proximal ureteric calculus.[10] garg et al. also reported higher immediate stone free rate in ll arm (p=0.001) with high stone migration in pl arm (16%).[11] results of these studies were in accordance with our study. akdeniz et al. reported 89.9% sfr in pl arm (n=109) and 87.9% sfr in ll arm (n=107) p=0.791.[12] irer et al. reported similar complication rate in pl (n=314) and ll arms (n=324); however there were more proximal migration in pl arm.[13] rabani et al. reported 79.31% stone free rate in ll arm (n=58) and 77.96% in pl arm (n=59) p=0.52. [14] results of these studies were contrary to our study. variables ll (n=105) pl (n=105) p-value mean operative time ± sd (min) 13.31 ± 3.24 14.7 ± 4.77 t (n=210) = 2.4701, p = 0.014 mean hospital stay ± sd (days) 1.01±0.1 1.08 ± 0.61 t (n = 210) = 1.1604, p = 0.247 immediate stone free rate (sfr) 104 (99.05%) 80 (76.19%) x2 (df =1, n= 210) =25.2843, p <0.001 stone migration (%) 1 (0.95%) 25 (23.81%) x2 (df=1, n= 210) =25.2843, p <0.001 re-ursl (%) 1 (0.95%) 15 (14.29%) x2 (df=1, n= 210) =13.2603, p <0.001 dj stenting (%) 73 (69.52%) 92 (87.62%) x2 (df= 1, n = 210) =10.2101, p <0.001 complications (%) 2 (1.90%) 10 (9.52%) x2 (df = 1, n = 210) = 5.6566, p = 0.017 table 2. comparison of operative and post-operative parameters (n=210). j. lumbini. med. coll. vol 8, no 1, jan-june 2020 koju r, et al. comparative study between pneumatic and laser lithotripsy for proximal ureteric calculus. jlmc.edu.np laser causes less tissue injury as it has least tissue penetration. there was no significant difference between mean hospital stay as all cases were done under spinal anaesthesia and we preferred to keep patients for one day as most of our patients were from remote places. cost factor was not considered in this study as there is no difference in cost between the two techniques in our institute. limitation of this study was short follow-up, not comparing the density of stones and comparing surgery done by various surgeons of different calibre. conclusion: laser lithotripsy group had less stone migration, less chance of re-intervention and high sfr than pneumatic lithotripsy group. however, both modalities were effective and safe for management of proximal ureteric calculus. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. javanmard b, fallah karkan m, razzaghi mr, ghiasy s, ranjbar a, rahavian a. surgical management of vesical stones in children: a comparison between open cystolithotomy, percutaneous cystolithotomy and transurethral cystolithotripsy with holmium-yag laser. j lasers med sci. 2018;9(3):183–7. pmid: 30809329 doi: https://doi.org/10.15171/ jlms.2018.33 2. abedi ar, razzaghi mr, allameh f, aliakbari f, fallahkarkan m, ranjbar a. pneumatic lithotripsy versus laser lithotripsy for ureteral stones. j lasers med sci. 2018;9(4):233. pmid: 31119016 doi: https://dx.doi. org/10.15171/2fjlms.2018.42 3. karkan mf, ghiasy s, ranjbar a, javanmard b. evaluation of 200 mm, 365 mm and 500 mm fibers of ho:yag laser in transurethral lithotripsy of ureteral: a randomize control trial. j lasers med sci. 2018;9(1):69– 72. pmid: 29399315 doi: https://dx.doi. org/10.15171/2fjlms.2018.14 4. leijte ja, oddens jr, lock tm. holmium laser lithotripsy for ureteral calculi: predictive factors for complications and success. j endourol. 2008;22(2):257-60. pmid: 18294030 doi: https://doi.org/10.1089/end.2007.0299 5. razzaghi mr, razi a, mazloomfard mm, mokhtarpour h, javanmard b, mohammadi r. trans-ureteral ureterolithotripsy of ureteral calculi:which is the best; pneumatic or holmium laser technique? j lasers med sci. 2011;2(2):59–62. doi: https://dx.doi. org/10.22037/2010.v2i2.2282 6. ali ai, abdel-karim am, abd el latif aa, eldakhakhny a, galal em, anwar az, et al. stone-free rate after semirigid ureteroscopy with holmium laser lithotripsy versus laparoscopic ureterolithotomy for upper ureteral calculi: a multicenter study. afr j urol. 2019;25(1):1-6. doi: https://dx.doi.org/10.1186/s12301-0190003-4 7. javanmard b, razaghi mr, ansari jafari a, mazloomfard mm. flexible ureterorenoscopy versus extracorporeal shock wave lithotripsy j. lumbini. med. coll. vol 8, no 1, jan-june 2020 koju r, et al. comparative study between pneumatic and laser lithotripsy for proximal ureteric calculus. jlmc.edu.np for the treatment of renal pelvis stones of 10-20 mm in obese patients. j lasers med sci. 2015;6(4):162–166. doi: https://dx.doi. org/10.15171/jlms.2015.12 8. razaghi mr, razi a. comparison between the holmium laser (made in iran) and pneumatic lithotripsy in patients suffering from upper ureteral stone between 1-2cm. j lasers med sci. 2012;2(4):144-7. doi: https://doi.org/10.22037/ jlms.v2i4.2623 9. cui y, cao w, shen h, xie j, adams ts, zhang y, shao q. comparison of eswl and ureteroscopic holmium laser lithotripsy in management of ureteral stones. plos one. 2014;9(2):e87634. pmid: 24498344 doi: https://dx.doi. org/10.1371/journal.pone.0087634 10. bapat ss, pai kv, purnapatre ss, yadav pb, padye as. comparison of holmium laser and pneumatic lithotripsy in managing upperureteral stones. j endourol. 2007;21(12):1425-8. pmid: 18186678 doi: https://doi.org/10.1089/ end.2006.0350 11. garg s, mandal ak, singh sk, naveen a, ravimohan m, aggarwal m, mete uk, santosh k. ureteroscopic laser lithotripsy versus ballistic lithotripsy for treatment of ureteric stones: a prospective comparative study. urol int. 2009; 82(3):341-5. pmid: 19440025 doi: https://doi. org/10.1159/000209369 12. akdeniz e, i̇rkılata l, demirel hc, saylık a, bolat ms, şahinkaya n, zengin m, atilla mk. a comparison of efficacies of holmium yag laser, and pneumatic lithotripsy in the endoscopic treatment of ureteral stones. turk j urol. 2014;40(3):13843. pmid: 26328167 doi: https://dx.doi. org/10.5152%2ftud.2014.46548 13. irer b, şen v, erbatu o, yıldız a, ongün ş, çınar ö, et al. comparison of efficacy and complications of holmium laser and pneumatic lithotripters used in the ureterorenoscopic treatment of proximal ureter stones, a multicenter study of society of urological surgery aegean study group. journal of urological surgery. 2018;5(3):158-63. doi: https://dx.doi. org/10.4274/jus.2143 14. rabani sm, rabani s, rashidi n. laser versus pneumatic lithotripsy with semi-rigid ureteroscope; a comparative randomized study. journal of lasers in medical sciences. 2019;10(3):185-88. pmid: 31749943 doi: https://dx.doi.org/10.15171%2fjlms.2019.29 lmc journal vol. 2.indd 93 situa on of environmental health of rural communi es in palpa district of nepal ghimire m and ghimire m department of community medicine, lumbini medical college, palpa, nepal corresponding author: mrs. moushami ghimire, lecturer, department of community medicine, lumbini medical college, palpa, nepal; e-mail: madhumds@gmail.com abstract background: sanita on refers to create and maintain hygienic condi ons, through services such as garbage collec on and its proper disposal, wastewater disposal, consump on of safe drinking water, housing condi on and its surrounding, an act or process of making sanitary, the promo on of hygiene and preven on of disease. human being is a social animal and being a part of society, factors aff ec ng the society also aff ect human and his surroundings. the study is concerned to demographic variables and environmental prac ces in rural communi es. objec ves: to fi nd out environmental situa on and observe an impact of demographic variables on environmental factors. materials and methods: a cross-sec onal study was followed to conduct the study in palpa district of nepal at 2012. three hundred thirty nine households were selected through simple random procedure. semi-structure interview schedule was used to collect informa on. data were analyzed using so ware spss for windows version 16.0. results: most of the families were faithful to ethnic group. prac ces of refuse and excreta disposable had unsa sfactory where percentages of throwing refuse and open fi eld defeca on was 39.2 and 9.1 respec vely. 77.6% households were consumed tap water. most of the households (53.4%) did not have proper drainage system around their houses. conclusion: family type and caste of households were strongly associated with prac ce related to excreta disposal, drainage system and refuse disposable. improper sanita on could be main threat to public health promo on and disease preven on in study areas. keywords: demographic variables, drainage system, open fi eld defeca on, palpa, waste disposal introduction sanita on is the hygienic means of promo ng health through preven on of human contact with the hazards of wastes. it has been observed that the kinds of environment in which we live also depict our lifestyle and standards of living, like in which kind of place a par cular family is residing, the surrounding is clean, type of housing, type of fl ooring, type of roofi ng, proper ventilation, overcrowding present or not, practices regarding management of safe drinking water and water used for household purposes, proper disposing of garbage and eff ec ve management of household waste, proba on for safe and eff ec ve excreta disposing techniques and avoiding of breeding grounds for vectors leading to vector-borne and water-borne diseases. environmental health is the branch of public health that is concerned with all aspects of the natural and built environment that may aff ect human’s health. it addresses all the physical, chemical, and biological factors external to a person, and all the related factors impac ng behaviors. world health organiza on stated that “environmental health comprises those aspects of human health, including quality of life that is determined by physical, biological, social, and psychosocial factors in the environment. it also refers to the theory and practice of assessing, correcting, controlling, and preven ng those factors in the environment that can poten ally aff ect adversely the health of present and future genera ons.”1 clean air, safe and suffi cient water, safe and adequate food, safe and peaceful se lements and stable global environment are essen al factors for safe environmental health. low socioeconomic status, women, children, elderly, ethnic minori es, disabled, indigenous peoples.2 quality water should be free from chemical and biological contamina on and must be acceptable in terms of colour, taste and odour in accordance with the world health organiza on guidelines on the quality of drinking water.3 wells, bore holes, ponds and streams need a great deal of protec on from pollu on and contamina on by poten al parasites, micro-organisms and harmful chemical substances. unfortunately, these water sources have become sites for breeding and harbouring of many diseases causing agents.4 waste is an inevitable by-product of our use of natural resources. the amount and make-up of waste in any given area depends on factors such as the local original article l m coll j 2013; 1(2): 93-97 94 journal of lumbini medical college popula on density, economic prosperity, me of year, type of housing and whether there are local waste minimiza on ini a ves such as home compos ng. 5 from longstanding to emerging hazards, environmental factors are a root cause of a significant burden of death, disease and disability globally and par cularly in developing countries. they range from poor water quality and access, vector-borne disease and air pollu on to toxic chemical exposures, climate change and degraded urban environments. the resulting impacts are es mated to cause over 25% of death and disease globally. 6 much of this burden rests upon the shoulders of the poor and vulnerable. many of these deaths are avoidable and much of this disease is preventable. however, eff ec ve ac on requires renewed moral commitment to sustainable development and determined poli cal ac on through interna onal and na onal partnerships.7 water-borne diseases are usually acquired by the consump on of polluted water containing human and animal faecal ma er from pa ents or healthy carriers.8 human excreta are important sources of pathogenic organisms, especially intes nal parasites which are causes of a high morbidity in the general popula on primarily due to inadequate disposal of excreta and lack of personal hygiene. most urban and rural communi es in the developing countries do not have adequate disposal system for human waste, and many inhabitants defecate indiscriminately in places not far from their dwelling places, including directly on the soil and rocks, by the sides of the streams, home ponds, wells, and in some cases into the streams.9 furthermore, excreta from children and free roaming animals are par cularly hazardous and a poten al source of health problems in both urban and rural communi es.10 environmental health aims to prevent contamina on of the environment by excreta and, therefore, to prevent transmission of pathogens that originate in faeces of an infected person. a wide range of technologies and methods exists to achieve this, which include sophis cated and high-cost methods like waterborne sewage systems and simple low-cost methods like the cat method, which involves the digging of a hole and covering faeces with soil a er defeca on.11 material and methods a cross sec onal study was carried out in four villages (damkada, dumre, gorkhekot and telgha) of palpa district of nepal. four villages were randomly selected from the list of the total villages of the district. sample size of 339 was calculated assuming margin of error 5%, nonresponse 10% with 95% confi dence interval (ci). three hundred and thirty nine households were selected randomly from study area. informa on was obtained on socio-demographic, housing, ven la on in house, water resources, and disposal prac ces of waste water, garbage and excreta. anonymity of the respondent had preserved. the above informa on was collected by ques oning the head of the family through a structured ques onnaire during the me period of december 2012 to june 2013. data were analyzed using so ware spss for windows version 16.0. results: table-1 explain that more than one third (40.7%) were devoted to magar only. sixty nine percent households fall under the nuclear type of family and unemployment rate was 9.4%. near about fi y fi ve percent houses were paccha. around sixty six percent were covered house with smoke outlet kitchen. prac ce of refuse and excreta disposable had unsa sfactory where percentages of throwing refuse and open fi eld defeca on was 39.2 and 9.1 respec vely. most of surveyed households (77.6%) used tap water for drinking proposes but they were unaware about the safeness of consumed water. most of the households (53.4%) did not have proper drainage system around their houses. table-1: demographic and environmental situa on (n=339) frequency percent family type nuclear 235 69.3 joint 104 30.7 caste brahmin 63 18.6 chhetri 67 19.8 magar only 138 40.7 schdueled cast 46 13.6 janaja 25 7.4 occupa on unemployed 32 9.4 teacher 31 9.1 farmer 80 23.6 business 115 33.9 others 81 23.9 house type kaccha 153 45.1 pucca 186 54.9 smoke outlet present 223 65.8 absent 116 34.2 refuse disposal throwing 133 39.2 dumping 87 25.7 manure pit 104 30.7 burning 15 4.4 excreta disposal open fi eld 31 9.1 sanitary latrine 282 83.2 insanitary 12 3.5 community latrine 14 4.1 overcrowding absent 266 78.5 present 73 21.5 source of water tap water 263 77.6 tube well 61 18.0 river 15 4.4 drainage system yes 158 46.6 no 181 53.4 the study revealed that type of family could strongly associate (p= 0.000) with prac ce related to excreta disposal, drainage system and refuse disposable 95 m ghimiri et al (0.004). it was also predic ve factors to determine overcrowding, smoke outlet, and consump on of water where p values of them were 0.016, 0.060, and 0.002 respec vely (table-2). table-2: associa on between family type and environmental factors (n =339) family type nuclear joint overcrowding absent 176 90 pearson chi-square value=5.785, df = 1 p = 0.016present 59 14 smoke outlet present 147 76 pearson chi-square value=3.54, df = 1 p = 0.060absent 88 28 refuse disposal throwing 87 46 pearson chi-square value=13.065df = 3 p = 0.004 dumping 68 19 manure pit 65 39 burning 15 0 drainage yes 154 4 pearson chi-square value=1.102,df = 1 p = 0.000no 81 100 excreta disposal open fi eld 31 0 pearson chi-square value=73.678,df = 3 p = 0.000 sanitary latrine 204 78 insanitary 0 12 community latrine 0 14 source of water tap water 171 92 pearson chi-square value=12.402,df = 2 p = 0.002 tube well 49 12 river 15 0 table-3 shows that cast of households could signifi cantly impact (p = 0.000) on environmental prac ces as: refuse disposable, drainage system, excreta disposable and source of drinking water. table-3: associa on between caste and environmental prac ces (n =339) caste brahmn chhetri magar scheduld janaja smoke outlet present 33 40 97 29 24 absent 30 27 41 17 1 pearson chi-square value = 17.668, df = 4, p = 0.001 refuse disposable throwing 18 0 54 45 16 dumping 18 3 57 1 8 manure pit 27 64 12 0 1 burning 0 0 15 0 0 pearson chi-square value = 2.660, df = 12, p = 0.000 drainage yes 34 37 82 0 5 no 29 30 56 46 20 pearson chi-square value = 59.741 df = 4, p = 0.000 excreta disposal open fi eld 0 0 15 16 0 sanitary latrine 63 55 109 30 25 insanitary 0 12 0 0 0 community latrine 0 0 14 0 0 pearson chi-square value = 1.129, df = 12, p = 0.000 source of water tap water 51 42 99 46 25 tube well 12 25 24 0 0 river 0 0 15 0 0 pearson chi-square value = 55.803, df = 8, p = 0.000 analysis shows that lighting system, kitchen with smoke outlet, excreta disposable, drainage system and presence of rodent inside the house are determined by types of house (p = 0.000) but there is no associa on(p = 0.958) between house type and cross –ven la on (table-4). table-4: impact of house type on environmental factors (n=339) house type total kachha pacca cross ven la on adequate 72 87 159 inadequate 81 99 180 pearson chi-square value = 0 .003, df = 1, p =0 .958 ligh ng adequate 109 169 278 inadequate 44 17 61 pearson chi-square value = 21.896, df = 1, p = 0.000 smoke outlet present 88 135 223 absent 65 51 116 pearson chi-square value = 8.463, df = 1, p = 0.004 refuse disposal throwing 60 73 133 dumping 57 30 87 manure pit 36 68 104 burning 0 15 15 pearson chi-square value = 31.583 , df = 3p = 0 .000 excreta disposal open fi eld 16 15 31 sanitary latrine 111 171 282 insanitary 12 0 12 community latrine 14 0 14 pearson chi-square value = 35.926 , df = 3, p = 0 .000 drainage yes 57 101 158 no 96 85 181 pearson chi-square value = 9.802 , df = 1, p = 0.002 rodent present 95 165 260 absent 58 21 79 pearson chi-square value = 33.278 , df = 1, p = 0.000 discussion sanita on remains one of the biggest development challenges in all developing countries. improving sanita on is the key to achieving the health-related millennium development goals (mdgs) of reducing child mortality and combating disease. however, these outcomes will remain pressing and persistent concerns for many nations even as they approach the goal of halving the number of the world's poor by 2015.12 the study analysed an environmental situa on of rural villages of palpa district and tried to fi nd out associa on between demographic and environmental variables. results from the study shows that most of the families (40.7%) in study area were devoted to magar but these communi es had caste diversi es as: bhrahmin, chhetri, other ethnic groups (except magar) and scheduled cast were living together coopera vely. sixty nine percent of respondent fall under the nuclear 96 journal of lumbini medical college type of family and unemployment rate was 9.4%. 54.5% had their own puccha house. 65.8% were covered house with smoke outlet kitchen. a typical solid waste management system in a developing country displays an array of problems, including low collection coverage and irregular collec on services, crude open dumping and burning without air and water pollu on control, the breeding of fl ies and vermin, and the handling and control of informal waste picking or scavenging ac vi es. these public health, environmental, and management problems are caused by various factors which constrain the development of eff ec ve solid waste management systems.13 poor solid waste management in the developing countries consists of a major threat to public health and environmental quality, and reduces the quality of life, par cularly for the poorer residents in both urban and rural areas.14 an es mated 2.6 billion people or 39% of the world’s popula on lack access to improved facili es for the disposal of human excreta, such as a basic pit latrine, a toilet connected to a sep c tank or piped sewer system, or a compos ng toilet according to the world health organiza on (who) and the united na ons children’s fund (unicef). in low-income regions, where people are most vulnerable to infec on and disease, only one in two people is covered by improved sanita on. more than one billion people s ll prac ce open defeca on.15 diarrhoea and water-borne diseases are leading causes of mortality and morbidity in developing countries.16 approximately 88% of diarrhoeal diseases are a ributed to unsafe water supply, inadequate sanita on and hygiene.17 the propor on of popula on in rural areas with access to safe drinking water and sanitary latrines has a direct impact on the health of the masses. water sources and sanita on facili es have an important infl uence on the health of household members, especially children.18 who/unicef joint monitoring report 2012 stated that 15 per cent of the global popula on prac ced open defeca on, countries that account for almost threequarters of the people who prac ce open defeca on as: india (626 million), indonesia (63 million), pakistan (40 million), ethiopia (38 million), nigeria (34 million), sudan (19 million), nepal (15 million), china (14 million), niger (12 million), burkina faso (9.7 million), mozambique (9.5 million) and cambodia (8.6 million).19 results from our study explain that prac ce of refuse and excreta disposable was unsa sfactory where throwing refuses and open fi eld defeca on were 39.2% and 9.1 % respec vely compared to the study conducted by rajiv ranjan karn and their friends in in katahari vdc of morang district at 2011 showed that 64% of the houses didn’t had toilet facili es and they were exposed to open defeca on.20 the study also revealed that drainage system in these communi es had inadequate where 53.4% households did not have proper drainage system around their houses. most of the households (77.6%) consumed tap water but the quality of water could be doubt to ensure safe drinking. all these condi ons may be responsible to develop epidemic of infec ous diseases which is due to faecal contaminated water. similar situa on was observed in other developing countries as more than half of the popula on did not have access to safe drinking water and about two-thirds lacked good sanitary means of excreta disposal in african countries. nigeria faced with the dilemma of inadequate disposal of excreta-related human waste discharged into the environment. rural farming communi es of southeast nigeria, promiscuous defeca on on open fi elds and farm lands had a common prac ce.21 many researches stated that inadequate sanita on, lack of access to clean potable water and poor domes c hygiene are the cause of 80% of all infec ous diseases (e.g. cholera, typhoid, hepa s, polio, cryptosporidiosis, ascariasis, and schistosomiasis) in the world and responsible for 10-25 million deaths each year, most them in the under 5 years age group. these diseases are mainly transmi ed via the faecal-oral route through faecally contaminated water, food or soil .22 the study analyzed demographic and environmental variables to find association between them so it revealed that the type of family and caste of households were strongly associated (p= 0.000) with practice related to excreta disposal, drainage system and refuse disposable (for association between family type and refuse disposable, p = 0.004). in the study family type could play role of predictive factors to determine overcrowding, kitchen with smoke outlet and consump on of water where p values of them were 0.016, 0.060, and 0.002 respec vely. it also found to be signifi cant associa on (p = 0.000) between type of house and other environmental factors as: ligh ng system, kitchen with smoke outlet, excreta disposable, drainage system and presence of rodent inside the house but there is no associa on (p = 0.958) between house type and cross –ven la on. conclusion unsatisfactory environmental condition of the communities observed during study period and it may create ideal condi on for spread of water borne diseases. some demographic factors as family type and caste were highly associated with inappropriate drainage system, open fi eld defeca on and open fi eld waste disposal. 97 m ghimiri et al reference 1. world health organiza on. defi ni on of environmental h e a l t h . r e t r i v e d f r o m . h t t p : / / w w w. h e a l t h . g o v / environment/defi ni onsofenvhealth/ehdef2.htm p:// www.health.gov/environment/defi ni onsofenvhealth/ ehdef2.htm. who. 1993. 2. yassi et al. basic environmental health. oxford university press. 2001: 1. 3. world health organisa on. who catalogue on health indicators? available at: h p://www.northampton.ac.uk/ ner/who/indicators/wbd.s.html. who.1996. 4. adams j. managing water supply and sanitation in emergencies, oxfam/oxford. 1999. 5. department for environment, food and rural aff airs. review of environmental and health eff ects of waste management: municipal solid waste and similar wastes. 2004:9,17. 6. smith kr, corvalán c, kjellstrom t. how much global ill health is attributable to environmental factors? j epidemiol 1999; 10(5): 573-84. 7. who/unep/ health and environment linkages ini a ve. health and environment: tools for eff ec ve decisionmaking: review of initial findings / the who-unep. available at h p://www.who.int/heli. heli. 2005;5. 8. cairncross s, feachem r. environmental health engineering in the tropics: an introductory text (2nd edi on john wiliey, chischester). 1993; 120. 9. adegoke a. the challenges of environmental management in africa. the nigeria experience. int j med sci 2000; 2: 13. 10. ukoli/ fam. sanita on in africa. int j med sci 2000; 2: 25-8. 11. who/unicef. progress on drinking water and sanita on. joint monitoring programme for water supply and sanita on. who. 2012. 12. world bank. community-led total sanita on in rural areas: an approach that works summary of fi eld report. water and sanita on program -south asia. 2007. 13. western pacifi c regional environmental health centre (ehc).the role of the private sector in developing countries: keys to success. paper presented by bartone at iswa conference on waste management 24-25 september. who/ehc. 1995. 14. hua w, jie h, yoonhee k, takuya k. municipal solid waste management in small townsan economic analysis conducted in yunnan, china. world bank. 2011; 2. 15. world health organiza on/united na ons children’s fund. water supply and sanita on progress on drinking water and sanita on. who/unicef. 2010. 16. world health organiza on and united na ons children’s fund. who/unicef joint monitoring programme for water supply and sanita on, global water supply and sanita on assessment, report. available at h p://www. who.int/water sanita on health/monitoring/jmp2000. who.2006. 17. world health organiza on. water sanita on and hygiene facts and figures 2004. available at /factsfi gures04/en/. who.2006. 18. national family health survey (nfhs-3). iips,india. 2005-06. 19. who/unicef. water sanitation and health (wash): fast facts. retrived from h p://www.who.int/water_ sanita on_health/monitoring/jmp2012/fast_facts/en/. who. 2013. 20. karn rr, bhandari b and jha n. a study on personal hygiene and sanitary prac ces in a rural village of mornag district of nepal. j nobel med coll 2012; (1 &.2): 39-44. 21. world health organiza on. a guide to the development of on-site sanita on. accessed at h p://www.who.int/ water_sanita on_health/hygiene/envsan/onsitesan/en. who. 2007. 22. world health organisa on.) health guildlines for the use of wastewater in agriculture and aquaculture. technical report series 778. who. 1989. lmc journal vol. 2.indd 98 ender’s nail fi xa on in paediatric femoral sha fractures. dwivedi r, shah s, acharya p and gurung s department of orthopaedics, lumbini medical college teaching hospital, palpa, nepal corresponding author: dr rajeev dwivedi ,ms,lecturer in orthopaedics ,lumbini medical college teaching hospital palpa, nepal; e-mail rd172002@gmail.com abstract introduc on: femoral sha fractures are among the most common major pediatric injuries treated by orthopaedic surgeons. treatment ranges from strictly nonsurgical methods to surgical stabiliza on. opera ve treatment of femoral sha fractures in children with intramedullary nails (ender’s and tanium elas c nails) is increasing because it has advantage of early mobiliza on, rapid healing and be er control of alignment. objec ves: we evaluated the results of ender’s nails fi xa on in femoral sha fractures in children. method: we studied 40 children with 40 femoral sha fractures in age group 5-15 years. there were twenty four fractures in middle third, 7 in distal third and 9 in proximal third. twenty fractures were transverse, 8 were oblique and 6 were spiral. communi on was seen in 6 cases. they were treated by closed reduc on and ender’s nail fi xa on. retrograde fi xa on was done in 38 cases, in 2 cases antegrade fi xa on was done. result: the mean follow up was 7.5 months. the average me to par al weight bearing was 3.8 weeks (2 to 6wks). the average me to full weight bearing was 8 weeks (6 to 12 wks). union was achieved in all pa ents within a mean of 11 weeks (8 to 16 wks). two pa ents had varus angula on of 8° and 6° each, whereas one had valgus angula on of 8°and one had anterior angula ons of 10°. lengthening of 1.2 cm was observed in one pa ent. in one case skin irrita on due to nail was observed and that subsided without interven on. according to the flynn criteria 34 had excellent and 6 had sa sfactory results. no poor results were seen. conclusion: ender’s nail fi xa on can be preferred method of treatment for femoral sha fractures in age group 5 -15 years as the results are excellent and sa sfactory. it is technically simple and can be done in a closed manner. it spares the vascularity and growth plate. keywords: ender’s nail, femoral sha fracture, children, flynn criteria introduction femoral sha fractures are among the most common major pediatric injuries treated by orthopedic surgeons.1 treatment ranges from strictly nonsurgical methods (e.g. closed reduction with spica casting or traction followed by spica casting) to surgical stabiliza on (using intramedullary devices, external fi xa on, or internal fi xa on with plate and screws).1 cas ng with or without trac on is s ll the preferred treatment for isolated femur fractures in children of preschool age.1 for children above 5years of age op on of surgical treatment is increasing because it has advantage of early mobiliza on, reduced dura on of hospital stay and reduced psychological adverse impact . flexible intramedullary nails (ender’s and titanium elas c nails), external fi xa on, compression pla ng and locked rigid intramedullary rod are the available op ons for fi xing femoral fractures in children. in the present study, we evaluated the outcomes of use of ender’s nails in trea ng pediatric femoral sha fractures. material and methods the present prospec ve study was conducted in the department of orthopedics at nepalgunj medical college teaching hospital, kohalpur over a period of 2 years from november 2009 to november 2011. we included children between 5 to 15 years with femoral sha fractures from a point fi ve cen meter (cm) distal to lesser trochanter to 5 cm proximal to distal femoral physis. children more than 15 years and less than fi ve years of age, children with pathological fracture and with open fracture were excluded from study. the results were evaluated using flynn's scoring criteria.2 major postoperative complication were defined as nonunion,delayed union, infection, r e f ra c t u r e , n a i l i r r i t a t i o n r e q u i r i n g h a rd w a r e removal, and nail breakage. minor postoperative complications were defined as nail irritation that resolved without intervention, asymptomatic nail migration, and any perioperative problem that resolved without surgical intervention or early hardware removal. original article l m coll j 2013; 1(2): 98-101 99 preopera ve x-ray showing transverse fracture of sha of femur in 10 years old boy operative technique nail diameter was theoretically chosen on the basis of 40% of the narrowest intracortical diameter but was ultimately determined intraoperatively by surgeon. approximate length of the nail was determined by measuring on x-rays and on normal side from tip of greater trochanter to adductor tubercle. nails were bent in an even curve. on a fracture table, close reduction was done under fluroscopic guideness. after incising the skin, insertion points were made one on medial and another on lateral side of distal femur, 2.5cm proximal to the distal epiphyseal plate. the nails were introduced right up to fracture site. then, one of the nail was passed across the already reduced fracture site followed by second nail. the nails were directed in such a way that medial nail was introduced into the neck and lateral just below trochanteric apophysis in a fan shaped manner. two divergent nails were used. results forty children with forty femoral shaft fractures were treated with ender’s nails. ages of children ranged from 5 to 15 years (mean 9.87 years). there were 24 boys and 16 girls. twenty two cases sustained right sided and 18 cases sustained left sided fractures. eighteen patients had injury due to fall from height, 13 patients sustained road traffic accident while 9 patients had injury while playing. no cases with bilateral fractures were seen. among all, 24 fractures were in middle third, 7 in distal third, and 9 in proximal third. twenty cases had transverse fracture, 8 were in oblique and 6 were spiral in pattern. six cases showed some comminution. among them on winquist 3 grading system, 3 were grade i, 2 were grade ii and 1 was grade iii. no case of winquist grade iv was seen. the interval between injury and surgery varied from 2 days to 6 days (average 2.9days). the mean hospital stay was 6.9 days. the average duration of surgery was 50 minutes. in 2 cases antegrade nailing was done whereas in 38 cases nails were inserted in a retrograde manner. postopera vely, no pa ent needed any protec ve splint. knee bending and quadriceps strengthening exercises were begun as soon as pa ent was comfortable. the average time to partial weight bearing on axillary crutches was 3.8 weeks (2to 6wks). full weight bearing could be commenced in about 2-4 weeks me more in most of the cases. the average me to full weight bearing was 8 weeks (6 to 12 week). union was achieved in all pa ents within a mean of 11 weeks (8 to 16 weeks). full movement of knee was achieved in 9 weeks (6 to 16 weeks). intraopera ve complica ons: in one case the opposite cortex got perforated but the nail was reintroduced. follow up: the mean follow up was 7.5 month (6 to 16 months). by this time, all the patients had fullunrestricted ac vity. none of the pa ents had any pain, limp or gait abnormality. six weeks post opera ve x-ray of same pa ent showing early callus r dwivedi et al 100 journal of lumbini medical college angular deformity more than 5 degree was observed in only 4 pa ents. two pa ents had varus angula on 8° and 6° each whereas one had valgus angula on of 8° and one had anterior angula on of 10°. on clinical examina on lengthening of more than 1cm (1.2 cm) was observed in one pa ent. in one case, skin irrita on due to nail was observed that subsided without interven on. on clinical examina on signifi cant malrota on was not seen in any pa ent. according to the flynn criteria 2 (table-1) 34 pa ents had excellent result, 6 had sa sfactory and no poor results were seen. table-1: flynn et al2(2001) criterion for assessment of results excellent satisfactory poor limb length discrepancy <1 cm <2 cm >2 cm malalignment < 5 degree 5-10 degree >10 degree pain none none present complica ons none minor major discussion there are a wide range of conserva ve and surgical op ons available for the treatment of children with femoral shaft fractures in age group 5-15 years. conserva ve (spica) treatment has disadvantages such as prolonged hospital stay, shortening, angular and torsional deformity and the psychosocial implica ons. these are avoided in surgical treatment with flexible intramedullary nails. 4,5 many orthopedician reserve surgical management only for mul ply injured pa ents. this study aimed to treat isolated femoral sha fractures surgically by ender’s nails. external fi xa on although is associated with minimal so ssue dissec on but it causes pa ent apprehension on account of external device, high rate of pin track infec on and real danger of refracture a er removal of fi xator.6 compression pla ng is associated with large so ssue dissec on opening of fracture site and major opera on for removal. rigid intramedullary nailing may damage the blood supply to the femoral head resul ng in avascular necrosis of femoral head or causing growth arrest at the greater trochanter resul ng in coxa valga. enders nailing is technically simple, me saving and can be done in a closed manner.4 two divergent ender’s nails provide adequate fi xa on and stability.7 the major advantages of ender’s nail is in healing with abundant callus, a ributed to non rigid fi xa on.8 it spares the vascularity and growthplate. it allows early mobiliza on, rapid external callus forma on and rapid restora on of con nuity of bones. this results in rapid fracture union and early return to full weight bearing while reducing hospital stay and treatment cost. fourteen weeks post opera ve x-ray showing union according to criterias given by flynn2 the fi nal results in our study were excellent in 34 (85%) cases, and sa sfactory in 6 (15%) cases. outcome of our study matched with several other studies. our study matched with mann et al9 (1986), they demonstrated excellent results with 100% union rate without any angular malunions or leg length discrepancies, however, this study was conducted in older children 9-15 years of age. karaoglu s and colleagues10 (1994) reported excellent results in their study, however, this study was conducted in children between the ages of 10 and 16 years. ozturkmen y et al 11 (2002) reported on twenty six children (mean age 8.9 years, range 5.9 to 12.3 years) they also demonstrated excellent results with ender’s nail in approximately 85% of patients. union was achieved in all pa ents within a mean of 6.6 weeks (range 5 to 12 weeks) and no observa on regarding delayed union, infec on, nonunion, growth arrest and refracture a er nail removal was seen. laghvendu shekhar et al12 (2006) reported in 34 femoral fractures treated by ender’s nail, 20 pa ents (83.3%) had excellent results , 4 (16.3%) had sa sfactory and none had poor result. kumar s et al 13 (2011) reported on sixty-two femoral sha fractures treated by elas c intramedullary nailing ( tanium elas c and ender nails) with mean age of the pa ents being 9.2 years. the result demonstrates 100% union rate irrespec ve of the age, weight and height 101 r dwivedi et al of the pa ent. they did not fi nd any mismatch in the results of fractures stabilized with tanium elas c nails with that of ender’s nails. lohiya et al14 (2011) reported outcomes of fl exible intramedullary nailing in 73 femoral sha fractures. titanium and ender nails were used in 43 and 30 cases respec vely. there were overall 59 excellent, 10 sa sfactory and 4 poor results however among ender’s group only one poor result was observed. to conclude, ender’s nailing can be preferred surgical op on for the treatment of children with femoral sha fractures in age group 5-15 years, as it can be done by closed method, outcomes are excellent and sa sfactory, associated with few complica ons and it spares the vascularity and growth plate. references 1. flynn jm, schwend rm. management of pediatric femoral sha fractures. j am acad orthop surg. 2004; 12(5): 347-59. 2. flynn jm, hresko t, reynolds ra, blasier rd, davidson r, kasser j. titanium elas c nails for pediatric femur fractures: a mul center study of early results with analysis of complica ons. j pediatr orthop 2001; 21(1): 48. 3. winquist ra, hansen st jr. comminuted fractures of the femoral sha treated by intramedullary nailing. orthop clin nort am 1980; 11:633-48. 4. mazda k, khairouni a, pennecot gf et al. closed fl exible intramedullary nailing of the femoral sha fractures in children. j pediatr orthop 1997; 6: 198-202. 5. gregory p, sullivan ja, hernodon wa. adolescent femoral sha fractures: rigid versus fl exible nails. orthopedics 1995; 18: 645-9. 6. gregory p, pevny t, teaque d. early complica ons with external fi xa on of paediatric femoral sha fractures. j orthop trauma 1996; 10:191-198 7. lee s, mahar at, newton po. ender nail fixation of pediatric femur fractures a biomechanical analysis. j pediatr orthop. 2001; 21(4): 442-5. 8. yamaji t, anodo k, nakamura t, washimi o, terada n, yamada h. femoral sha fracture callus forma on a er intramedullary nailing a comparison of interlocking and ender nailing. j orthop sci 2002; 7 (4):472-6. 9. mann dc, weddington j, davenport k. closed ender nailing of femoral sha fractures in adolescents. j pediatr orthop 1986; 6(6): 651-5. 10. karaoğlu s1, bak r a, tuncel m, karakaş es, sakir tm.) closed ender nailing of adolescent femoral sha fractures. injury 1994; 25(8): 501-6. 11. ozturkmen y, dogrul c, karli m. intramedullary fi xa on of femoral sha fractures in children with elas c enders nail. acta orthop traumatol turc 2002; 36(3): 220-7. 12. shekhar l, mayanger j c. a clinical study of ender nails fi xa on in femoral sha fractures in children. indian j orthop 2006; 40: 35-7. 13. 13. kumar s, roy sk, jha ak, cha erjee d, banerjee d, garg ak. an evalua on of fl exible intramedullary nail fi xa on in femoral sha fractures in paediatric age group. j indian med assoc 2011; 109(6): 416-7, 425. 14. lohiya r, bachhal v, khan u et al. flexible intramedullary nailing in paediatric femoral fractures. a report of 73 cases. j orthop surg res 2011, 6: 64 j. lumbini. med. coll. vol 9, no 1, jan-june 2021 rana s, et al. nursing students’ perception of online learning amidst covid-19 pandemic jlmc.edu.np ___________________________________________________________________________________ submitted: 30 october, 2020 accepted: 02 may, 2021 published: 08 may, 2021 alecturer, college of nursing bassistant professor, college of nursing clumbini medical college teaching hospital, palpa, nepal. corresponding author: sunita rana e-mail: rsunita25@gmail.com orcid: https://orcid.org/0000-0002-4987-6607_______________________________________________________ abstract: introduction: the declaration of covid-19 pandemic on 11th march 2020 by world health organization forced many countries including nepal to choose online mode of nursing education. hence, it is essential for the educators to find out students’ perception that ensures their readiness to learn in this new environment. this study sought to examine the perception of online learning among nursing students. methods: after obtaining ethical clearance, a cross-sectional descriptive study was conducted among 211 nursing students using enumerative sampling method. self-administered structured online questionnaire was used. calculated cronbach's alpha value was 0.828. descriptive (frequency, percentage, mean etc.) and inferential statistics (chi-square test) were used to analyze data. results: the mean age of the participants was 19.80±1.87 years. all (100%) had mobile phone. most (93.8%) had internet facility at home. more than half (59.7%) strongly agreed that face-to-face learning was more effective. less than half (44.6%) strongly agreed that interrupted internet connection was an obstacle. more than half (56.9%) participants had positive perception of online learning. age, enrolled nursing program and device used were statistically significant with perception of online learning. conclusion: the perception of nursing students towards online learning is positive. students are satisfied with their learning opportunities amidst covid-19 through online education. however, interrupted internet connection, unfeasible practical natured courses, load-shedding etc. were perceived as obstacles to online learning. age, enrolled nursing program, academic year, and devices used had an impact on positive perception. keywords: covid-19 pandemic; nursing student; online learning perception original research articlehttps://doi.org/10.22502/jlmc.v9i1.408 sunita rana,a,c chandra kumari garbuja,b,c geeta rai a,c nursing students’ perception of online learning amidst covid-19 pandemic how to cite this article:how to cite this article: rana s, garbuja ck, rai g. nursing students’ perception of online learning amidst covid-19 pandemic. journal of lumbini medical college. 2021;9(1):6 pages. doi: https://doi.org/10.22502/jlmc. v9i1.408. epub: may 8, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: it is no secret that a good education has the power to transform student’s lives. it is the responsibility of good educators to integrate several learning approaches into their teaching based on the need of the student. traditional teacher-centered learning focuses more on classroom lectures. the emergence of flexible learning opportunities is playing a vital role recently. according to casey & wilson, flexible learning is flexible in terms of start and end times, teaching modes, study materials, place, time, and assessment.[1] one of the common approaches of flexible learning is online learning which offers instruction that can be delivered anytime and from anywhere through web-based courses, online discussion forums, synchronous virtual classes, video and audio streaming, online simulations etc.[2,3] nursing education in the developed countries has already incorporated online learning into their nursing curricula, whereas developing countries like nepal are far behind. [1,2,4] the declaration of covid-19 pandemic on 11th march 2020 by world health organization forced many countries including nepal to choose j. lumbini. med. coll. vol 9, no 1, jan-june 2021 rana s, et al. nursing students’ perception of online learning amidst covid-19 pandemic jlmc.edu.np online mode of nursing education.[5-11] hence, it is essential for the educators to find out students’ perception towards online learning that ensures students’ readiness to learn in this new environment. it also increases students’ attendance, satisfaction and motivation thus generates an effective and meaningful learning environment.[8] this study sought to examine the perception of online learning among nursing students of lumbini medical college and teaching hospital (lmcth), palpa, nepal. methods: a cross-sectional descriptive design was adopted to study the online learning perception of nursing students studying in proficiency certificate level (pcl) and bachelor of science (b.sc.) nursing program of lmcth. ethical clearance (irclmc 06-i/026) was obtained from the institutional review committee of lmcth. enumerative sampling method was used to collect data from 2nd to 15th october 2020. out of 213, only 211 students participated in the study resulting 99% response rate. confidentiality and anonymity were maintained strictly throughout the study. data was collected using self-administered structured questionnaire that was developed by the researchers based on relevant literatures.[3,8,10,1214] data was collected via google form. pretesting was done among 10% of the sample size i.e., 21 nursing students. the value of cronbach's alpha was 0.828. the tool consisted of three partspart i: demographic variables of the participants (age, enrolled nursing program, academic year, average monthly family income) part ii: availability and skills required to use computer/internet of the participants (having own computer/mobile phone, duration of use of computer/mobile/internet, training to use computer, availability of internet at home, type of connection, purpose to use internet, previous online learning experience, devices used for online learning and skill rating to use computers/internet). part iii: five-dimensionperceived effectiveness (14), perceived ease of use (6), perceived obstacles (7) perceived difference between face-to-face and online learning (7) and perceived satisfaction (4) perception tool with 38 total items was used to assess participants’ perception regarding online learning during covid-19 pandemic. the first four dimensions were measured in five-point likert scale as 1=strongly disagree, 2=disagree, 3=neutral, 4=agree and 5=strongly agree. perceived obstacles and difference between face-to-face and online learning dimensions had negative items thus scored reversely. the fifth dimensionperceived satisfaction was measured in five-point likert scale as 1=very dissatisfied, 2=somewhat dissatisfied, 3=neither satisfied nor dissatisfied, 4=somewhat satisfied and 5=very satisfied. the overall score of the tool was 38-190. based on the overall mean score, perception of the students was categorized as positive (if the score was equal to or above the mean score) and negative (if the score was below the mean score). data was analyzed using statistical packages for social sciences (spss) software version 16. frequency, percentage, mean, standard deviation and range were used for descriptive statistics whereas chi square test was used to find out the association between selected variables and perception of online learning. the confidence level was set at 95% and p-value at <0.05. results: the mean age of the participants was 19.80±1.87 years. more than half (56.4%) of them were studying in pcl nursing. more than half (55%) had monthly family income of npr. 25,00050,000. nearly one-fourth (24.2%) participants did not have their own laptop and 27.5% of them had been using computer for 1-3 years. all (100%) had mobile phone. regarding availability of the internet, most (93.8%) of them had internet facility at their home. very few (7.1%) of them had previous online learning experience. nearly two-third (62.1%) rated their skill to use computers/internet as good. most participants had expressed agreement on all 14 components of perceived effectiveness dimension of online learning. nearly three-fourth (71.1%) participants agreed that online contents were effective and almost two-third (64.9%) of them agreed that online contents were relevant. similarly, about two-third (62.1%) agreed that online learning was useful for distant education. greater agreement was seen in effective time utilization during lockdown j. lumbini. med. coll. vol 9, no 1, jan-june 2021 rana s, et al. nursing students’ perception of online learning amidst covid-19 pandemic jlmc.edu.np (62.6%) and better cope with covid-19 situation (67.8%) as perceived effectiveness of online learning. regarding perceived ease of online learning, more than half (58.3%) of the participants agreed that online learning contents were easy to understand. two-third (66.8%) of them agreed that basic computer operating skills were enough. regarding perceived obstacle, participants showed strong agreement on interrupted internet connection (42.7%) and unfeasible practical natured courses (57.8%). furthermore, they agreed that high internet charge (39.8%) and load shedding (46%) were the obstacles. likewise, more than half (59.7%) of the participants strongly agreed that face-to-face learning was more effective. more than half (51.2%) stated strong agreement on better interaction and 46.9% had agreement on easy group assignment through face-to-face learning. concerning participant’s satisfaction, majority (75.4%) were very satisfied with teacher’s preparation. more than half (63%) of them were somewhat satisfied with the overall quality of student’s learning. table1 depicts scores obtained by participants in various perception dimensions of online learning. higher mean scores were obtained by the participants on perceived satisfaction followed by effectiveness and ease of use. however, they scored low on perceived obstacles and difference between online and face-to-face learning. more than half (56.9%) of the participants had positive perception towards online learning (table 2). table 2. participant’s perception of online learning (n=211). perception frequency n (%) positive 120 (56.9 %) negative 91 (43.1 %) age (p<0.0001), enrolled nursing program (p<0.0001), academic year (p=0.033) and device used for online learning (p=0.024) had statistical association with the perception of online learning of participants (table 3). discussion: our study revealed nursing student’s perceptions of online learning during covid-19 pandemic. regarding ownership, present study found that nearly three-fourth (75.8%) participants had their own computer/laptop. another study that assessed e-learning in first year medical students found only 20% of them using laptop. this highlights the significance of use of electronic devices in modern education process.[15] in the present study, more than half (53.6%) of the participants had obtained formal education or training to use computers which is similar with other study.[14] all (100%) participants in the present study had their own mobile phone. this result agrees with other studies. [15,16] majority (93.8%) of the participants in the current study had internet facility at home which is consistent with other study[3] but incongruent with findings from south african and egyptian studies. [10,13] as most of the participants in this study were from urban areas with good internet facility may have resulted this finding. current study revealed that majority (82.9%) of the participants used internet for academic activities which concurs with other study.[15] regarding devices used for online learning, less than half (43.1%) of the participants in the current study used mobile phone. other studies have opposing findings.[10,17,18] this may be due to possibility of use of mobile internet data for online learning and availability of mobile phone. in the present study, more than half (62.1%) participants had rated their skills for computer/internet use as good which is supported by another study.[15] table 1. scores obtained by participants in perception dimensions regarding online learning (n=211). perception domains no. of items obtainable score range mean ± sd perceived effectiveness 14 14-70 50.89±4.914 perceived ease of use 6 6-30 21.62± 2.915 perceived obstacles 7 7-35 13.63±3.338 perceived difference between face-to-face and online learning 7 7-35 11.94±3.578 perceived satisfaction 4 4-20 16.64± 2.096 overall 38 38-190 114.71±10.592 j. lumbini. med. coll. vol 9, no 1, jan-june 2021 rana s, et al. nursing students’ perception of online learning amidst covid-19 pandemic jlmc.edu.np participants in this study showed agreement on online learning as informative (71.1%), relevant during covid-19 (64.9%), tailored to learner’s need (57.8%), interesting and enjoyable (46%), useful for distant education (62.1%) and productive (66.8%). the result was supported by other studies.[3,9,10,15] regarding perceived ease of use, majority of the participants agreed that having basic skills to use computer/internet and mobile devices was sufficient for online learning. these findings are in line with other studies’ findings.[3,19] in the present study, the participants stated agreement on technical problems from teacher’s side (45.5%), difficulty staying motivated (54%), load-shedding (46%), high internet charge (39.8%) and lack of fair evaluation (46.9%) as well as strong agreement on internet issues (42.7%) and unfeasible practical natured courses (57.8%) to be the obstacles to online learning. the result was supported by other studies as well.[8,9,15]while online methods support and facilitate educational activities, the pros and cons of technology to harness its potentials is equally important.[8] furthermore, policy-related issues such as network security, bandwidth, storage solutions, copyright and intellectual property as well as accessibility need to be addressed by the academic institution for successful implementation of online learning.[20] majority of the participants strongly agreed that face-to-face learning was more effective, more motivating and more interactive compared to online learning. this finding is consistent with a pakistani study where majority (84%) of the students rated that e-teaching has limited student-teacher interaction. [13] similarly, nepali medical students perceived online classes as poorer than traditional classes. [18] an indian study also supports this finding.[16] even though virtual learning has become a part of the overall education process; face-to-face learning is equally important especially to directly evaluate students’ learning activities and providing solutions to overcome their limitations. hence, an integrated approach that uses both, traditional and e-learning methods, seems the best for better outcome in medical education.[15] likewise, most participants were very satisfied on teacher’s preparation in the present study. an egyptian study also discusses that quality of education system, service delivery and instructor’s quality had positive effect on learner’s satisfaction. [10] the role of teachers in the educational process is beyond limitation.[15] the present study showed that highest scores were obtained on perceived satisfaction followed by perceived effectiveness and perceived usefulness which is supported by an egyptian study.[10] the continuity and enhancement of their academic competence as well as provision of distance education amidst covid-19 pandemic might be the factors. the present study found that more than half of the participants had positive perception which is supported by other study findings[9,19] but contradictory to a pakistani study which revealed that about three-fourth (77%) students had negative perception.[13] this may be due to lack of readiness of students to shift forcibly from face-to-face to table 3. association between selected variables and online learning perception of participants (n=211). variables perception df chi-square value p-value positive n (%) negative n (%) age, in years ≤20 >20 93 (68.4) 27 (36) 43 (31.6) 48 (64) 1 20.667 <0.001 enrolled nursing program pcl b.sc. 81 (68.1) 39 (42.4) 38 (31.9) 53 (57.6) 1 13.946 <0.001 academic year first second third fourth 38 (73.1) 36 (57.1) 34 (48.6) 12 (46.2) 14 (26.9) 27 (42.9) 36 (51.4) 14 (53.8) 3 8.753 0.033 device used for online learning laptop mobile both 20 (60.6) 60 (65.9) 40 (46.0) 13 (39.4) 31 (34.1) 47 (54) 2 7.445 0.024 j. lumbini. med. coll. vol 9, no 1, jan-june 2021 rana s, et al. nursing students’ perception of online learning amidst covid-19 pandemic jlmc.edu.np online classes due to covid-19 pandemic. also, the pakistani study was conducted very early period of pandemic (april 2020) and the students were yet to accept and be ready for online learning. the present study revealed that age, enrolled nursing program, academic year, and devices used were statistically significant with online learning perception of the nursing students which is contradictory to the findings from a nigerian study. [3] conclusion: nursing students had positive perception of online learning. they were very satisfied that their teaching learning activities were carried out amidst covid-19. age, enrolled nursing program, academic year, and devices used had an impact on positive perception. however, obstacles perceived by the students need to be addressed by the academic institution to improve quality of online education. in conclusion, the current pandemic has caused severe damage to our society but it also provides a great opportunity for educators to capitalize on this and integrate approaches such as online-learning to the mainstay nursing education that creates more student-centered learning environment. acknowledgement: nuring college, devdaha medical college. class coordinators, pcl and b.sc. nursing program, lumbini medical college and teaching hospital. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. references: 1. pangeni sk. open and distance learning: cultural practices in nepal. european journal of open, distance and e-learning. 2016;1;19(2):32-45. doi: https://doi.org/10.1515/eurodl-2016-0006 2. elbasuony mmm, gangadharan p, janula r, shylaja j, gaber fa. undergraduatenursing students’ perception and usage of e-learning and blackboard learning system. middle east journal of nursing 2018;12(2):3-13. doi: https:doi. org/10.5742/mejn.2018.93394 3. opeyemi oz, adeyemi aa, olajuwon td, nike o, oladeji bs. perception of nursing students towards online learning: a case study of lautech open and distance learning centre, ogbomoso, oyo state, nigeria. galore international journal of health sciences & research 2019;4(4):2330. available from: https://www.gijhsr.com/ gijhsr_vol.4_issue.4_oct2019/5.pdf 4. singh f, masango t. information technology in nursing education: perspectives of student nurses. the open nursing journal. 2020;14:1828. doi: http://dx.doi.org/10.2174/1874434602 014010018 5. marinoni g, van’t land h, jensen t. the impact of covid-19 on higher education around the world. iau global survey report. 2020 may. available from: https://www.iau-aiu.net/img/ pdf/iau_covid19_and_he_survey_report_final_ may_2020.pdf 6. rajab mh, gazal am, alkattan k, h rm, m ga, k a. challenges to online medical education during the covid-19 pandemic. cureus. 2020;12(7):e8966. doi: https://dx.doi. org/10.7759/cureus.8966 pmid: 32766008 pmcid: pmc7398724 7. thapa m. education under lockdown. the record. 2020. available from: https://www. recordnepal.com/category-explainers/educationunder-lockdown/ 8. dhawan s. online learning: a panacea in the time of covid-19 crisis. journal of educational technology systems. 2020 1;49(1):5–22. doi: http://doi.org/10.1177/0047239520934018 9. ana a, minghat ad, purnawarman p, saripudin s, muktiarni m, dwiyanti v, et al. students’ perceptions of the twists and turns of e-learning in the midst of the covid 19 outbreak. romanian j. lumbini. med. coll. vol 9, no 1, jan-june 2021 rana s, et al. nursing students’ perception of online learning amidst covid-19 pandemic jlmc.edu.np journal for multidimensional education / revista romaneasca pentru educatie multidimensionala. 2020;12(1sup2):15-26. doi: https://doi. org/10.18662/rrem/12.1sup2/242 10. diab gmae-h, elgahsh nf. e-learning during covid-19 pandemic: obstacles faced nursing students and its effect on their attitudes while applying it. american journal of nursing science. 2020;9(4):300. doi: http://doi. org/10.11648/j.ajns.20200904.33 11. atreya a, acharya j. distant virtual medical education during covid-19: half a loaf of bread. clin teach. 2020;17(4):418-419. pmid: 32558269. doi: https://dx.doi.org/10.1111/ tct.13185 12. karaman s. nurses’ perceptions of online continuing education. bmc medical education. 2011;11(1):86. doi: https://doi. org/10.1186/1472-6920-11-86 13. abbasi s, ayoob t, malik a, memon si. perceptions of students regarding e-learning during covid-19 at a private medical college. pak j med sci. 2020;36(covid19-s4):s57-s61. doi: https://dx.doi.org/10.12669/pjms.36. covid19-s4.2766 pmid: 32582315 pmcid: pmc7306963 14. akimanimpaye f, fakude lp. attitudes of undergraduate nursing students towards e-learning at the university of the western cape, south africa. african journal for physical, health education, recreation and dance (ajpherd). 2015;21(suppl 1):418-33. available from: https://core.ac.uk/download/pdf/62636195.pdf 15. hiwarkar m, taywade o. assessment of knowledge, attitude and skills towards e-learning in first year medical students. international journal of research in medical sciences. 2019;7(11):4119–23. doi: http://dx.doi. org/10.18203/2320-6012.ijrms20194977 16. daroedono e, siagian fe, alfarabi m, cing jm, arodes es, sirait rh, et al. the impact of covid-19 on medical education: our students’ perception on the practice of long distance learning. international journal of community medicine and public health. 2020;7(7):2790–6. doi: https://dx.doi.org/10.18203/2394-6040. ijcmph20202545 17. kapasia n, paul p, roy a, saha j, zaveri a, mallick r, et al. impact of lockdown on learning status of undergraduate and postgraduate students during covid-19 pandemic in west bengal, india. child youth serv rev. 2020;116:105194. doi: https://doi. org/10.1016/j.childyouth.2020.105194 18. nepal s, atreya a, menezes rg, joshi rr. students' perspective on online medical education amidst the covid-19 pandemic in nepal. j nepal health res counc. 2020;18(3):551555. doi: https://doi.org/10.33314/jnhrc.v18i3.2851 pmid: 33210658 19. biswas b, roy sk, roy f. students perception of mobile learning during covid-19 in bangladesh: university student perspective. aquademia. 2020;4(2):ep20023. doi: https://doi.org/10.29333/aquademia/8443 20. frehywot s, vovides y, talib z, mikhail n, ross h, wohltjen h, et al. e-learning in medical education in resource constrained lowand middle-income countries. hum resour health. 2013;11:4. doi: https://doi.org/10.1186/14784491-11-4 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 regmi a, et al. chondromyxoid fibroma of patella: a rare case. 96 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 04 february, 2020 accepted: 02 june, 2020 published: 02 july, 2020 afellow, arthroplasty and sports medicine bregistrar, department of orthopedics and traumatology cchief, department of orthopedics and traumatology dgrande international hospital, kathmandu, nepal. corresponding author: ajaya regmi e-mail: regmiajaya1@gmail.com orcid: https://orcid.org/0000-0002-5207-0591__________________________________________________ abstract introduction: chondromyxoid fibroma is a rare benign tumor with aggressive behavior accounting for less than 0.5% of all bone tumors. there are several case-reports of this tumor occurring in different bones. case report: here we report a case of 19 years old male with the tumor arising from the inferior pole of right patella which was treated by complete excision of the lesion. the histopathology report was consistent with chondromyxoid fibroma. conclusion: chondromyxoid fibroma is a benign but locally aggressive tumor which may occur at unusual sites. key words: chondromyxoid fibroma, osteochondroma, patella, tumor case reporthttps://doi.org/10.22502/jlmc.v8i1.318 ajaya regmi,a,d asish rajak,a,d sushil sharma,b,d chakra raj pandey c,d chondromyxoid fibroma of patella: a rare case how to cite this article:how to cite this article: regmi a, rajak a, sharma s, pandey cr. chondromyxoid fibroma of patella: a rare case. journal of lumbini medical college. 2020;8(1):96-98. doi: https://doi.org/10.22502/jlmc.v8i1.318 epub: 2020 july 2. introduction: chondromyxoid fibroma is one of the rare benign bone tumors. it accounts for less than 0.5% of all biopsied primary bone tumors.[1] the common sites of involvement are metaphysis of long bones in young adults and children, the most common location being proximal tibia.[1] though benign, local recurrence rate varies from 10% to 80% after intralesional treatment.[2] histologically, it is composed of chondroid, fibrous, and myxoid areas in varying proportions in cartilage-like matrix. [1] we present here an unusual case of chondromyxoid fibroma arising from the inferior pole of patella. case report: a 19 years old male presented with the history of pain and swelling over his right knee for the past one year. pain followed direct low energy trauma over the knee. he also noticed the swelling of the same knee which gradually increased in size over one year. on examination, there was a bulge inferolateral to the inferior pole of patella. the quadriceps was moderately wasted with an extensor lag of 15 degrees. radiographic examination (fig. 1) showed a mass arising from the inferior pole of patella, growing towards the joint. fig 2: ct scan (3 dimensional) showing the same mass fig 1: x ray lateral view showing bony outgrowth from the inferior pole of patella. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 regmi a, et al. chondromyxoid fibroma of patella: a rare case. 97 jlmc.edu.np a computed tomography (ct) scan (fig. 2) showed a well-defined osseous outgrowth from the inferior pole of patella, with a size 4x3x1.5 cm and a pedicle of 1.8x1.5 cm. the surface of the growth was irregular. the direction of growth was behind the patellar tendon extending towards the infrapatellar fat pad with an 18 mm thick smooth outlined soft tissue density lesion suggestive of osteochondroma with thick cartilaginous cap. magnetic resonance (mr) images showed 5x3.5x2.5 cm sized mixed signal intensity lobulated mass growing towards hoffa’s fat pad connected to inferior pole with 1 cm wide stalk (fig. 3). probable diagnoses suggested with mri were chondroblastoma, and osteochondroma with thick cartilaginous cap. the patient underwent excisional biopsy. the tumor was removed in two pieces measuring 3.8x2.2 cm with cartilaginous cap: 1.7 cm and 2.5x2.2 cm bony component (fig. 4). the histopathology reports showed hypocellular lobules of poorly formed hyaline cartilage composed of chondroblasts. in the myxoid areas, stellate cells with long processes were noted with areas of calcification. the final diagnosis after histopathological examination was chondromyxoid fibroma. the patient was under regular follow up examinations and we saw no signs of recurrence till two months of follow up. discussion: chondromyxoid fibroma is a rare tumor and its occurrence in patella is a rarer incidence. it was first described by jaffe and litchenstein in 1948 as a lesion derived from cartilage forming tissue, composed of chondroid, myxoid and fibrous tissue in various proportions. it accounts for less than 0.5% of all bone tumors.[1].it may occur at any age but most commonly occurs in patients from 10 to 30 years of age[3]. radiological features include well circumscribed lesion with a rim of sclerosis in the metaphysis of a long bone and may have a bubbly appearance mimicking a nonossifying fibroma.[1] various treatment options have been suggested including simple curettage, curettage with phenol application and en bloc resection with bone grafting.[2] our case had an unusual presentation as an outgrowth from the inferior pole of patella. thus, there was no role of grafting and complete excision of the tumor was performed. several cases of chondromyxoid fibroma have been reported in the literature. durr h r et al. reported fig 3: mri shows a definite pedicle connecting inferior pole to the mass. fig 5: histopathological images: mass composed of hypocellular lobules of poorly formed hyaline cartilage composed of chondroblasts. periphery is more cellular. myxoid area: stellate cells with long process. areas of calcification seen. fig 4: intra operative picture after complete excision of the mass. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 regmi a, et al. chondromyxoid fibroma of patella: a rare case. 98 jlmc.edu.np three cases with involvement of proximal tibia, proximal humerus, and proximal femur.[4] all the three cases were diagnosed by radiology as well as incisional biopsy. the first patient underwent marginal excision and phenol application. for the second patient, en bloc resection and bone graft was done. both the patients healed without recurrence one and three years postoperative respectively. the third patient refused any treatment and no change was seen in three years. khan .m a et al. reported a case of 12 years old female with the lesion in right proximal ulna which was treated by en bloc excision and polymethyl methacrylate (pmma) grafting. [5] soni r et al. reported a 15-year-old male with juxtacortical chondromyxoid fibroma in proximal tibia, which was treated with en bloc excision and bone grafting with no recurrence in one year follow up.[6] immunohistochemichal analysis for sox9 suggests chondrogenic component of tumor and may aid in case of doubtful diagnosis.[7] conclusion: chondromyxoid fibroma is rare, benign but locally aggressive tumor with a tendency to recur. it is often misdiagnosed as osteochondroma or chondroblastoma and diagnosed only after histopathological examination. it may present in unusual sites like patella. proper pre-operative investigations, proper planning, counseling and regular follow up is required for the management of the patient. conflict of interest: authors declare that no competing interest exists. financial disclosure: no funds were available for the study. references: 1. canale st, beatty jh. campbell’s operative orthopaedics. 12th ed. philadelphia: mosby elsevier; 2013. available from: https://www. e l s e v i e r. c o m / b o o k s / c a m p b e l l s o p e r a t i v e orthopaedics/canale/978-0-323-07243-4 2. damle rp, suryawanshi kh, dravid nv, gadre a, borse yme. chondromyxoid fibroma of bone. journal of case report. 2013;3(2):228-31. doi: http://dx.doi.org/10.17659/01.2013.0054 3. abdelwahab if, klein mj. surface chondromyxoid fibroma of the distal ulna: unusual tumor, site, and age. skeletal radiol. 2014; 43(2):243-6. pmid: 24057439. doi: https://doi.org/10.1007/s00256-013-1720-6 4. dürr h, lienemann a, nerlich a, stumpenhausen b, refior hj. chondromyxoid fibroma of bone. arch orthop trauma surg. 2000;120(1-2):42-7. pmid: 10653103. doi: https://doi.org/10.1007/ pl00021214 5. khan ma, reddy pk, ahmed sf. a rarest presentation of chondromyxoid fibroma in proximal ulna. international journal of science and research. 2019;8(2):543-47. available from: https://www.ijsr.net/search_index_results_ paperid.php?id=4021901 6. soni r, kapoor c, shah m, turakhiya j, golwala p. chondromyxoid fibroma: a rare case report and review of literature. cureus. 2016;8(9):e803. pmid: 27833828. doi: https:// doi.org/10.7759/cureus.803 7. konishi e, nakashima y, iwasa y, nakao r, yanagisawa. immunohistochemical analysis for sox9 reveals the cartilaginous character of chondroblastoma and chondromyxoid fibroma of the bone. hum pathol. 2010;41(2):208-13. pmid: 19801163. doi: https://doi.org/10.1016/j. humpath.2009.07.014 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 6, no 2, july-dec 2018 ___________________________________________________________________________________ a assistant editor, journal of lumbini medical college b assistant professor, department of obstetrics and gynecology, lumbini medical college teaching hospital, palpa corresponding author: shreyashi aryal e-mail: shreyashiaryal@gmail.com orcid: http://orcid.org/0000-0002-6832-3530 how to cite this article: aryal s. integration of physical and mental health: a reproductive health necessity. journal of lumbini medical college. 2018;6(2):2 pages. doi: 10.22502/jlmc.v6i2.275. epub: 2019 feb 10._______________________________________________________ editorialhttps://doi.org/10.22502/jlmc.v6i2.275 shreyashi aryala,b integration of physical and mental health: a reproductive health necessity mental health is a determinant of physical health. this holds true largely in the perspective of female reproductive health. a woman has to go through various stages of mental and physical changes in her life from adolescence to pregnancy, puerperium and menopause. studies have shown association of all these stages with various mental disorders like anxiety, mood disorders and depression.[1] in addition to these physiological changes, some women go through distressing life events like abortion, hysterectomy, sterilization and gender based violence. unfortunately some suffer from chronic morbidities like sexually transmitted diseases, hiv/aids, fistulas, or pelvic organ prolapse. a few numbers of women also go through traumatic experiences in health care facilities during abortions, family planning counseling, childbirth or postpartum periods. all these have a potential for mood and anxiety disorders. [2][3] regrettably, this association has been inconspicuously addressed. the association of physical and mental health has been explored but implicated primarily on hormonal imbalance, namely oestrogen. this association has a biological basis but is partly guided by the stereotyped concept of blaming womens’ problems on hormones. a direct link to hormonal imbalance is social issues which cannot be disregarded. women in developing nations have low education and employment opportunities, have extra unpaid workload of taking care of children and household tasks and also have lesser role in household and political decision making. increase in the number of male migrant workers has added responsibilities to women who are left alone at home. all these factors add to mental burden of these women and when physical distress sets in, the effect is exponentially increased. in developing nations, this integration of gender and reproductive rights is still an unconsidered issue. but without a combined approach, women cannot be treated as a whole and an important aspect of womens’ health will be missed. the first approach to this integration would be to focus on research establishing the cause and effect of mental and reproductive health and addressing the socio-economic factors related to mental and physical well being of women. so far, research in this field has been done from the perspective of health care providers giving evidence on physical effects of reproductive health but we need studies that address issues from the mental health perspective of a female patient. statistics on psychological effects of reproductive events like miscarriage, still birth, prolonged labor, or menopause have merely been addressed. there are studies which address mental health issues after humanitarian crisis like earthquake or civil war with some thought on sexual health, [4] but most scientists do not include reproductive changes in their models.[5][6] our knowledge is very limited in these aspects. research integrating these two aspects in relation to the socio economic context of the country needs to be enforced. another step to this integration would be to train health service providers to see beyond the physical symptoms. screening tools need to be developed which detect mental disturbances in women who come seeking for physical ailments but otherwise keep their mental problems to themselves. mechanisms to identify these silent sufferers have to be systematically integrated. health centers are https://orcid.org/0000-0002-6832-3530 aryal s. integration of physical and mental health: a reproductive health necessity jlmc.edu.npj. lumbini. med. coll. vol 6, no 2, july-dec 2018 the first point of contact between rural women and service providers. they come to these facilities with their physical problems, so these centers can be developed as screening sites for mental symptoms. these women in early stages of mental disturbance can then be identified, counseled and referred for specialized care. roles of primary health care professionals are to be defined in these aspects so that they can assess psychological wellbeing and provide comprehensive care to all women. finally, reproductive health services should target delivery of quality care which would be an atraumatic experience for women. counseling, sensitivity, empathy, support and comfort are all a part of quality health care which might reduce the chances of developing mental symptomatology in a woman undergoing medical treatment. in low income nations, where basic health care is still a struggle, mental health of women is low priority but if we want to reduce gender disparity, then it is necessary to combine physical and mental heath and give our women a sound mind in a sound body. there is a need of professional debates and policies designed to expand the existing reproductive health services to incorporate a mental health perspective within socio economic contexts. with some changes in health care policy, we might be able to achieve for our women, a pleasant sail-through from adolescence to menopause. references: 1. health organization, united nations population fund, key centre for women's health in society. mental health aspects of women's reproductive health: a global review of the literature. world health organization; 2009. 2. fisher j, cabral de mello m, izutsu t, vijayakumar l, belfer m, omigbodun o. mental health aspects of sexual and reproductive health in adolescents. international journal of social psychiatry. 2011;57(1):86-97. doi: 10.1177%2f0020764010396697 3. coleman r, morison l, paine k, powell ra, walraven g. women’s reproductive health and depression. social psychiatry and psychiatric epidemiology. 2006 sep 1;41(9):720-7. epub 2006 jun 22. pmid: 16794765 doi: 10.1007/s00127-006-0085-8 4. advocacy forum and international centre for transitional justice (ictj). across the lines: the impact of nepal’s conflict on women. kathmandu: advocacy forum and international centre for transitional justice; 2010 p. 1-101. available from: https://www.ictj.org/sites/default/files/ictj-nepalacross-lines-2010-english.pdf  5. kane jc, luitel np, jordans mj, kohrt ba, weissbecker i, tol wa. mental health and psychosocial problems in the aftermath of the nepal earthquakes: findings from a representative cluster sample survey. epidemiology and psychiatric sciences. 2018 jun;27(3):301-10. epub 2017 jan 9.pmid: 28065208 doi: 10.1017/ s2045796016001104 6. luitel np, kene j, jordans m, kohrt b, tol w. mental health problems in the aftermath of earthquakes in nepal. european psychiatry. 2016 mar 1;33:s194-5. doi: 10.1016/j.eurpsy.2016.01.353 https://doi.org/10.1177%2f0020764010396697 https://doi.org/10.1007/s00127-006-0085-8 https://www.ictj.org/sites/default/files/ictj-nepal-across-lines-2010-english.pdf https://www.ictj.org/sites/default/files/ictj-nepal-across-lines-2010-english.pdf https://doi.org/10.1017/s2045796016001104 https://doi.org/10.1017/s2045796016001104 https://doi.org/10.1016/j.eurpsy.2016.01.353 tracheal resection and anastomosis for postintubation tracheal stenosis: a case report anup acharya,a,d madan mohan singh,b,d yeshwant gajanan tambayc —–————————————————————————————————————————— abstract: introduction: tracheal stenosis is one of the dreaded complication of tracheal intubation. tracheal resection and anastomosis is an established definitive treatment for stenosis more than one cm. here, we present a case of postintubation tracheal stenosis managed by resection and anastomosis, first of its kind in our centre. case report: we present a case of 26-year female who underwent tracheal intubation during her treatment of tubercular meningitis. two weeks later, she returned with respiratory difficulty. a diagnosis of post-intubation tracheal stenosis was made. tracheal resection and anastomosis was done. recovery was uneventful and she was discharged on 14th post-operative day. conclusion: post-intubation tracheal stenosis is still a dreaded complication even after the introduction of high volume low pressure cuff. they can be successfully managed. care personnel in intensive care unit (icu) should perform to prevent this complication. keywords: anastomosis • postintubation • resection • tracheal stenosis —–————————————————————————————————————————— ___________________________________________________________________________________ a assistant professor b associate professor and head c professor and head, department of surgery lumbini medical college d department of ent head and neck surgery, lumbini medical college corresponding author: dr. anup acharya e-mail: anupent@gmail.com how to cite this article: acharya a, singh mm, tambay yg. tracheal resection and anastomosis for post-intubation tracheal stenosis: a case report. journal of lumbini medical college. 2014;2(2):48-50. doi: 10.22502/jlmc.v2i2.58. ___________________________________________________________________________________ j. lumbini. med. coll. vol 2, no 2, july-dec 2014 jlmc.edu.np case reporthttps://doi.org/10.22502/jlmc.v2i2.58 introduction: tracheal stenosis is defined as the narrowing of trachea. it has several grades. incidence of tracheal stenosis following intubation has been reported up to 21%.1 however, only a few (1-2%) of these patients present with the symptoms. tracheal resection and anastomosis has been established as the definitive treatment of benign tracheal stenosis more than one cm in length.2 the current study aims to present a case of benign tracheal stenosis managed by resection and anastomosis, first of its kind at our institution. case report: a 26 years old lady was brought to casualty department with severe difficulty in breathing since one week. examination revealed a young lady in severe distress of breathing. she was dyspneic, had tachycardia and air hunger. history revealed that she had been treated at our institution for tubercular meningitis for about a month ago, during which she was on ventilatory support for six days and was extubated two weeks later. the patient was on anti tubercular therapy. a clinical diagnosis of tracheal stenosis was made following intubation. x-ray of soft tissue neck, lateral-view fig 1: x-ray of soft tissue neck, lateral-view showing tracheal stenosis at c6-c7 48 j. lumbini. med. coll. vol 2, no 2, july-dec 2014 jlmc.edu.np acharya a. et al. tracheal resection and anastomosis for post-intubation tracheal stenosis showed cervical tracheal stenosis (fig 1). emergency tracheostomy was done as endotracheal intubation was impossible. during operation, trachea was found to be severely stenosed and hence tracheostomy was not only difficult but had to be done distally at a distance. investigations including ct scan (fig 2) and rigid tracheoscopy confirmed diagnosis of tracheal stenosis. there was grade iii (90%) stenosis over the third tracheal ring with narrowing extending proximally up to second ring. ct scan showed a stenotic segment of 2.5 cm. the patient and her relatives were explained about the current problem and the options available. they later agreed for a reconstructive surgery and a tracheal resection and anastomosis was planned. during surgery the stenotic portion of the trachea was resected and end to end anastomosis with 3/0 prolene with knots outside was performed between 1st and 5th tracheal rings (fig 3,4). a mentosternal suture with neck in flexion to restrict neck movement was placed with 1/0 prolene (fig 5). patient made uneventful recovery and was discharged on 14th postoperative day. at five weeks follow up, patient was asymptomatic with normal breathing. since then she had moved to india with fig 2: ct neck, axial cuts (upper two) and reconstructed sagittal (lower) shows tracheal stenosis just above tracheostomy tube. fig 3: upper and lower tracheal stump and the stenotic portion fig 4: resected stenotic portion of trachea fig 5: mento sternal suture 49 j. lumbini. med. coll. vol 2, no 2, july-dec 2014 acharya a. et al. tracheal resection and anastomosis for post-intubation tracheal stenosis jlmc.edu.np her husband and lost the follow up. discussion: among many other etiological factors, endotracheal intubation is a well-known causes of benign tracheal stenosis. the other important cause being complication of tracheostomy and external trauma.3 nowadays, anesthetists use a high volume and low pressure cuffed tube to prevent this complication, despite which it still remains an important cause of stenosis. stenosis is a result of ischemic injury to the tracheal mucosa by the cuff of the tube. in our case, intubation for ventilatory support needed during treatment of tb meningitis is the most likely cause of tracheal stenosis. usually stenosis is slow in progress and may take few months to develop and reach the severe state. however, in our case neither the duration of intubation was too long (six days), and also the time taken to reach the present severity was also too short (less than four weeks after extubation). this prompted us to share our experience with others through this short case report. development of tracheal stenosis following intubation has been reported to occur even with two days of intubation.4 a period up to two weeks in adults and even longer in children is generally consider safe. the factors that are related to development of stenosis with shorter duration of intubations are large size of the tube, high pressure in cuff, not deflating cuff periodically, struggling or restless patient, traumatic intubation, multiple intubation, infection around the cuff site.3-5 all these factors might have played a role in development of stenosis in our case. most patients who develop stenosis remains asymptomatic till late. those who are involved in active physical activities, they may present at an earlier stage.6 conclusion: endotracheal intubation is lifesaving when there is a need for artificial ventilation, but it isn’t without risk. development of tracheal stenosis, that too of higher grade, is one of the most dreaded complication. intensive care personnel should be aware of this fact and do their best to obviate such complication. however, such conditions can be managed with high degree of success. conflict of interest: the principal author was not involved in the editorial decision making. 1. grillo hc, donahue dm, mathisen dj, wain jc, wright cd. postintubation tracheal stenosis. treatment and results. j thorac cardiovasc surg. 1995 mar;109(3):486-92. 2. anand vk, alemar g, warren et. surgical considerations in tracheal stenosis. laryngoscope. 1992 mar;102(3):23743. 3. cinnamond mj. stridor. in: kerr ag, groves j, evans jg (editors). scott-brown’s otolaryngology (5th ed.). london: butterworths & co ltd;1987.p.420-7. 4. zias n, chroneou a, tabba mk, gonzalez av, gray aw, lamb cr, et al. post tracheostomy and post intubation tracheal stenosis: report of 31 cases and review of the literature. bmc pulm med. 2008 sep;8:18. doi: 10.1186/1471-2466-8-18. 5. keshava k, weingarten ja, grosu hb. “benign” tracheal stenosis in an 18-year-old man. ann am thorac soc. 2013 dec;10(6):701-3. doi: 10.1513/annalsats.201306-199ot. 6. pookamala s, kumar r, thakar a, karthikeyan cv, bhalla as, deka rc. laryngotracheal stenosis: clinical profile, surgical management and outcome. indian j otolaryngol head neck surg. 2014 jan;66(suppl 1):198-202. doi: 10.1007/s12070-011-0424-2. references: 50 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 baral s, et al. baral s, et al. axial torsion and meckel’s diverticulitis: a diagnostic conundrum licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 19 february, 2020 accepted: 20 april, 2020 published: 21 may, 2020 a consultant ophthalmologist boptometrist, csagarmatha choudhary eye hospital, siraha, lahan, nepal ddristi eye hospital, birgunj , nepal corresponding author: dr. sharad gupta e-mail: sharadgupta00839@gmail.com orcid: https://orcid.org/0000-0001-8654-5172 _______________________________________________________ ———————————————————————————————————————— abstract introduction: best disease or vitelliform macular dystrophy is a rare autosomal dominant disorder with bilateral presentation characterized by subretinal accumulation of yellowish material in the macular area. macular findings range from a small yellow spot, multiple vitelliform or atrophic lesions to a chorio-retinal scar. case report: a 35 years male presented to our outpatient department with chief complaint of blurring of vision of both eyes for the past three months. his visual acuity was 6/12 in both right and left eyes. on slit-lamp bio-examination anterior segments of both eyes were normal. on fundus examination, both eyes revealed a single, circular, yellow-opaque egg yolk-like macular lesion with no other abnormalities. optical coherence tomography of both eyes revealed deposits of homogenous hyperreflective material beneath retinal pigment epithelium at fovea. fundus fluorescence angiography showed blocked fluorescence at the site of vitelliform lesion of both eyes. conclusion: best vitelliform macular dystrophy is a rare genetic disorder with incomplete penetrance. optical coherence tomography and fundus fluorescence angiography support the diagnosis. keywords: best disease, fundus fluorescence angiography, optical coherence tomography case reporthttps://doi.org/10.22502/jlmc.v8i1.316 sharad gupta,a,c hari sharma,a,d reenayadav,a,c sanjay kumar singh,a,c sushma chaudharyb,c adult onset best vitelliform macular dystrophy: a case report how to cite this article:how to cite this article: gupta s, sharma h, yadav r, singh sk, chaudhary s. adult gupta s, sharma h, yadav r, singh sk, chaudhary s. adult onset best vitelliform macular dystrophy: a case report. onset best vitelliform macular dystrophy: a case report. journal of lumbini medical college. 2020;8(1):3pages. doi: journal of lumbini medical college. 2020;8(1):3pages. doi: https://https://doi.org/10.22502/jlmc.v8i1.316doi.org/10.22502/jlmc.v8i1.316 epub: 2020 may 21. epub: 2020 may 21. introduction: inherited macular dystrophies are arbitrarily classified on the basis of their tissue of origin into those originating from choroid, bruch’s membrane, retinal pigment epithelium (rpe) alone, photoreceptors and rpe, and nerve fibre layers. best disease, also termed as vitelliform macular dystrophy, is a separate entity among the inherited macular dystrophies. it was first reported by adam and the first pedigree was described by dr. friedrich best, a german ophthalmologist, in 1905.[1] it is a rare autosomal dominant disorder with incomplete penetrance and variable expression which typically present in childhood involving the long arm of chromosome 11 (11q12q13).[1,2,3] usually the fundus lesions are bilateral (yellow or orange egg-yolk appearance) at the macula but can be unilateral. many individuals with best disease are asymptomatic initially but the yellow material is gradually resorbed over time, leaving atrophic area of the rpe and often followed by subretinal fibrosis. the diagnostic test for best disease is electrooculogram (eog) with abnormal arden ratio. optical coherence tomography (oct), fundus fluorescence angiography (ffa) and full-field electro-retinograph (erg) are the tests done to support the diagnosis. here we report a case of best disease with bilateral presentation. case report: a 35 years old male presented to our retina department with chief complaint of blurring of vision of both eyes for the last three months. there were no other complaints. he did not give history of any trauma, redness, watering or discharge from j. lumbini. med. coll. vol 8, no 1, jan-june 2020 gupta s, et al. gupta s, et al. adult onset best vitelliform macular dystrophy: a case report.adult onset best vitelliform macular dystrophy: a case report. jlmc.edu.np either eye. he had no significant past ocular or systemic histories. there was no similar history in his family members. on examination his presenting visual acuity was 6/12 in each eye. visual acuity did not improve even with pinhole or best refractive correction. on slit-lamp examination, anterior segments of both eyes were unremarkable. on posterior segment evaluation, fundus of both eyes revealed a normal welldefined vertically oval optic disc along with single, yellow or orange well-circumscribed dome shaped egg-yolk like sub-retinal lesion approximately disc diameter in size at macula(figs. 1a and 1b). figs 1a and 1b: right and left fundus showing yellow or orange well-circumscribed dome shaped egg-yolk like sub-retinal lesion approximately disc diameter in size at macula. intraocular pressure of both the eyes were within reference limit. with above history and clinical findings best’s vitelliform macular dystrophy was suspected and the patient was investigated with oct and ffa. oct revealed deposit of homogenous hyper-reflective lesion beneath rpe at macula showing rpe disruption and thickening suggestive of pigment accumulation (figs. 2a and 2b). figs. 2a and 2b: oct of both eyes revealed deposit of homogenous hyper-reflective lesion beneath retinal pigment epithelium at macula showing rpe disruption and thickening suggestive of pigment accumulation. ffa showed blocked fluorescence at the site of vitelliform lesion of both eyes (figs. 3a and 3b). figs 3a and 3b: fundus fluorescence angiography showed blocked fluorescence at the site of vitelliform lesion of both eyes. the eog and full-field erg were not done due to unavailability of the test in our hospital. the patient was diagnosed as a case of best vitelliform macular dystrophy and advised for follow-up yearly. discussion best vitelliform macular dystrophy is a rare autosomal dominant disorder of unknown prevalence due to the mutation of best1 gene with incomplete penetrance and variable expression.[2] it is characterized by accumulation of heterogeneous material between rpe and bruch’s membrane, which is likely derived from the degenerating rpe cells containing lipofuscin.[4] it typically affects young patients in whom a macular lesion gradually evolves through several characteristic stages. mohler and fine classified the evolution of best disease in different stages:[5] stage 0:normal macula with abnormal eog. stage i: disturbance of the rpe of the macula. stage ii: typical vitelliform or egg yolk lesion. stage iia: break up of the vitelliform cyst or scrambled egg phase. stage iii: pseudo-hypopyon phase where yellow material forms a fluid level in the vitelliform cyst. stage iva: atrophy of pigment epithelium and possibly retina produces an orange-red lesion in the macula. stage ivb: white hypertrophic scar of fibrous tissue in the macula. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 gupta s, et al. gupta s, et al. adult onset best vitelliform macular dystrophy: a case report.adult onset best vitelliform macular dystrophy: a case report. jlmc.edu.np stage ivc: neovascularization of the fibrous scar. in best disease mutation in best 1 gene disturbs the ion transport resulting in acculmulation of lipofuscin materials and fluid between rpe and photoreceptors.[6]visual function generally remains good until the disease process progresses to cause disruption of photoreceptors and rpe and structural alterations in the outer retinal layers. similarly, lesions in best disease are frequently single and central but there are few reports which describe multiple peripheral lesions outside the macula and posterior pole.[7]best disease could be diagnosed clinically but eog is the diagnostic test for it which is abnormal in all stages. other tests such as full field erg, oct, and ffa are done to support the diagnosis. in our case the electrophysiological test was not done due to unavailability of test in our hospital. there is no definite treatment to slow the progression of this disorder. the role of antioxidant supplementation in best disease is of only theoretical benefit.[8] the patient of best disease along with choroidal neovascularization should be treated with either photodynamic therapy or intravitreal anti-vascular endothelial growth factors. conclusion best vitelliform macular dystrophy is a rare autosomal dominant disorder. visual function is good in the early stage but gradually decreases in the late stage. there is no effective treatment available to slow the progression of best disease. long term follow up is recommended to see the development of choroidal neo-vascularisation that may have to be treated using intravitreal anti-vascular endothelial growth factors or photodynamic therapy. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. references: 1. deutman af, hoyng cb. macular dystrophies. in: schachat ap, hengst tc. (eds.) medical retina. 3rd ed. london: mosby; 2001. p.1225 2. querques g, zerbib j, santacroce r, margaglione m, delphin n, rozet jm, et al. functional and clinical data of best vitelliform macular dystrophy patients with mutations in the best1 gene. mol vis. 2009;15:2960-72. pmid: 20057903 3. stone em, nichols be, sterb lm, kimura ae, sheffield vc. genetic linkage of vitelliform macular degeneration (best’s disease) to chromosome 11q13. nat genet. 1992;1(4):24650. pmid: 1302019. doi: https://doi.org/10.1038/ ng0792-246 4. frangieh gt, green wr, fine sl. a histopathologic study of best’s macular dystrophy. arch ophthalmol. 1982;100(7):111521. pmid: 7092655. doi: https://doi.org/10.1001/ archopht.1982.01030040093017 5. mohler cw, fine sl. long-term evaluation of patients with best’s vitelliform dystrophy. ophthalmology. 1981:88(7):688-92. pmid: 7267039. doi: https://doi.org/10.1016/s01616420(81)34965-3 6. hartzell hc, qu z, yu k, xiao q, chien lt. molecular physiology of bestrophins: multifunctional membrane proteins linked to best disease and other retinopathies. physiol rev. 2008;88(2):639-72. pmid: 18391176. doi: https://doi.org/10.1152/physrev.00022.2007 7. weingeist ta, kobrin j, watzke rc. histopathology of best’s macular dystrophy. arch ophthalmol. 1982;100(7):1108-14. pmid: 7092654. doi: https://doi.org/10.1001/ archopht.1982.01030040086016 8. schmitz-valckenberg s, holz fg, bird ac, spaide rf. fundus autofluorescence imaging: review and perspectives. retina. 2008;28(3):385-409. pmid: 18327131. doi: https://doi.org/10.1097/ iae.0b013e318164a907 education status of husband and wife and its influence on acceptance of contraception buddhi kumar shrestha,a,c subha shresthab,c —–————————————————————————————————————————————— abstract: introduction: acceptance of family planning is influenced by a variety of interrelated factors such as age at marriage, education, economic status, religion, number of living children etc. this study is an endeavor to assess the relation between education status of husband and wife and acceptance of contraception among postpartum women at lumbini medical college teaching hospital. methods: a prospective, observational analytical study was conducted in obstetrics and gynecology department of lumbini medical college. the information on socio-demographic data, educational status of husband and wife and willingness to accept any form of contraception within the next three months was obtained by an interview, utilizing a questionnaire. results: there were 615 postpartum ladies accompanied by their husbands who were included in the study. mean age of wives was 25.11 years (sd=5.36, range 17-45) and husbands was 27.89 years (sd=5.55, range 20-47). contraceptive acceptance was shown to increase significantly with literacy status. illiterate husbands and wives refused to accept the contraception which was statistically significant. (p<0.001) conclusion: contraceptive acceptance was significantly poor in illiterate wives and husbands whereas it was significantly higher in educated wives and husbands of all education levels. we feel the need of more education programs and education friendly socio-economic conditions which increases the acceptance of contraception thereby assisting family planning and population control. keywords: contraception • educational status • postpartum —————————————————————————————————————————————— ___________________________________________________________________________________ a assistant professor b lecturer cdepartment of obstetrics and gynecology lumbini medical college teaching hospital corresponding author: dr. buddhi kumar shrestha e-mail: drbuddhi205@gmail.com how to cite this article: shrestha bk, shrestha s. education status of husband and wife and its influence on acceptance of contraception. journal of lumbini medical college, 2015;3(1):5-7. doi: 10.22502/jlmc.v3i1.60. ___________________________________________________________________________________ j. lumbini. med. coll. vol 3, no 1, jan-june 2015 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v3i1.60 introduction: an unintended pregnancy is a pregnancy that is either mistimed (i.e., they occurred earlier than desired) or unwanted (i.e. they occurred when no children, or no more children were desired) at the time of conception. in nepal, most of them have been occurring due to non-use of family planning method or because of contraception failure.1 contraceptive counseling has become an integral part of antenatal and postpartum programs as pregnant and postpartum women are generally highly motivated towards controlling their fertility either in birth spacing or in stopping their fertility altogether. the time during pregnancy and that immediately after delivery may be the only time for the obstetrician to connect with women who are poorly motivated to obtain routine healthcare, best described as 'crisis-oriented'.2,3 the postpartum period is potentially an ideal time to begin contraception as women are more strongly motivated to do so at this time, which also has the advantage of being convenient for both patients and health-care providers.4 acceptance of family planning is influenced by a variety of interrelated factors such as age at marriage, education, economic status, religion, number of living children etc. education status of husband and wife may affect the acceptance of contraception. therefore, we aim to assess the educational status of the couple delivered at lumbini medical college teaching hospital (lmcth) and to know its impact on acceptance of contraceptives during postpartum period. 5 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 jlmc.edu.np shrestha bk. et al. education status of husband and wife and its influence on acceptance of contraception methods: this was a prospective, observational analytical study conducted from october 2014 to march 2015 at lumbini medical college teaching hospital. all postpartum ladies of child bearing age (18-45 years) in the postnatal ward of department of obstetrics and gynecology were included in the study. ladies who were not accompanied by husband at the time of delivery, had a mental disability and refused to be involved in the study were excluded. the information on socio-demographic data, educational status of husband and wife and willingness to accept any form of contraception within the next three months was obtained by an interview, utilizing a questionnaire. the questionnaire was pretested by a panel of experts working in the respective fields. data were collected in microsoft excel 2007 and analyzed in spss 21. descriptive and inferential statistics were applied and a p value <.05 was considered significant. results: total deliveries at lmcth during study period were 1052 and out of those 615 couples who met the inclusion criteria were included in the study. mean age of wives was 25.11 years (sd=5.36, range 17-45) and husbands was 27.89 years (sd=5.55, range 20-47). literacy and educational status of husbands and wives is presented in table 1 and 2. chi-square test of independence in table 1 shows that there is no difference in literacy status in different gender. chi-square goodness of fit test in table 2 shows that the level of education is comparable across all levels in husbands and wives. illiterate n (%) educated n (%) husbands 127 (20.6%) 488 (79.4%) x2=2.67, df=1 p=.1wives 152 (24.7%) 463 (75.3%) table 1: literacy status of husbands and wives education status husbands n wives n illiterate (n=279) 127 152 x2=2.24, df=1, p=.13 primary level (n=360) 195 165 x2=2.5, df=1, p=.11 high school level (n=543) 266 277 x2=.22, df=1, p=.64 graduate level (n=48) 27 21 x2=.75, df=1, p=.39 table 2: education status of husbands and wives according to level of education acceptance of contraception in wives according to educational level is shown in table 3. chisquare test of goodness of fit shows that illiterate wives refused to accept the contraception which was statistically significant. on the other hand, educated wives of all levels accepted some form of contraception, which was again statistically significant. education status accepted not accepted illiterate (n=152) 22 130 x2=76.74 df=1, p<.001 primary level (n=165) 97 68 x 2=5.1, df=1 p=.02 high school (n=277) 215 62 x2=84.5 df=1, p<.001 graduate (n=21) 16 5 x2=5.76 df=1, p=.02 table 3: education status and acceptance of contraception in wives acceptance of contraception in husbands according to educational level is shown in table 4. chi-square test of goodness of fit shows that illiterate husbands refused to accept the contraception which was statistically significant. on the other hand, educated husbands of all levels accepted some form of contraception, which was again statistically significant. education accepted notaccepted illiterate (n=127) 20 107 x2=59.6 df=1, p<.001 primary level (n=195) 126 69 x2=16.67 df=1, p<.001 high school (n=266) 237 29 x2=162.65 df=1, p<.001 graduate (n=27) 22 5 x2=10.7 df=1, p=.001 table 4: education status and acceptance of contraception in husbands discussion: family planning is a basic human right. all individuals have right to access, choice, and benefits of the scientific progress in the selection of family planning method. this study examined how education status affects approval of contraception among couples. it was found that the education status and the level of education of both husband and wife were positively associated with the use of contraception by couples. in family planning, the programs usually 6 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 shrestha bk. et al. education status of husband and wife and its influence on acceptance of contraception jlmc.edu.np aim women as the target group and ignore the role of men. in traditional society where decisions are largely taken by men, they should be actively involved in reproductive decision of the couple.5 this study revealed that the education status and level of the husband is associated with acceptance of any kinds of contraceptives. husband approval of family planning is also important to those women who intend to use modern contraceptives in future.6 in our study, we found that use of contraception was more in literate and educated group compared to illiterate group. we also found that it was easier to explain the advantages and disadvantages of different contraceptive methods amongst educated group. most of the couples with higher education could choose contraceptive as per their convenience as in a study by radulovic et al., in which the couples with higher education gave the best definition of contraception and also could choose contraceptive of their choice.7 this study also revealed that the women with primary education use less protection from unwanted pregnancy than women with secondary and higher degree which is similar to the finding in our study. while interviewing the couples, we realized that education plays a very important role in the acceptance of different family planning method. as correctly stated by world bank agenda 21, we found that educated women were more independent in making decision regarding family planning issues.8 issues affecting women such as education and access to health care have significant consequences on sustainable development therefore educating couples may play an important role in determining overall levels of reproductive health. conclusion: contraceptive acceptance was significantly poor in illiterate wives and husbands whereas it was significantly higher in educated wives and husbands of all education levels. we feel the need of more education programs and education friendly socioeconomic conditions which increases the acceptance contraception which would help in family planning and population control. conflict of interest declared: none financial interest: none references: 1. center for research on environment health and population activities. management of abortion related complications in hospitals of nepal – a situation analysis. crehpa, kathmandu; 2000. 2. mohamed sa, kamel ma, shaaban om, salem ht. acceptability for the use of postpartum intrauterine contraceptive devices assiut experience. med princ pract. 2003 jul-sep;12(3):170-5. 3. darnel l, jones md, david r, helbert md. postpartum contraception. clin med. 1975;82:20–2. 4. xu jx, reusche c, burdan a. immediate post-placental insertion of intrauterine device: a review of chinese and world experiences. adv contracept. 1994;10:71–82. 5. ha b, jayasuriya r, owen n. predictors of men's acceptance of modern contraceptive practice: study in rural vietnam. health education and behavior. 2005;32(6):738-50. 6. shahjahan md, mumu sj, afroz a, chowdhury ha, kabir r, ahmed k. determinants of male participation in reproductive healthcare services: a cross-sectional study. reprod health. 2013;10(1):27. 7. radulovic o, sagric c, visnjic a. the influence of education level on family planning. medicine and biology. 2006;13(1):58-64 8. world bank. advancing sustainable development: the world bank and agenda 21. rio earth summit; 1997. 7 asymptomatic bacteriuria in diabetic adults ajay adhikaree,a suresh chandra kohli,b,e daya ram pokhrel,c,e dharma bhattad,e —–————————————————————————————————————————————— abstract: introduction: urinary tract infection (uti) is a wellknown complication of diabetes mellitus (dm). its spectrum ranges from asymptomatic bacteriuria (abu) to acute pyelonephritis. many studies have delineated an increased prevalence of abu in dm whereas to the same degree other studies have come to naught showing insignificant association. hence, this study was drafted to evaluate the presence of abu among diabetics and assess various risk factors. methods: total of 116 diabetic adults without symptoms of uti attending medical out-patient department, manipal teaching hospital were enrolled by detailed clinical history, examination and laboratorial examination as per standard set of questionnaire from february 2013 to may 2014. data were analyzed by spss (17.0). results: the rate of abu in diabetic adults was 10.3% and was significantly associated with duration of dm, fasting blood glucose level and poor glycaemic control. escherichia coli was the most frequently isolated pathogen which was sensitive to nitrofurantoin and imipenem. conclusion: being asymptomatic, diabetics fail to recognise abu, however, abu is preponderant in dm and is linked mainly with duration of dm and poor glycaemic control. hence screening for abu is imperative in diabetic adults if above mentioned risk factors are present. keywords: asymptomatic • bacteriuria • diabetes mellitus • risk factors • urinary tract infection ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, department of medicine lumbini medical college teaching hospital, palpa, nepal b professor, department of medicine c assistant professor, department of biochemistry d associate professor, department of microbiology e manipal college of medical sciences, pokhara, nepal corresponding author: dr. ajay adrikaree e-mail: ajay.bijay@gmail.com how to cite this article: adhikaree a, kohli sc, pokhrel dr, bhatta d. asymptomatic bacteriuria in diabetic adults. journal of lumbini medical college. 2015;3(2):25-9. doi: 10.22502/jlmc.v3i2.66. ___________________________________________________________________________________ j. lumbini. med. coll. vol 3, no 2, july-dec 2015 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v3i2.66 introduction: asymptomatic bacteriuria (abu) refers to the presence of bacteria in urine at levels often regarded as clinically significant in patients with no symptoms suggestive of urinary tract infection (uti).1,2 it is defined as isolation of a specified quantitative count of bacteria in an appropriately collected urine specimen from an individual without symptoms or signs of uti.3 the prevalence of abu in the population varies widely with age, gender, body mass index (bmi), disease status including diabetes mellitus (dm), previous history of uti, sexual activity, presence of genitourinary abnormalities, previous genitourinary instrumentation, intervention or surgery, and albuminuria.4 it is commonly believed that the incidence of infection is higher in person with dm and that such infection results in complication and death more frequently than would be anticipated in otherwise healthy individuals.5 moreover, uti is a significant problem in patients with dm because of multiple effects of dm on the urinary tract and host immune system.6 an association between uti and dm was first noted in an autopsy series in 1940's. many studies have shown an increased prevalence of bacteriuria in diabetics whereas almost equal numbers of studies have failed to show a significant association.5 there is paucity of data on prevalence of abu in wider age group of diabetic patients in nepalese population.7 hence, the aim of the present study was to evaluate the prevalence of abu among wider age group diabetic adult patients, to assess the associated risk factors including age, gender, duration of dm, bmi, glycaemic control and identification of bacteriological profile along with antibiotic sensitivity pattern of those isolates. 25 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 jlmc.edu.np adhikaree a. et al. asymptomatic bacteriuria in diabetic adults. methods: this was a hospital based prospective analytical study conducted from february 2013 to may 2014 at manipal teaching hospital, pokhara, nepal. after ethical clearance, a standard set of questionnaire was prepared and a written consent taken from all participants. diagnosis of dm was made as per history and past medical treatment in all known cases and as per american diabetes association (ada) criteria in all new cases.8 all those diabetics giving consent, age ≥ 18 years and asymptomatic individuals (without features of dysuria, frequency, urgency, strangury, fever) were enrolled. patients with recent hospitalisation or surgery (within past four months), renal disease (serum creatinine > 1.5 mg/dl), known urinary tract abnormalities (including cystopathy or recent urinary tract instrumentation), pregnancy, and use of recent anti-microbial drugs (within the preceding 14 days) were excluded. a detailed history with special reference to symptomatology and risk factors along with clinical examinations were performed. cases were divided into male and female group and further subdivided into different sub-groups. after careful explanation of the procedure, a mid-stream urine (msu) specimen (after washing of the perineal area in females and penile area in males) was collected in a well labelled screw capped universal container which was promptly transported to the laboratory. all urine samples were inoculated on mac-conkey and blood agar plates aerobically at 37℃ for 48 hours. a second urine sample was taken in males whose urine culture showed mixed growth or growth < 105 colony forming unit /milliliter (cfu/ ml). identification of the isolates were carried out using standard microbiological methods.9 semiquantitative estimation of colony count was calculated by standard loop method.10 antibiotic susceptibility testing (ast) of the isolates were performed on mueller hinton agar by kirby-bauer disc diffusion method. selection of antibiotic discs were as per national committee for clinical laboratory standards (nccls) guidelines.11 diagnosis of abu in male was defined as the presence of ≥ 105 cfu/ml of one or two bacterial species. for female, it was confirmed by a second urine culture as per infectious diseases society of america (idsa) guidelines.4 in addition, urine routine and microscopic examination, fbs and ppbs, hba1c, complete blood count (cbc), serum urea, creatinine (cr) were performed. the following associated risk factors i.e. age, gender, duration of dm, bmi, significant pyuria (>5 leucocyte/mm3) and glycaemic control (good control with hba1c level < 7 % and poor control with hba1c ≥ 7 %) were also studied.8 analyses were performed using spss 17.0 (il, chicago, usa) statistical package. data for categorical variables were expressed in number or percentage while continuous variables were expressed in mean and standard deviation. independent sample t-test for continuous variables and chi-square test and fisher exact test for nominal variables were used. a binary logistic regression was used to assess the association between abu as the dependent variable and gender, age group, duration of dm, bmi, fbs, ppbs, glycaemic control and significant pyuria as independent variables. value of p < 0.05 was considered significant. results: table 1 shows the baseline characteristics of the patients. male were significantly elder than female. other parameters were comparable between gender. out of 116 diabetic adults, 12 diabetics (9 female, 3 male) had abu with an occurrence of 10.3%. variables male (n= 55) female (n= 61) statistics age (years) 60.96 (sd=11.12) 56.46 (sd=10.48) t=2.24, df=114, p=.03 duration of dm (years) 4.50 (sd=4.67) 5.40 (sd=5.05) t=.95, df=114, p=.34 bmi (m/kg2) 24.53 (sd=4.58) 24.20 (sd=4.26) t=.4, df=114, p=.69 fbs (mg/dl) 149.07 (sd=68.25) 148.8 (sd=59) t=.02, df=114, p=.98 ppbs (mg/dl) 224.44 (sd=76.81) 232.33 (sd=81.36) t=.54, df=114, p=.59 hba1c (%) 6.59 (sd=0.96) 6.68 (sd=1.09) t=.47, df=114, p=.63 urea (mg/dl) 31.78 (sd=7.51) 30.44 (sd=6.87) t=1, df=114, p=.32 creatinine (mg/dl) 1.06 (sd=0.19) 1.02 (sd=0.17) t=1.2, df=114, p=.23 sbp (mm hg) 126.15 (sd=13.95) 129.54 (sd=17.66) t=1.14, df=114, p=.26 dbp (mm hg) 78.76 (sd=7.26) 79.08 (sd=8.68) t=.21, df=114, p=.83 tlc 7356.36 sd=1686.74 7293.44 sd=1774.62 t=.2, df=114, p=.85 significant pyuria 6 (10.9%) 10 (16.4%) x2=1, df=1, p=.32 asymptomatic bacteriuria 3 (5.45%) 9 (14.75%) x2=3, df=1, p=.08 table 1: baseline characteristics of the patients 26 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 adhikaree a. et al. asymptomatic bacteriuria in diabetic adults. jlmc.edu.np table 2 shows the odds ratio of several variables, with abu as dependent variable. escherichia coli was the predominantly isolated pathogen (n=9, 75%) followed by klebsiella pneumoniae (n=2, 16.7%) and staphylococcus aureus (n=1, 8.3%). the antibiograms for the individual micro-organisms are shown in table 3. table 2. odds ratio (exponentiated coefficients), abu as dependent variable. variables odds ratio p age group (years) 25-39 reference reference 40-54 1 0.99 55-69 8.08 0.53 70-84 6.25 0.6 gender male reference reference female 1.47 0.28 duration of dm (years) 0-5 reference reference 6-10 1.01 0.01 11-15 1.08 0.15 >15 1.31 0.40 bmi (m/kg2) < 18.5 reference reference 18.5-22.9 4.03 0.99 23-24.9 2.16 0.99 25-29.9 1.50 0.99 >30 6.44 0.99 fbs (mg/dl) 2.64 0.04 ppbs (mg/dl) 2.71 0.85 glycaemic control good (< 7.0%) reference reference poor (≥ 7.0%) 1.06 0.01 significant pyuria no reference reference yes 4.28 0.73 microorganisms amp/ amo cex/ cez gen/ ami/ net nor/ cip cot nit imi e sc he ri ch ia co li n (% ) 5 (55.6) 5 (55.6) 8 (88.9) 8 (88.9) 6 (66.7) 9 (100) 9 (100) k le bs ie lla pn eu m on ia e n (% ) 1 (50) 0 1 (50) 2 (100) 2 (100) 1 (50) 2 (100) st ap hy lo co ccu s au re us n (% ) 1 (100) 1 (100) 0 0 0 0 0 table 3: antibiogram amp/amo: ampicillin/amoxycillin, cex/cez: cephalexin/cephazolin, gen/ami/net: gentamicin/amikacin/netilmicin, nor/cip: norfloxacin/ciprofloxacin, cot: co-trimoxazole, nit: nitrofurantion and imi: imipenem. disscussion: this occurrence of abu in diabetic adults of 10.3% in our study was comparable with few other studies,12-14 while many other studies reported higher rate.15-23 although no definite comment can be made, different inclusion criteria in these studies might explain their high prevalence. duration of dm had a positive significant association in our study (table 2). this result was supported by various other studies.19,24-25 a contradictory finding was reported by a study which might be due to the presence of other risk factor like nephropathy in their study making abu common even in early period of dm.26 similarly, patients with poor glycaemic control compared to those with good glycaemic control had significant higher prevalence of abu in our study (table 2). this finding was also supported by some studies,21-22, 27 while few other studies failed to show significant relationship.28-30 escherichia coli (n=9, 75%) was the most common pathogen in our study followed by klebsiella pneumoniae (n=2, 16.7%). various researchers have found similar findings,14-15,17-18,20,22,24, 26-27,31-34 while few other studies reported the predominance of klebsiella pneumoniae, coagulase negative staphylococci, enterococcus faecalis or staphylococcus aureus respectively in their studies.21,35-37 this is the first study that reported the occurrence of abu in a wider age group of diabetic adult nepalese population. however, limited sample size, expensive cost of laboratorial tests to differentiate the types of dm was the limitation of our study. being a hospital based study in a specific geographical area, it may not represent exact scenario of general diabetic population. therefore, we believe that this study will be a road-map study for future researchers who would like to continue with similar studies in different parts of nepal. 27 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 adhikaree a. et al. asymptomatic bacteriuria in diabetic adults. jlmc.edu.np conclusion: in diabetic adults, abu is highly prevalent and associated mainly with duration of dm and poor glycaemic control. hence, screening for abu is warranted in diabetics if above mentioned risk factors are present. abbreviations: abu: asymptomatic bacteriuria, ada: american diabetes association, ast: antibiotic sensitivity test, ami: amikacin, amp/ amo: ampicillin/ amoxicillin, bmi: body mass index, cbc: complete blood count, cex/ cez: cephalexin/ cephazolin, cfu: colony-forming units, cip: ciprofloxacin, cot: co-trimoxazole, cr: creatinine, dbp: diastolic blood pressure, dm: diabetes mellitus, fbs: fasting blood sugar, gen: gentamicin, hba1c: glycosylated haemoglobin a1c, idsa: infectious disease society of america, imi: imipenem, msu: mid-stream urine, nclss: national committee for clinical laboratory standards, net: netilmicin, nit: nitrofurantoin, nor: norfloxacin, ppbs: post prandial blood sugar, sbp: systolic blood pressure, uti: urinary tract infection. conflict of interest: the principal author did not take part in editorial decisions. references: 1. ahmed s, rashid hu. urinary tract infection in adults: a review, bangladesh. renal j. 1996;15:23-31. 2. cormican m, murphy aw, vellinga a. interpreting asymptomatic bacteriuria. bmj. 2011;343:d5084. 3. fekete t, hooton tm. approach to the adult with asymptomatic bacteriuria. in: uptodate. post tw (ed). uptodate. waltham, ma. 2014. 4. nicolle le, bradley s, colgan r, rice jc, schaeffer a, hooton tm. infectious diseases society of america guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. clin infect dis. 2005;40:643-54. 5. sentochnik de, eliopoglous. infection and diabetes. in: kahn cr, weir gc, king gl, jacobson am, moses ac, smith rj(editors). joslin’s diabetes mellitus (14thed). boston:lipincott williams and wilkins.2005;p. 1017-34. 6. patterson je, andriolevt. bacterial urinary tract infections in diabetes. infect dis clin north am. 1997;11:735-50. 7. jha bk, singh yi, khanal lk, yadab vc, sanjana rk. prevalence of asymptomatic bacteriuria among elderly diabetic patients residing in chitwan. kathmandu univ med j. 2009;7(26):157-61. 8. standards of medical care in diabetes. j diabetes care. 2014 jan;37(suppl 1):14-62. 9. winn wc, allen s, janda w, koneman e, procop g, schreckenberger p, et al. koneman’s color atlas and textbook of diagnostic microbiology (6thed). philadelphia: lippincott williams and wilkins. 2006. 10. collee jg, miles rs, watt b. tests for identification of bacteria.in: collee jg, fraser ag, marmion bp, simmons a, editors. mackie and mccartney practical medical microbiology(14thed).new york. churchill livingstone: 2006. 11. clinical and laboratory standards institute. performance standards for antimicrobial susceptibility testing. twentyfirst informational supplement. m100-s21. wayne, pennsylvania: clinical and laboratory standards institute. 2011. 12. karunajeewa h, mc-gechied, stuccio g, stingemore n, davis wa, davis te. asymptomatic bacteriuria as a predictor of subsequent hospitalization with urinary tract infection in diabetic adults: the fremantle diabetes study. diabetologia. 2005;48:1288-91. 13. renko m, tapanainen p, tossavainen p, pokka t, uhar m. meta-analysis of the significance of asymptomatic bacteriuria in diabetes. diabetes care. 2011;34(1):230-5. 14. patil nr, mali us, ramtirthkarmn, bhave (sule) pa. asymptomatic bacteriuria in diabetic women. ijabpt. 2012;3(4):165-9. 15. njunda al, assob jcn, nsagha sd, nde pf, kamga hlf, ajebe fn, et al. uropathogens from diabetic patients with asymptomatic bacteriuria and urinary tract infections. west lond med j. 2013;5(1):7-14. 16. hari a, sinha a. asymptomatic bacteriuria in patients with diabetes attending a tertiary care level: a descriptive study. ijptm. 2013;1:2-4. 17. singh l, murthy r, singh h, nigam p. asymptomatic bacteriuria in patients with type-2 diabetes mellitus. njirm. 2013;4(6):1-4. 18. samuel, sakyi a, ephraim rkd, adebisi bo, yeboah jo, berchie go. asymptomatic bacteriuria among type 2 diabetics in sekondi-takoradi metropolis, ghana. j med sci. 2013;13(4):290-5. 19. alebiosu co, osinupebi oa, olajubu fa. significant asymptomatic bacteriuria among nigerian type 2 diabetics. j natl med assoc. 2003;95:344-51. 20. goyal a, goyal s, agrawal a, dubey k, agrawal p. prevalence and antimicrobial sensitivity pattern of asymptomatic bacteriuria in type 2 diabetes mellitus patients presenting in tertiary care hospital of agra, north india. indian journal of medical specialities. 2013. http:// dx.doi.org/10.7713/ijms.2013.0046. 21. priyadharshini a, mangaiyarkarasi t, balasubramaniam 28 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 adhikaree a. et al. asymptomatic bacteriuria in diabetic adults. jlmc.edu.np r, pragash ds, gopal r. biofilm production and antibiotic resistance among uropathogens causing bacteriuria in diabetic individuals. sch j app med sci. 2014;2(2a):56871. 22. turan h, serefhanoglu k, torun an, kulaksizoglu s, kulaksizoglu m, pamuk b, et al. frequency, risk factors and responsible pathogenic microorganisms of asymptomatic bacteriuria in patients with type 2 diabetes mellitus. jpn j infect dis. 2008;61:236-8. 23. meiland r, geerlings se, stolk rp, netten pm, schneeberger pm, hoepelma am. asymptomatic bacteriuria in women with diabetes mellitus: effect on renal function after 6 years of follow-up. arch intern med. 2006;166:2222-7. 24. aswani sm, chandrashekar uk, shivashankara kn, pruthvi bc. clinical profile of urinary tract infections in diabetics and non-diabetics. australas med j. 2014;7(1):2934. 25. schmitt jk, fawcett cj, gullickson g. asymptomatic bacterium and hemoglobin a1. diabetes care. 1986;9(5):518-20. 26. reddy as, dasu k, krishnan v, reddy rm, kandati j, rao ps. prevalence of asymptomatic bacteriuria and its antibiotic sensitivity in type-2 diabetic women along the sea coast. int j res med sci. 2013;1(4):487-95. 27. bonadio m, boldrini e, forotti g, matteucci e, vigna a, mori s, et al. asymptomatic bacteriuria in women with diabetes: influence of metabolic control. clin infect dis. 2004;38(6):e41-5. 28. geerlings se. stolk rp, camps ml, netten pm, hoekstra jl, bouter kp, et al. asymptomatic bacteriuria may be considered a complication in women with diabetes. diabetes care. 2000;23(6):744-9. 29. boroumand ma, sam l, abbasi sh, salarifar mk, kassaian e, forghani s. asymptomatic bacteriuria in type 2 iranian diabetic women: a cross-sectional study. bmc women's health. 2006;6:4. 30. kasyan g, berketova ty, rogozin ak, pushkar dy. asymptomatic bacteriuria in postmenopausal women with diabetes mellitus. cent eur j urol. 2013;66:320-6. 31. shill mc, huda nh, moain fb, karmakar uk. prevalence of uropathogens in diabetic patients and their corresponding resistance pattern: results of a survey conducted at diagnostic center in dhaka, bangladesh. oman med j. 2010;25(4):282-5. 32. douri fe. prevalence of silent bacteriuria in patients with diabetes mellitus. the iraqi postgraduate medical journal. 2008;7(1):60-4. 33. makuyana d, mhlabi d, chipfupa m, munyombwe t, gwanzura l. asymptomatic bacteriuria among outpatients with diabetes mellitus in an urban black population. cent afr j med. 2002;48(7-8):78-82. 34. yismaw g, asrat d, woldeamanuel y, unakal cg. urinary tract infection: bacterial etiologies, drug resistance profile and associated risk factors in diabetic patients attending gondar university hospital, gondar, ethiopia. euro j exp bio. 2012;2(4):889-98. 35. bissong ma, fon pn, fritz o, besong t, akenji tn. asymptomatic bacteriuria in diabetes mellitus patients in southwest cameroon. african health sciences. 2013;13(3):661-6. 36. vishwanath s, sarda r, d’souza oa, mukhopadhyay c. asymptomatic bacteriuria among patients with diabetes mellitus at a tertiary care center. ntl j of lab med. 2013;2(3):16-9. 37. odetoyin wb, aboderin ao, ikem rt, kolawole ba, oyelese ao. asymptomatic bacteriuria in patients with diabetes mellitus in ile-ife, south-west, nigeria. east afr med j. 2008;85(1):18-23. 29 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 chhetri ud, et al. risk factors and perinatal outcome of meconium stained amniotic fluid 77 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 09 february, 2020 accepted: 25 may, 2020 published: 02 july, 2020 a associate professor, department of pediatrics, b assistant professor, department of obstetrics and gynecology, c lumbini medical college teaching hospital, palpa, nepal. corresponding author: uma devi chhetri e-mail: udchhetri@yahoo.com orcid: https://orcid.org/0000-0002-7896-5393_______________________________________________________ —–———————————————————————————————————————————— abstract: introduction: meconium stained amniotic fluid (msaf) is a frequent finding during deliveries and is a cause for perinatal morbidity and mortality. meconium aspiration syndrome (mas) in neonates is an association in these deliveries with some infants requiring mechanical ventilation. this study was done with the aim of finding the risk factors for msaf and its perinatal outcome. methods: this was a hospital based, cross-sectional study. all the inborn babies delivered with msaf were included in the study. antenatal risk factors and perinatal outcomes like mode of delivery, apgar score, nicu admission and neonatal morbidities mainly mas were noted. results: msaf was seen in 202 (13.6%) neonates out of which 30 (15%) developed mas. antenatal risk factors were present in 97 (48%) cases. mode of delivery was caesarean section in 78 (39%) and instrumental in 25 (13%) cases. twenty three percent of the neonates required resuscitation at birth while 34% required respiratory support. morbidities observed were meconium aspiration, pneumonia, septicaemia, perinatal asphyxia, shock, meconium gastritis and persistent pulmonary hypertension. neonatal mortality amongst all neonates with meconium was 1.5%. conclusion: meconium stained amniotic fluid leading to aspiration is a significant cause of neonatal mortality and morbidity. most of the risk factors for mas are preventable. key words: amniotic fluid, meconium, meconium aspiration syndrome original research articlehttps://doi.org/10.22502/jlmc.v8i1.314 uma devi chhetri,a,c shreyashiaryal b,c risk factors and perinatal outcome of meconium stained amniotic fluid how to cite this article:how to cite this article: chhetri ud, aryal s. risk factors and perinatal outcome of meconium stained amniotic fluid. journal of lumbini medical college. 2020;8(1):77-82. doi: https://doi.org/10.22502/jlmc. v8i1.314 epub: 2020 july 02. introduction: meconium stained amniotic fluid (msaf) complicates delivery in approximately 8-25% of live births.[1] about 5% of neonates born with msaf develop meconium aspiration syndrome (mas) and approximately 50% of these infants require mechanical ventilation.[1] neonates born with msaf can aspirate meconium into lungs and develop respiratory distress. this may lead to atelectasis, emphysema, pneumothorax, pneumo-mediastinum, pneumo-pericardium, chemical-pneumonitis or may progress to respiratory failure.[2] msaf increases the rate of perinatal morbidity (3-5%) and mortality.[3]mas is a serious and potentially preventable condition. some of the risk factors for mas include post-dated pregnancy, small for gestationalage (sga), oligohydramnios, hypertensive disease of pregnancy (hdp), gestational diabetes and maternal drug abuse. this study was therefore done with the aim of finding the risk factors for msaf and its perinatal outcome in a tertiary care center. methods: this was a hospital based, descriptive, cross sectional study conducted in department of pediatrics, lumbini medical college teaching hospital (lmcth) for a duration of six months from 1st january 2019 to 30th june 2019. ethical j. lumbini. med. coll. vol 8, no 1, jan-june 2020 chhetri ud, et al. risk factors and perinatal outcome of meconium stained amniotic fluid. 78 jlmc.edu.np approval was obtained from the institutional review committee of the institute (irc-lmc). the objective of the study was to find out the rate of msaf and mas, analyze maternal and neonatal risk factors, mode of delivery and neonatal morbidity and mortality in msaf among women delivering at lmcth. sample size was calculated using the formula: n= z(1-α/2)2 *p(1-p)/d2. taking the incidence of meconium (p) as15%,[4] the minimum sample size required was 196. all the neonates delivered in the obstetric ward of the hospital with msaf during the study period were included. informed consent was taken from the mother after diagnosis of msaf. the neonates were followed till discharge. still births, neonates with congenital malformations and, multiple gestations were excluded from the study. a performa was filled for each case after delivery of the baby by the attending paediatrician or paediatric resident. this included demographic characteristics of the mother and baby, antenatal risk factors like postdated pregnancy, anemia, hdp, diabetes, intrauterine growth retardation, antepartum hemorrhage and oligohydramnios. need for induction of labour and drugs used for induction were also noted. the phase of labour in which meconium was noted was recorded along with the type of meconium. msaf was diagnosed as green colored amniotic fluid and thick meconium was described as having a pea soup appearance. also, the need of resuscitations like orogastric suction, bag and mask ventilation or endo-tracheal intubation was noted along with neonatal intensive care unit (nicu) management like oxygenation, bubble continuous positive airway pressure (cpap) or mechanical ventilation. mas was diagnosed by the presence of meconium in the amniotic fluid at the time of birth long with respiratory distress. data were entered to and analyzed by statistical package for social sciences (spsstm) software version 21.0. results were expressed as frequency, percentage and, mean and standard deviations. results: fig. 1. total deliveries and case inclusion. out of 1478 total deliveries which included 1099 vaginal deliveries and 379 caesarean sections, 207 (14%) cases were with msaf. among them, one with multiple congenital anomalies and four with intra-uterine fetal death (iufd) were excluded and only 202 were selected for the study. mas was seen in 14.8% of msaf. of all msaf cases, 60% had vaginal delivery and 40% had caesarian section. out of 202 pregnant ladies, teenage pregnancy (15-19 years) was 42 (20.7 %) and four (1.9%) were more than 35 years of age (table 1). table 1. maternal demographic and antenatal characters in msaf parameters frequency n (%) maternal age, in years 15-19 42 (20.7) 20-24 90 (44.5) 25-29 49 (24.2) 30-34 17 (8.4) ≥35 4 (1.9) gravidity primigravida 127 (62.9) multigravida 75 (37.1) antenatal visit <4 46 (22.8) ≥4 156 (73.2) labour induction yes 94 (46.5) no 168 (53.5) drugs used for induction misoprostol 60 (29.7) oxytocin 34 (16.8) type of meconium thick meconium 89 (44.1) thin meconium 113 (55.9) msaf detection before onset of labor 20 (9.9) latent phase 94 (46.5) active phase 41 (20.3) second stage 39 (19.3) intra operative 8 (4) j. lumbini. med. coll. vol 8, no 1, jan-june 2020 chhetri ud, et al. risk factors and perinatal outcome of meconium stained amniotic fluid. 79 jlmc.edu.np one hundred and eight patients had antenatal risk factors. hemoglobin was less than 11gm/dl in 28% cases. four cases had oligohydramnios, five were diabetic. fifteen developed pre-labor rupture of membrane (table 2). table 2. antenatal risk factors in cases of msaf. parameters frequency n (%) antenatal risk factors absent 94 (46.5) present 108 (53.46) anemia (hemoglobin<11 gm/dl) 57 (28) hdp 9 (4.45) prom>18 hours 15 (7.4) oligohydramnios 4 (2) diabetes mellitus-ii 5 (2.47) antepartum hemorrhage 5 (2.5) intrauterine growth restriction 10 (4.95) hepatitis b positive 2 (1) others 1 (0.49) prom: prelabor rupture of membranes table 3. clinical profile of babies with msaf. parameters n % gestation age in weeks 37-38 8 4 39-40 65 32 41-42 129 63.8 mode of delivery vaginal delivery 95 47 emergency lscs 78 38.6 elective lscs 4 2 vacuum delivery 18 8.9 forceps delivery 7 3.5 at birth vigorous 173 85.6 non vigorous 29 14.4 apgar score <4 at 1 min 13 6.4 <4 at 5 min 2 1 birth weight in kg <2.5 21 10.4 2-5-3.5 162 80.2 >3.5 19 9.4 sex male 100 49.5 female 102 50.5 table 4. resuscitation and respiratory support at birth. resuscitation at birth n % none 156 77.2 orogastric suction 11 5.5 endotracheal suction 13 6.4 bag and mask ventilation 17 8.4 endotracheal ventilation 6 3 more than one technique 4 2 respiratorysupport none 134 66.3 oxygen via head box/ nasal prongs 43 21.3 cpap* 22 10.9 mechanical ventilation 3 1.5 *continuous positive airway pressure one hundred and sixty-two deliveries had weight range group of 2.5-3.5 kg. one hundred and twenty-nine deliveries occurred at 41-42 weeks of gestation. ninety five women had vaginal deliveries while 78 had emergency lscs. seventy eight (38.6%) underwent emergency caesarean section. thirteen percent had instrumentation with vacuum or forceps. apgar score was more than 7 in 71.3% neonates at one minute and 94.6 neonates at five minutes. twenty three percent (n=46) babies required one or more forms of resuscitation at birth. thirty four percent (n=68) were put on respiratory support like oxygen via head-box/ nasal prongs, bubble cpap, or mechanical ventilation (table 4). one hundred and seventy-two (85.2%) babies delivered were healthy with no complications. pneumonia was seen in 19 babies and four had septicemia. three cases had expired (table 5). discussion: this study was conducted to find out the incidence and analyze the risk factors for msaf and mas. the incidence of msaf was 13.6% in our study and among those babies 14.8% developed mas. similar incidence has been reported in another study by dohbit js et al.,[5] with msaf being reported as 11.15% out of which 2.34% was mas. the reason for low mas in the study could be explained by the large sample size of more than 2000 babies. thirupathi ra et al.,[4] showed the j. lumbini. med. coll. vol 8, no 1, jan-june 2020 chhetri ud, et al. risk factors and perinatal outcome of meconium stained amniotic fluid. 80 jlmc.edu.np incidence of mas to be 13.12% while gurubacharya s et al.,[6] reported msaf and mas in 14.8% and 6.6% respectively. however addisu d et al.,[7] reported prevalence of msaf 17.8% among 495 mothers in felege hiwot referral hospital in north west ethiopia which is also a low-income country like nepal. table 5. final diagnosis of babies born through msaf their outcome. final diagnosis n % healthy babies without complications 172 85.2 mas with pneumonia 19 9.4 mas with septicemia 4 2 perinatal asphyxia with mas 3 1.5 mas with shock 2 1 mas with meconium gastritis 1 0.5 mas with pphn 1 0.5 outcomes discharged 197 97.5 expired 3 1.5 referred 1 0.5 left against medical advice 1 0.5 pphn: primary pulmonary hypertension. akhila s et al.,[8] in their study of 348 live births in india showed msaf in 7.13% cases. lamichane a[9] reported msaf in 7.72% and mas 12.20% in an 11 months study done in western part of nepal. this incidence is similar to ours as this institute is near to lmcth and women might have similar risk factors as they are hailing from the same rural locality. similarly, mohammad n et al.,[10] reported msaf 7.84% and mas 12% in a study in pakistan. the incidence of mas was 10/1000 live births in university hospital of west indies, jamaica in a retrospective study done over five years by panton et al.[11] although the exact cause of msaf is unclear; fetal distress, cord accidents and maternal hypertension have been identified as potential risk factors.[4] msaf was seen in 21% of teenage pregnancy in our study which is higher than the national figure of 17% in ndhs 2016 but equivalent to that of rural areas (22%).[4] the study site is also located in the a rural area so higher the rate of teenage pregnancy, higher would be the rate of msaf. sixty three percent of our mothers were primigravidae similar to the report of chaudhary r et al.[3] primigravida and/ or teenage pregnancy have increased risk of prolonged labor which in turn may increase the risk of msaf or mas.[3] on the other hand, the rate of teenage pregnancy might also depend on education status of mothers. antenatal visits have a role in counseling and explaining danger signs and identifying risk factors for msaf. seventy three percent of women with msaf had more than four antenatal visits which is similar to the national anc coverage data.[12] this study aimed to identify the risk factors for msaf. sixty four percent of mothers with msaf were between 41-42 weeks while the rest were between 37-40 weeks of gestation in our study. postdated pregnancy was seen in 30% in a study by panton et al.[11] there were no post term (>42 weeks) pregnancy in this study. this could be because women came to hospital in time and were more aware of pregnancy related complications and thus had less incidence of msaf. chaudhary r et al.,[3] in jhanshi reported that 59% of mothers with msaf were of 38-40 weeks of gestation. post term pregnancy increased the risk of mas. maternal risk factors for msaf in decreasing frequency were maternal age <25 years, post-dated pregnancy, anaemia, primipara, thick meconium, small for gestational age, prom, intrauterine growth restriction, hdp, antepartum hemorrhage, diabetes and oligohydramnios.[3] hdp with msaf is caused by underlying utero-placental insufficiency, which causes fetal hypoxia, resulting in passage of meconium, meconium aspiration, respiratory distress and its consequences.[2] similar risk factors have been mentioned in studies by chaudhary et al.,[3] dohbit et al.,[5] avula tr et al.[4] and gurubacharya s et al.[6] maternal anemia was present in 28.2% in our study which is higher than that of the study by chaudhary r et al.,(12.05%).[3] nepal has a high prevalence of anemia so this could be the reason for higher rate of anemia.[12] cesarean section (cs)was the mode of delivery in 40% cases. msaf is the risk for neonatal morbidities so increased cs rate is justifiable. chaudhary r et al.,[3] had 54.22% (n=45) of mas babies born via cs which is similar to this study. neonatal morbidities in our study in decreasing order of frequency were mas pneumonia followed by mas with culture positive septicemia, asphyxia and shock. one of the babies had mild j. lumbini. med. coll. vol 8, no 1, jan-june 2020 chhetri ud, et al. risk factors and perinatal outcome of meconium stained amniotic fluid. 81 jlmc.edu.np symptoms of vomiting and feed intolerance with meconium gastritis. one had significant preand post-ductal spo2 difference and echocardiography diagnosis of pphn. all of these signs and symptoms are the consequences of mas. similar morbidities like jaundice, pneumonia, birth asphyxia, and septicemia were reported in the study by chaudhary r et al.[3] neonatal resuscitation, neonatal asphyxia and neonatal infection were noted in the study by dohbit j s et al.[5]. low apgar, low birth weight, intrauterine growth restriction, immediate resuscitation, endotracheal suctioning, nursery admission and mas were seen in a study done in pakistan.[10]the study by panton l et al.[11] in west indies, jamaica reported morbidities like fetal distress, post dated pregnancy, emergency cesarean section, mechanical ventilation, bubble cpap, hypoxic ischemic encephalopathy (hie), pphn and pneumothorax. sixty eight (34%) of our neonates required respiratory support in the form of oxygen via headbox/ nasal prongs, bubble cpap and mechanical ventilation. avula tr et al.,[4] in their study in a tertiary health facility showed 42.85% of mas babies required ventilation support in the form of cpap and intermittent mandatory ventilation (imv). [4] mas babies requiring mechanical ventilation and bubble cpap were 6% and 15% respectively in the study by panton l et al.[11] bubble cpap and imv support were required in 6-15% in other studies done by edmond et al.,[13] and shaikh et al.[14] msaf is a threat to a neonatal life unless measures like close labour monitoring and timely interventions like emergency cs, effective neonatal resuscitation, nicu care and judicious management are given to save the life. low apgar scores at one and five minutes had association with thick meconium.[10] it was associated with fetal distress and mothers with hdp. in our study, mortality rate was 1.5%, which was similar to2.34% in another studydone in two hospitals in cameroon by dohbit js et al.[5] and 4.7% in the study by edmond mn et al.[13] mortality rates vary from minimum mortality at0.86% in a study done in maharasthra, india by akhila s et al.[8] to as high as11% to 24% in studies done by chaudhary r et al.,[3] thirupathi et al.[4] and gurubacharya s et al.[6]this difference could be due to the difference in sample size. the study with high number of study population have high incidence rate of msaf and high mortality rate. this study has a few limitations. it was conducted in a small population over a short time. the incidence of msaf and mas in relation to educational status and economical status of the mother was not studied but it forms a basis for prevalence of msaf and mas in a tertiary center in nepal. conclusion: meconium aspiration syndrome is a common complication of meconium stained amniotic fluid. it is a significant yet preventable cause of neonatal morbidity and mortality. identifying risk factors may help in timely diagnosis and interventions reducing the neonatal morbidity and mortality. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 chhetri ud, et al. risk factors and perinatal outcome of meconium stained amniotic fluid. 82 jlmc.edu.np references: 1. heather hb.meconium aspiration (429-434) in: john p clohartymanual of neonatal care 7th ed.; lippincott williams & wilkins 2016. 2. ghai, essential pediatrics 9th ed. vinod k paul, arvind bagga; cbs publishers & distributors pvt ltd. 3. chaudhary r, sethi rs, chaurasiya os, sethi as. study of meconium aspiration syndrome in relation to birth weight and gestational age. people’s journal of scientific research. 2018;11(2):16-21. available from: https://www. pjsr.org/201811/a3.pdf 4. avula tr, bollipo s, potharlanka s. meconium-stained amniotic fluid and meconium aspiration syndrome--a study on risk factors and neonatal outcome. journal of evolution of medical and dental sciences. 2017;6(70):4971-74. available from: https:// jemds.com/data_pdf/suneetha%20bollipo-a. pdf 5. dohbit js, mah em, essiben f, nzene em, meka eun, foumane p et al. maternal and fetal outcomes following labour at term in singleton pregnancies with meconium stained fluid: a prospective cohort study. open journal of obstetrics and gynecology. 2018;8(9):790-802. doi: https://doi. org/10.4236/ojog.2018.89082 6. gurubacharya s, rajbhandari s, gurung r, rai a, mishra m, sharma kr, et al. risk factors and outcome of neonates born through meconium stained amniotic fluid in a tertiary hospital of nepal. journal of nepal paediatric society. 2015;35(1):44-8. doi: https://doi.org/10.3126/jnps.v35i1.12171 7. addisu d, asres a, gedefaw g, asmer s. prevalence of meconium stained amniotic fluid and its associated factors among women who gave birth at term in felege hiwot comprehensive specialized referral hospital, north west ethiopia: a facility based cross-sectional study. bmc pregnancy childbirth. 2018;18(1):429. pmid: 30376814. doi: https://doi.org/10.1186/s12884-0182056-y 8. akhila s, koppad am, aundhakar cd. study of neonatal outcome in meconium stained amniotic fluid. international journal of medical and health research. 2018;4(3):134-38. available from: http://www.medicalsciencejournal.com/ download/804/4-3-23-196.pdf 9. lamichane a. clinical profile of neonates born through meconium stained amniotic fluidone year experience in a tertiary hospital of nepal. devdaha medical journal. 2018;1(1). 10. mohammad n, jamal t, sohaila a, ali sr. meconium stained liquor and its neonatal outcome. pak j med sci. 2018;34(6):139296. pmid: 30559791. doi: https://doi. org/10.12669/pjms.346.15349 11. panton l, trotman h. outcome of neonates with meconium aspiration syndrome at the university hospital of the west indies, jamaica: a resource-limited setting. american journal of perinatology. 2017;34(12):1250-54. available from: https:// www.thieme-connect.com/products/ejournals/ abstract/10.1055/s-0037-1603330 12. ministry of health, new era, icf. nepal demographic and health survey 2016. kathmandu, nepal: ministry of health. report number: fr336, 2017. available from: https:// dhsprogram.com/pubs/pdf/fr336/fr336.pdf 13. mesumbe en, nana pn, nouetchognou js, dohbit js, mah e, eko fe, et al. perinatal outcome in term pregnancies with meconium stained amniotic fluid in two referral hospitals of yaoundécameroon. journal of scientific & technical research. 2018;2(2):2533-2537. doi: http://dx.doi. org/10.26717/bjstr.2018.02.000736 14. shaikh em, mehmood s, shaikh ma. neonatal outcome in meconium stained amniotic fluid-one year experience. j pak med assoc. 2010;60(9):711-4. pmid: 21381573. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 maharjan n, et al. external ophthalmomyiasis by maharjan n, et al. external ophthalmomyiasis by oestrus ovisoestrus ovis: two case reports from nepal: two case reports from nepal jlmc.edu.np ___________________________________________________________________________________ submitted: 16 october, 2020 accepted: 15 march, 2021 published: 24 march, 2021 alecturer, department of microbiology bresident, department of ophthalmology cprofessor, department of ophthalmology, dlumbini medical college and teaching hospital, palpa, nepal. corresponding author: nabina maharjan e-mail: nabinamaharjan75@gmail.com orcid: https://orcid.org/0000-0003-1873-4646_______________________________________________________ abstract introduction: ophthalmomyiasis is an infestation of eye with larvae of dipteran flies most commonly by oestrus ovis (sheep nasal botfly). external ophthalmomyiasis in humans is a rare condition seen in people residing in rural areas and also living close to livestock. case report: we report two cases of external ophthalmomyiasis in 22 years old male and 38 years old female both having history of sudden onset of foreign body sensation and redness in left and right eyes respectively. conclusion: this external ophthalmomyiasis presenting nonspecific symptoms similar to acute conjunctivitis is the first case reported in nepal to the best of our knowledge. this report may aware all ophthalmologists about larval conjunctivitis preventing misdiagnosis. keywords: conjunctivitis; nepal; ophthalmomyiasis; oestrus ovis case reporthttps://doi.org/10.22502/jlmc.v9i1.407 nabina maharjan,a,d ashish jamarkattel,b,d bhagavat prasad nepal c,d external ophthalmomyiasis by oestrus ovis: two case reports from nepal how to cite this article:how to cite this article: maharjan n, jamarkattel a, nepal bp. external ophthalmomyiasis maharjan n, jamarkattel a, nepal bp. external ophthalmomyiasis by by oestrus ovisoestrus ovis: two case reports from nepal. journal of lumbini : two case reports from nepal. journal of lumbini medical college. 2021;9(1):4 pages. doi: medical college. 2021;9(1):4 pages. doi: https://doi.org/10.22502/ jlmc.v9i1.407. epub: 2021 march 24. epub: 2021 march 24. introduction: myiasis is an infestation of larval stage of dipteran flies in animals or humans.[1] the common sites are skin wounds, however nose, nasal sinuses, throat, eyes and urogenital tract are also infested.[2] oestrus ovis is an obligate parasite in nasal cavities of sheep and goat, whereas humans are accidental hosts.[3] oestrus ovis belong to class insecta, order diptera and family oestridae.[4] the adult fly looks like honey bee having yellow to grey brown color, 10-12 mm length.[3] this viviparous adult fly deposit newly hatched first stage larvae in nostril, conjunctiva and mouth of usual host like sheep, goat and horse.[5] this larva transforms from first stage larvae to third stage larvae in host and this third mature larvae get expelled down in ground and pupate in soil and adult fly emerge after 3-4 weeks that live for a month. in accidental host that is in human first stage larvae is incapable of developing beyond first stage and larva can live only for 10 days but within this period it can penetrate the sclera and reach the vitreous and retina causing severe panuveitis or endophtalmitis.[6] ophthalmomyiasis occurs in three forms namely external, internal and orbital. external ophthalmomyiasis refers to infestation of the lids or conjunctivae, whereas internal ophthalmomyiasis refers to intraocular infestation. orbital myiasis can also occur but is very rare.[7] external ophthalmomyiasis in humans is rare cosmopolitan disorder, mainly those residing in rural areas living close to livestock areas.[5] to the best of our knowledge no case reports have been published regarding oestrus ovis in nepal. we report here two cases of external ophthalmomyiasis in out patient department of ophthalmology at lumbini medical college and teaching hospital, palpa. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 maharjan n, et al. external ophthalmomyiasis by maharjan n, et al. external ophthalmomyiasis by oestrus ovisoestrus ovis: two case reports from nepal: two case reports from nepal jlmc.edu.np case report: case 1 a 22-year-old male presented to the outpatient clinic of ophthalmology with a chief complaint of sudden onset of foreign body sensation with associated redness, watering and intolerance to light in the left eye for one day. he tried splashing his eye with plain water frequently for symptomatic relief but to no avail. he had no history of trauma, other ocular and systemic illness. on examination, his visual acuity of both eyes were 6/6. both eyelids of left eye were mildly edematous. conjunctiva was diffusely congested with profuse watering. there were no follicles, discharge and pre-auricular lymphadenopathy. extraocular muscle movement was full. slit lamp examination revealed multiple tiny whitish 1.5 to 2 mm larva in lower forniceal conjunctiva initially. few were actively mobile wriggling on bulbar and forniceal conjunctiva and few were attached to conjunctiva by its black head. after application of 4% lignocaine drop 25 larvae were taken out and were sent to microbiology department in normal saline for identification. posterior segment evaluation was done by 90 dioptre lens in slit-lamp biomicroscope after dilatation of pupil by tropicamide 1%. fundus examination findings revealed no abnormality. right eye examination was normal. macroscopic examination revealed larva which measured 1.5 to 2 mm in length and had white slender body with black colored heads (fig. 1). microscopically, it had 11 segments (metamers), each segment with two to three rows of spines (fig. 2a). the cephalic end fig 1: white translucent larva of oestrus ovis on conjunctiva. had two large buccal hooks and caudal end had two tubercle each containing ten curved spines (figs. 2b and c). the patient was prescribed with ofloxacin and ketorolac eye drops to be applied to the affected eye four times daily. the patient’s signs and symptoms were markedly improved and no other larva were identified on further detailed examination in the follow up next day. fig 2: alarva of oestrus ovis larva (x 100). b-cephalic portion of oestrusnovis larva (x400) showing two black buccal hooks. c-posterior end of the larvae (x400) showing two tubercles and many curved spines. case 2 a 38-year-old female, presented to outpatient department of ophthalmology with history of sudden onset of foreign body sensation, redness, swelling of her eyelids of right eye for three days following insect sting while cutting grass at her field. her husband noticed mobile worms in her right eye and removed five worms at home but her symptoms were unalleviated. she had no other known ocular and systemic illness in the past. on examination, her visual acuity of both eyes was 6/6. both eyelids of right eye were mildly edematous. conjunctiva was diffusely congested and profuse watering. there were no follicles, discharge and pre-auricular lymphadenopathy. extraocular muscle movement was full. slit lamp examination revealed multiple tiny whitish larvae in lower bulbar and forniceal conjunctiva. few were actively mobile and few were attached to conjunctiva by its black j. lumbini. med. coll. vol 9, no 1, jan-june 2021 maharjan n, et al. external ophthalmomyiasis by maharjan n, et al. external ophthalmomyiasis by oestrus ovisoestrus ovis: two case reports from nepal: two case reports from nepal jlmc.edu.np head. after application of 4% lignocaine drop nine larvae were taken out and were sent to microbiology department in normal saline for identification. posterior segment evaluation was done by 90 dioptre lens in slit-lamp biomicroscope after dilatation of pupil by tropicamide 1%. fundus examination revealed no abnormality. examination of the left eye was normal. the patient was too prescribed with ofloxacin and ketorolac similar to the first case who showed improvement at next day follow up. discussion: we described herein two first reported cases of human external ophthalmomyasis caused by oestrus ovis (sheep nasal botfly) in nepal. based upon the morphological description the larvae were at the first stage of development in the present case. [2,5,8] the viviparous sheep botfly deposits larva in human eyes accidentally while flying. mostly larva is presented in external ocular surface where it holds in conjunctiva by its pointed hooks. this causes development of symptoms similar to acute conjunctivitis with itching, foreign body sensation and watering.[9] timely removal of all larvae from eye is the first step in treatment of external ophthalmomyiasis. irrigation of eye is not useful to remove larvae as it holds tightly to the conjunctival surface with its hooks. so they should be removed with the help of cotton swab and forceps on local anesthesia carefully. [8] in order to provide relief from symptoms and to prevent secondary infection, topical antibiotics along with anti-inflammatory drugs are prescribed. followup examination was recommended to avoid post treatment complications or recurrence.[3] oestrus ovis are not able to produce proteolytic enzymes so are unable to penetrate cornea or sclera.[9] however, external ophthalmomyiasis requires prompt management as it may lead to serious complications like corneal ulcer, decreased vision and invasion into eye globe causing endophthalmitis, iridocyclitis and even blindness.[2,9] these complicated conditions were not seen in our case as timely removal of larvae with proper treatment was provided promptly. both patients in the present study belonged to rural area, involved in agricultural activities and had a history of close contact with livestock. most of the other case studies also showed greater frequency of opthalmomyiasis among farmers and shepherds. [2] the patient in the first case had domesticated three buffaloes and three goats at his home, and was in close contact with them daily. the patient in the second case too had one buffalo, three cows and six goats at her home. oestrus ovis has three annual peaks in spring, summer and autumn.[5] in our study also the first case presented to us in may and the second case in august. many previous papers have also reported most of the external ophthalmomyiasis cases in spring and summer seasons.[2] conclusion: external ophthalmomyiasis by oestrus ovis are first reported cases in nepal. it is one of the differential diagnosis of conjunctivitis especially in rural area where people live very close contact with their livestock. misdiagnosis and delay in treatment may lead to many severe complications. all ophthalmologists should be very aware about this external ophthalmomyiasis to prevent its complications. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 maharjan n, et al. external ophthalmomyiasis by maharjan n, et al. external ophthalmomyiasis by oestrus ovisoestrus ovis: two case reports from nepal: two case reports from nepal jlmc.edu.np references: 1. atreya a, nepal s, bhattarai a, kanchan t. obligate myiasis: a case series from nepal. kathmandu univ med j (kumj). 2018;16(63):269-71. pmid: 31719320. 2. pandey a, madan m, asthana ak, das a, kumar s, jain k. external ophthalmomyiasis caused by oestrus ovis: a rare case report from india. korean j parasitol. 2009;47(1):57-9. pmid: 19290093. doi: https://doi.org/10.3347/ kjp.2009.47.1.57 3. abdellatif mz, elmazar hm, essa ab. oestrus ovis as a cause of red eye in aljabal algharbi, libya. middle east afr j ophthalmol. 2011;18(4):305-8. pmid: 22224020. doi: https://doi.org/10.4103/0974-9233.90133 4. zhang a, nie q, song j. external ophthalmomyiasis caused by oestrus ovis in east china. trop doct. 2018;48(2):169171. pmid: 29111870. doi: https://doi. org/10.1177/0049475517737456 5. basmaciyan l, gabrielle ph, valot s, sautour m, buisson jc, creuzot-garcher c, et al. oestrus ovis external ophtalmomyiasis: a case report in burgundy france. bmc ophthalmol. 2018;18(1):335. pmid: 30577838. doi: https:// doi.org/10.1186/s12886-018-1003-z 6. akdemir mo, ozen s. external ophthalmomyiasis caused by oestrus ovis misdiagnosed as bacterial conjunctivitis. trop doct. 2013;43(3):120-3. pmid: 23780871. doi: https://doi.org/10.1177/0049475513492153 7. albert dm, miller j. albert and jakobiec’s principles and practice of ophthalmology. 3rd ed. (4 volume set). elsevier inc; 2013. indian reprint isbn: 978-81-312-3542-3. 8. rao s, radhakrishnasetty n, chadalavada h, hiremath c. external ophthalmomyiasis by oestrus ovis: a case report from davangere. j lab physicians. 2018;10(1):116-117. pmid: 29403219. doi: https://doi.org/10.4103/jlp. jlp_18_17 9. dutta majumder p, jeswani p, jeyathilakan n, biswas j. external ophthalmomyiasis due to oestrus ovis. indian j ophthalmol. 2019;67(3):404-5. pmid: 30777968. doi: https://doi.org/10.4103/ijo.ijo_1391_18 perinatal outcome of deliveries after one previous caesarean section: a prospective study from mid-west hilly nepal narinder kaur,a,c sushila jainb,c —–————————————————————————————————————————————— abstract: introduction: contrary to the who recommended caesarean section (cs) rate of 15%, there is an alarming trend of increasing caesarean section rates. an important reason for this is repeat caesarean section (rcs). vaginal birth after caesarean (vbac) is one of the methods of reducing cs rates in women with history of previous cs. this study was done with the aim to see the maternal and fetal outcome among parturient with history of single previous caesarean section and to determine the rate of vbac at lumbini medical college, nepal. methods: this is a prospective study done for a period of ten months. seventy parturient fulfilling inclusion criteria of term pregnancy with single live fetus and history of one lower segment caesarean section (lscs) were enrolled in the study. patients meeting the criteria for vbac were given trial of labour and others were taken for elective repeat cs. this cohort was analyzed further, with respect to age, parity, period of gestation, mode of delivery, indication for cs, maternal and fetal complications and outcomes. results: vbac was successful in 27.14% of patients (n=19) while the rest 51 (72.85%) underwent rcs . indications for rcs was mainly scar tenderness 7 (13.7%), fetal distress 6 (11.7%), non progress of labour 6 (11.7%), meconium stained liquor 6 (11.7%) and post-dated pregnancy 6 (11.7%). maternal morbidity was comparable in women undergoing rcs or vbac. there was one still birth and one early neonatal death in each group due to complications of meconium aspiration. conclusion: patients with previous cs are at high risk of rcs. if trial of labor is allowed under careful patient selection and supervision, the rate of vaginal delivery after caesarean section can be increased safely. as there is no added perinatal morbidity and mortality in cases of vbac as compared to rcs, vbac shows the right way forward to decrease the rate of caesarean section. keywords: cesarean section • postpartum • repeat • trial of labor • vaginal birth —————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer b assistant professor c department of obstetrics and gynecology lumbini medical college teaching hospital corresponding author: dr. narinder kaur e-mail: drkaurnarinder@gmail.com how to cite this article: kaur n, jain s. perinatal outcome of deliveries after one previous caesarean section: a prospective study from mid-west hilly nepal. journal of lumbini medical college, 2015;3(1):19-22. doi: 10.22502/jlmc.v3i1.64 ___________________________________________________________________________________ j. lumbini. med. coll. vol 3, no 1, jan-june 2015 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v3i1.64 introduction: caesarean section (cs) is the most common surgery performed in modern obstetrics. originally it was performed for maternal indications, but is now frequently done for fetal indications.1 the cs rate has increased drastically over the past two decades. according to these global study reports, a higher rate of cs was associated with a greater risk of maternal and perinatal morbidity and mortality, compared to vaginal delivery.2,3 increasing numbers of primary cs have led to an increase in population with history of prior caesarean delivery. parturient with such history may be offered either planned vaginal birth after cesarean (vbac) or repeat cesarean section (rcs). it is hoped that by promoting vbac, the incidence of cs will be reduced. vaginal birth has less maternal and perinatal morbidity and mortality.2,3 cragin’s dictum “once a cs is always a cs” was a highly acceptable management guideline for the era when classical cs was the norm.4 now the dictum is “once a cs, always an institutional delivery”. therefore, recent clinical attention has focused on the role of trial of vaginal birth after 19 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 jlmc.edu.np kaur n. et al. perinatal outcome of deliveries after one previous caesarean section: a prospective study from mid-west hilly nepal. caesarean (vbac). most published series indicate a success rate of vbac between 60% to 80%.5-8 success is enhanced by careful patient selection prior to permitting vbac. ensuring integrity of the lower segment scar, adequacy of pelvis for safe passage of fetus, and ruling out a recurring cause is a must. oxytocin may be used judiciously, ensuring prevention of hyper stimulation. uterine dehiscence or rupture of uterine scar is the most serious complication of vbac. it is life threatening for both mother and fetus with an incidence of 0.5 1.5% for scar rupture.1 this study was done with the aim of determining the maternal and fetal outcome among parturient with history of single previous caesarean section and to determine the rate of vbac. methods: this prospective study was undertaken for a period of 10 months (august 2013 to may 2014) in the department of obstetrics and gynecology at lumbini medical college teaching hospital after approval from the ethical committee of the institute. parturient fulfilling inclusion criteria of term pregnancy with single live fetus and history of one previous lscs were enrolled in the study. patients with history of more than one previous lscs were taken for elective lscs and were not included in the study. the criteria for elective repeat caesarean section (rcs) were: birth spacing of less than 18 months, estimated fetal weight of more than four kgs on ultrasonography, postdated pregnancy, malpresentation, antepartum haemorrhage, presence of medical disorders, and recurrent indications like cephalopelvic disproportion. patients who did not have any of the above indications for rcs, were planned for vbac after informed consent. only those patients with spontaneous onset of labour were given a trial of labour after caesarean (tolac) but induction of labour was not done in any patients. all patients undergoing rcs or tolac were monitored throughout intrapartum or intraoperative period and upto 48 hours postpartum. this cohort was analyzed with respect to age, parity, period of gestation, mode of delivery, indication for previous cs and repeat cs, any intrapartum complications and maternal and fetal outcomes. data entry and analysis was done in spss 11. mean, standard deviation, percentage and pearsons chi-square test was used to analyze the data. p <0.05 was considered as significant. results during this period, there were 2851 deliveries, out of which 569 patients underwent caesarean section. thus the cs rate at this institute for the study period was 19.95%. seventy patients (2.45%) among the 2851 delivered had history of one previous cs which were included in this study. all patients had birth spacing of more than two years. most patients (n=62) were aged between 21 to 30 years which is the period of maximum fertility (table 1). the mean age was 24.84 years (sd=3.81). age in years n (%) <20 5 (7.1) 20 – 25 37 (52.8) 26 – 30 25 (35.71) 3135 2 (2.8) >35 1 (1.4) total 70 (100) mean age = 24.84 yrs, sd = 3.81 table 1. age distribution of women with one previous lscs sixty two women in this cohort were second gravidae with one living issue. remaining eight women were multipara with history of single cs performed for placenta previa, pregnancy induced hypertension and abnormal presentation. repeat cs (rcs) was done in 51 cases (72.85%). of these, 34 were emergency cs. spontaneous vaginal delivery (vbac) was achieved in 19 (27.14%) patients (table 2). two patients required vacuum delivery. mode of delivery n (%) repeat cs 51 (72.85) elective caesarean section 17 emergency caesarean section 34 vaginal birth after caesarean section 19 (27.14) assisted vaginal delivery (vacuum) 2 (2.85) total 72 (100) table 2. mode of delivery in women with one previous lscs fetal distress, breech presentation and nonprogress of labor were the main indications for cs in the previous pregnancy (table 3). repeat caesarean section was indicated mainly for scar tenderness, fetal distress, non progress of labour, and meconium stained liquor with oligohydramnios (table 4). 20 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 kaur n. et al. perinatal outcome of deliveries after one previous caesarean section: a prospective study from mid-west hilly nepal. jlmc.edu.np indication n (%) rcs vbac p breech presentation 12 (17.1) 7 5 x2=.33, p=.56 fetal distress 13 (18.5) 7 6 x2=.08, p=.78 non progress of labour 10 (14.2) 8 2 x2=3.6, p=.058 gestational hypertension 5 (7.1) 4 1 placenta praevia 4 (5.7) 4 0 premature rupture of membranes 4 (5.7) 3 1 cord prolapse 2 (2.8) 1 1 cephalopelvic disproportion 6 (8.5) 6 0 unknown 14 (20) 11 3 total 70 (100) 51 19 x2=14.63 p<.001 table 3. indication of previous caesarean section and mode of delivery in this pregnancy table 4. indications for repeat cs indications n (%) scar tenderness 7 (13.7) fetal distress 6 (11.7) meconium stained liquor with oligohydramnios 6 (11.7) non progress of labour 6 (11.7) post date pregnancy 6 (11.7) cephalo-pelvic disproportion 5 (9.8) premature rupture of membranes 4 (7.8) breech presentation 3 (5.8) gestational hypertension 3 (5.8) placenta praevia 3 (5.8) polyhydramnios 2 (3.9) total 51 (100) regarding the maternal outcome, there was postpartum haemorrhage in four patients who underwent rcs and in one patient who underwent vbac, controlled in both cases by uterotonic drugs and fresh blood transfusion. hospital stays of patients after rcs varied between 6 to 7 days. all patients who had vbac were discharged after 48 hours. none of the vbac group had scar tenderness or rupture. three patients, all in the vbac group, had puerperal pyrexia controlled by antibiotics. there were no maternal deaths. the neonatal outcome in women undergoing rcs and vbac is depicted in table 5. variables n (%) rcs vbac weight in grams <2500 12 (17.1) 6 6 2501-3500 48 (68.5) 37 11 >3500 10 (14.2) 8 2 nicu admissions 10 (14.2) meconium aspiration 6 1 5 presumed sepsis 4 2 2 still birth 1 (1.4) 1 0 neonatal death 1 (1.4) 0 1 table 5. neonatal outcome discussion: the past two decades have witnessed a tremendous increase in the use of caesarean delivery, which is one of the most important changes to have occurred in operative obstetrics, because of its safety, fewer hassles and elimination of exhaustive trials of labour. at its inception, cs was performed for maternal indications. in current practice, cs is performed mostly in the interest of the fetus.1 good nicu care has made it possible to salvage many preterm and small for date neonates. in present day obstetrics, avoidance of difficult instrumental delivery has also added to the rising rate of cs. cs on demand for neither medical nor obstetric causes is controversial, but continues to increase the number of cs. in our institute it is not encouraged. so, the increased rcs rate and need for vbac trial is essentially due to a rising primary cs rate. a study by indian council of medical research in 33 tertiary care institutions noted that average cs rate increased from 21.8% in 1993-1994 to 25.4% in 1998-1999.2 who recommends a cs rate of 15%. 2,3 the cs rate in our study was 19.95%. the difference was not statistically significant (x2[n=2851, df=1] =0.31, p=.31). vbac has been advocated as a safe and practical means of reducing the overall cs delivery rate. more than 20000 women with history of cs delivery undergoing a trial of labour have been studied with successful vaginal delivery rate ranging from 50% to 80%.1,5 the rate of vaginal delivery after one cs was 27.14% in our study, which is much less than international figures averaging 70%. a likely reason for this finding is that at our institution, tolac is given only in those patients who have spontaneous onset of labor. induction of labour is not done for patients with history of cs. 21 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 kaur n. et al. perinatal outcome of deliveries after one previous caesarean section: a prospective study from mid-west hilly nepal. jlmc.edu.np on 26th of october 1998, acog updated its guidelines concerning vbac. the committee on obstetrics, maternal and fetal medicine stated that "the concept of routine rcs birth should be replaced by specific indications for subsequent abdominal delivery, and in the absence of any contraindication, a woman with previous cesarean section (pcs) with low transverse incision should be counseled and encouraged to attempt labour in her current pregnancy".9 sing justin et al. have reported a rate of 6% for forceps delivery in women undergoing vbac and a rate of 5% for use of vacuum extractor.10 in our study two of the vbac cases required instrumental delivery. wing et al. have reported the risk of scar dehiscence to be greater in cases induced with misoprostol or oxytocin.11 at our institute, induction of labour is not done for patients with previous uterine surgery. trial of vbac is reserved for patients with spontaneous onset of labor, and judicious augmentation with oxytocin was done. therefore, there was no case with disruption of previous caesarean scar in our study. chances of success with tolac are greater if patient had prior vaginal delivery, prior birth after cs, spontaneous onset of labor, favorable cervix and non recurring cause.11 in our study, chances of vbac was high with birth weight less than 3.5kg, and with non recurring indication for previous lscs like fetal distress and breech presentation. conclusion: patients with previous cs are at high risk of rcs. if trial of labor is allowed under careful patient selection and supervision, the rate of vaginal delivery after caesarean section can be increased safely. as there is no added perinatal morbidity and mortality in cases of vbac as compared to rcs, vbac shows the right way forward to decrease the rate of caesarean section. references: 1. daftary sn, chakrawarty s. manual of obstetrics, updated edition of the classic holland & brews manual of obstetrics. 3rd ed. india: elsevier india; 2011, 596 p. 2. purandare cn. the over roofing rates of caesarean section. the journal of obstetrics and gynecology of india. 2011; 61(5): 501–2. 3. appropriate technology for birth. lancet.1985; 326 (8452), 436-37. [no authors listed] 4. sellappan s, sivanesaratnam v. operative obstetrics. 2nd ed. arulkumaran s, sivanesaratnam v, chatterjee a, kumar p. essentials of obstetrics. new delhi: jaypee; 2010. 449-56 p. 5. zelop cm, shipp td, repke jt, cohen a, coughey ab . am j obstet gynecol. 1991;181(2): 882-6. 6. leitch cr, walker jj. caesarean section rates. evaluate the reasons for surgery. bmj. 1994;308 (6921):133-4. 7. subedi s. rising rate of caesarean sectiona year review. journal of nobel medical college nepal. 2012:1(2):72-6. 8. cunningham fg, gant nf, leveno kj, gilstrap lc, hauth jc, wenstrom kd. cesarean section and postpartum hysterectomy. william’s obstetrics. 21st ed. new york: mcgraw hill; 2001. 882-86p. 9. joseph gf, stedman ca, robichaux ag. vaginal birth after caesarean section. the impact of patients’ resistance to a trial of labor. am j obstet gynecol. 1991;164:1441-7. 10. sing cw, halboob rk. audit on trends of vaginal delivery after one caesarean section. j obst and gynae. 2004;24:1358. 11. wing da, lovett k, paul rh. disruption of prior uterine incision following misoprostol for induction of labor in women with previous caesarean delivery. obst and gynecol. 1998;91:828-30. 22 endoscopic management of epistaxis in lumbini medical college anup acharya,a,d madan mohan singh,b,d arati shresthac,d —–————————————————————————————————————————————— abstract: introduction: epistaxis is one of the commonest ear nose throat (ent) emergency. proper guidelines for its management are lacking; on the other hand, the management is mostly done by the junior health service providers which has invited non-standardized practice of epistaxis management. thereby this study was much inclined towards assessment of the effectiveness of endoscopic management of epistaxis. methods: this prospective study included patients above 16 years who were diagnosed with idiopathic epistaxis visiting out patient of ent department or in the emergency department of lumbini medical college from 1st of july 2014 to 30th of june 2015. ent examination was done to find the cause and site of bleeding. thereafter different epistaxis management interventions were done depending on the bleeding condition. the data were collected, entered and then analyzed using spss version 21. the descriptive statistics were applied. results: of the total 116 patients, 53 (45.69%) were male and 63 (54.31%) were female showing no gender preponderance with epistaxis in our study. majority (49%) of the patients were managed with cauterization with silver nitrate or electrocautery in out-patient clinic. second most common (18%) procedure was endoscopic sphenopalatine artery cauterization. nasal packing was done only in three cases with zero posterior pack. conclusion: endoscopic intervention of epistaxis seems to be safe, simple, fast, and effective for the management of epistaxis with low rates of morbidity and complications. thereby it can be preferred over the conservative nasal packing and considered as immediate second-line management. keywords: electrocoagulation • epistaxis • ligation • packing • sphenopalatine ——————————————————————————————————————————————— ___________________________________________________________________________________ a assistant professor, b associate professor and head c medical officer d department of ent head and neck surgery lumbini medical college, palpa, nepal corresponding author: dr. anup acharya e-mail: anupent@gmail.com how to cite this article: acharya a, singh mm, shrestha a. endoscopic management of epistaxis in lumbini medical college. journal of lumbini medical college. 2015;3(2):38-40. doi: 10.22502/jlmc.v3i2.70 ___________________________________________________________________________________ j. lumbini. med. coll. vol 3, no 2, july-dec 2015 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v3i2.70 introduction: epistaxis is defined as bleeding from the nasal cavities. dry weather, use of alcohol, and use of nsaids have a proven association with epistaxis whereas hypertension and septal deviation do not. epistaxis, most commonly, occurs from the little’s area in the septum. there are various modalities of management of epistaxis namely medical, cauterization, nasal packing, hot water irrigation, septal surgery, endoscopic sphenopalatine artery ligation (espal) or cauterization, and embolization.1 epistaxis is the second most common cause of emergency admission to ent services. despite of such an important condition, there are no guidelines for management, and the most junior members are often the main caregiver resulting in several areas of controversy and non-standardised practices.2 the first step in general algorithm for the management of epistaxis is assessment and resuscitation. if the site of the bleeder is identified, it is cauterized chemically or electrically. if site is not found and there is no active bleeding, patient is observed with medical treatment. with active bleeding and site not found, nasal packing is applied. if epistaxis continues despite nasal packing, further management has to be done, which includes posterior nasal packing, endoscopic sphenopalatine artery ligation, embolization etc.3 nasal packing has been very commonly used for the management of epistaxis when bleeder is not identified on initial clinical examination. in 38 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 acharya a. et al. endoscopic management of epistaxis in lumbini medical college. jlmc.edu.np a study, at a setup similar to ours, nasal packing was done in about 60% of the cases admitted for epistaxis.4 nasal packing has been associated with many complications including pain and discomfort, swallowing difficulty, trauma to the structures while packing, pressure necrosis of the palate, alar or columellar skin, displacement with airway obstruction, sinus infection, synechia, otitis media, hypoxia, and toxic shock syndrome. packing also requires antibiotics to prevent development of sinus infection or toxic shock syndrome.2,5 conventionally, endoscopic intervention like espal was tried after failed or unsuccessful nasal packing.3,6 with widespread popularization of endoscopic sinus surgery and a greater understanding of nasal anatomy, endoscopic control of the sphenopalatine artery has been advocated as a desirable and effective alternative for the control of posterior epistaxis.7,8 espal is technically straightforward to perform, allows direct, secure ligation of the major vessel supplying the posterior nasal cavity, can be easily done under local anaesthesia in cooperative adults, avoids nasal packing, has an excellent patient tolerance, makes hospitalization if required much shorter, and has few side effects. the aim of this prospective study was to assess the effectiveness of endoscopic management in patients with epistaxis in whom bleeding site was not localized during initial clinical examination. methods: patients above 16 years of age coming to out patient of ent department or in the emergency department of lumbini medical college from 1st of july, 2014 to 30th of june, 2015 with diagnosis of idiopathic epistaxis were included in the study. on arrival, patients were assessed for airway, breathing, and circulation (abc). patients were resuscitated, if seemed necessary, with iv fluids while waiting for the investigation reports. ent examination was done to find the cause of bleeding. if nose was packed from the referral site, it was removed and examination done. nose was gently packed with cotton soaked in 4% lidocaine and 0.5% oxymetazoline for 20 minutes before examination to improve the visualization of the nasal cavities. if the bleeder was identified on initial examination, it was cauterized chemically with silver nitrate or with electrocautery. if the bleeder was not identified, patient was taken to operation theatre (ot) for rigid nasal endoscopy under local anaesthesia to identify the bleeder. severely deviated nasal septum (dns) hampering the visualization of posterior nasal cavity was corrected in the same setting under local anaesthesia. if the bleeder was identified, it was cauterized with electrocautery. if bleeder was still not identified even after thorough endoscopic nasal examination, endoscopic sphenopalatine artery cauterization was done on the side of epistaxis. we preferred local anaesthesia as it decreases the cost, does not require nil per oral status, reduces hospital stay, and avoids general anaesthesia related complications. general anaesthesia was reserved for uncooperative patients. three ml (3ml) of 2% lidocaine with 1:200,000 adrenaline was injected into the pterygopalatine fossa through greater palatine foramen to anesthetize the posterior part of nasal cavities. additional three ml of same solution was injected in the inferior and middle turbinates. then the espa cauterization was done. nasal packing was not done in these patients. the patients whose houses were nearby and could come anytime within 30 minutes in case of any problem occurred, were discharged after two hours of observation. patients undergoing general anaesthesia or septoplasty with postoperative nasal pack, were admitted for 48 hours. if patient developed bleeding from the same side in this period, anterior nasal packing was done. if epistaxis persisted posteriorly, posterior and anterior nasal packing was done and patient admitted in icu for continuous monitoring for 72 hours before packs were removed. results: there were a total of 116 patients included in the study. of those, 53 (45.69%) were male and 63 (54.31%) were female. chi-square goodness of fit test did not show a significant difference, x2(n=116, df=1) = 0.86, p = 0.35. thus, there was no gender preponderance with epistaxis in our study. the mean age of all the patients was 38.67 year (sd=11.29). management modality of the cases is shown in table 1. majority of the patients were managed with cauterization with silver nitrate or electrocautery in out-patient clinic. second most common procedure was endoscopic sphenopalatine artery cauterization. nasal packing was done only in three cases with zero posterior pack. 39 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 jlmc.edu.np acharya a. et al. endoscopic management of epistaxis in lumbini medical college. modality n (%) cauterization 57 (49.1) spa cauterization 21 (18.1) endoscopic cauterization 11 (9.5) anterior nasal pack 3 (2.6) posterior nasal pack 0 no bleeder was identified and patient refused further treatment 24 (116) table 1: management modality of epistaxis (n = 116) discussion: in our study, there was no gender preponderance to epistaxis. studies in different places of our country, however, showed male preponderance to this condition.4,9 we are unable to explain the cause of this difference. half (49.14%) of the patients with epistaxis could be managed in opd by cauterization of visible bleeder. this emphasize the fact that a careful and meticulous clinical examination of the nose, of a patient with epistaxis, is necessary to reduce further unnecessary investigation and procedures. in our experience, preparation of the nose with 4% lidocaine solution mixed with 0.5% oxymetazoline for 20 minutes improves the visualization of the nasal cavities. traditionally, for the treatment of epistaxis, if the bleeder is not identified during clinical examination, and there is active bleeding from the nose, nasal packing is done. this makes nasal packing one of a common treatment option of epistaxis despite its several complications. in a study, 10 years back, in one of the biggest hospital of our country, 60% of epistaxis were managed by nasal pack and only 2% were managed by arterial ligation.4 even in ninewells hospital in united kingdom, nasal packing is done before endoscopic intervention.10 in our study we prevented nasal packing as a procedure for treatment of epistaxis to an absolute minimum i.e. three (2.6%), thus reducing all the complications and discomfort related to nasal packing. these three cases had to be packed as there was active bleeding and operation room was not available for next few hours. there was no case of rebleed after spa cauterization. three out of 21 cases of shpenopalatine artery cauterization had to be done under general anaesthesia due to poor cooperation of the patients. two of the 24 patients who did not have active bleeding at the time of initial evaluation and refused further procedure returned with rebleed. one was managed with endoscopic cauterization of a bleeding vessel in the posterior part of septum, the other underwent spa cauterization under local anaesthesia. both were discharged the same day. the current study emphasizes on the early assessment of nasal cavities with endoscopes to localize bleeders and cauterize them. in case the bleeder is not found, sphenopalatine artery can be cauterized or ligated at the same setting. widespread popularization and easy availability of nasal endoscopes, greater understanding of nasal anatomy, relative ease of endoscopic control of the sphenopalatine artery etc. has brought up this procedure in the hierarchy of treatment of epistaxis.7 conclusion: endoscopic management of epistaxis is an effective method of treatment of epistaxis. it should be preferred to nasal packing due to its effectiveness, less adverse effects, less hospital stay, and direct and secure ligation of the major vessels. references: 1. mcgarry gw. epistaxis. in: gleeson m, browning gg, burton mj, clarke r, hibbrt j, jones ns, et. al. (eds). scott brown’s otorhinolaryngology, head and neck surgery (7 ed). hodder arnold, london. p.1596-1608. 2. spielmann pm, barnes ml, white ps. controversies in the specialist management of adult epistaxis: an evidencebased review. clin otolaryngol. 2012 oct;37(5):382–9. 3. barnes ml, spielmann pm, white ps. epistaxis: a contemporary evidence-based approach. in: smith tl(ed). evidence based clinical practice in otolaryngology. uk. p.925-1202. 4. adhikari p, pradhananga rb, thapa nm, sinha bk. aetiology and management of epistaxis at tu teaching hospital. j inst med. 2006;28(2):2-4. 5. paul j, kanotra sp, kanotra s. endoscopic management of posterior epistaxis. indian j otolaryngol head neck surg. 2011;63(2):141-4. doi 10.1007/s12070-010-0054-0 6. pritikin jb, caldarelli dd, panje wr. endoscopic ligation of the internal maxillary artery for treatment of intractable posterior epistaxis. ann otol rhinol laryngol. 1998 feb;107(2):85-91. 7. shah ag, stachler rj, krouse jh. endoscopic ligation of the sphenopalatine artery as a primary management of severe posterior epistaxis in patients with coagulopathy. ear nose throat j. 2005 may;84(5):296-7. 8. abdelkader m, leong sc, white ps. endoscopic control of the sphenopalatine artery for epistaxis: long-term results. j laryngol otol. 2007;121:759-62. doi:10.1017/ s0022215106003379. 9. bhatta r. clinical profile of idiopathic epistaxis in a hospital. j nepal med assoc. 2012 oct-dec;52(188):167-71. 10. barnes ml, spielmann pm, white ps. epistaxis: a contemporary evidence based approach. otolaryngol clin north am. 2012 oct;45(5):1005-17. doi: 10.1016/j. otc.2012.06.018. 40 contributing factors for perceived satisfaction with nursing care among inpatients in general wards mamta koirala,a mohan laxmi koiralab —–————————————————————————————————————————————— abstract: introduction: patients' perceived satisfaction with quality of care may affects health outcomes. patients who are satisfied with their nursing care are more likely to follow treatment and consequently to have better health outcomes. it encourages them to behave in a healthy way after discharge, and positive rating of service quality seems to be correlated with no hesitation about revisiting the same hospital ward in time of need. this study was done to identify the contributing factors for perceived satisfaction with nursing care among inpatients in general wards in lumbini medical college. methods: a descriptive cross sectional study was conducted in lumbini medical college teaching hospital throughout the month of august, 2015. a total of 60 heterogeneous study population from three different wards (medical, surgical, and orthopedics), who gave consent for participation, were included using non-probability convenient sampling technique. nepalese version of newcastle satisfaction with nursing scale (nsns) was used to measure the satisfaction score. results: there were a total of 60 respondents with mean age of 30.08 years (sd= 9.72). male, duration of hospital stay, and number of hospital stay had a significant relation with the satisfaction score when calculated individually. however, the relationship was not significant when adjusted for other variables by linear regression. conclusion: majority of respondents were satisfied with the quality of nursing care. male, duration of hospital stay, and number of hospital admission had a significant relation with the satisfaction score when calculated individually. the nurses should know the factors influencing patients' satisfaction and work on those to improve the quality of nursing care. keywords: patient satisfaction • nursing care • quality of health care • inpatients ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, college of nursing lumbini medical college teaching hospital, palpa, nepal b nursing officer, united mission hospital, palpa, nepal corresponding author: mamta koirala e-mail: koirala.mamta10@gmail.com how to cite this article: koirala m, koirala ml. contributing factors for perceived satisfaction with nursing care among inpatients in general wards. journal of lumbini medical college. 2015;3(2):34-7. doi: 10.22502/jlmc. v3i2.69 ___________________________________________________________________________________ j. lumbini. med. coll. vol 3, no 2, july-dec 2015 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v3i2.69 introduction: there has been increasing interest in patients' satisfaction with nursing care in the past few decades. patient satisfaction with nursing care is considered an important factor in explaining patients' perceptions of service quality.1 patient satisfaction has been used as an indicator of quality services provided by health care personnel. the most important predictor of patients' overall satisfaction with hospital care is particularly related to their satisfaction with nursing care. patient satisfaction is defined as the extent of the resemblance between the expected quality of care and the actual received care.2,3 patient satisfaction is defined as the extent of the resemblance between the expected quality of care and the actual received care. patient satisfaction with nursing care is important for any health care agency because nurses comprise the majority of health care providers and they provide care for patients 24 hours a day.4-7 patients' satisfaction is now a critical variable in any calculation of quality or value and therefore in the assessment of corporate/individual accountability. it is a legitimate and important measure of quality of care.6,8,9 health care providers in developing countries seem to be ignoring the importance of patients' perceptions of health services.10 thus, a scarcity of literature made it difficult to find studies 34 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 koirala m. et al. contributing factors for perceived satisfaction with nursing care. jlmc.edu.np examining patients' satisfaction with nursing care in developing countries. quality of health care in developing countries usually is defined by health care providers from technical perspective. recent literature however, emphasizes the importance of patients' perspective in assessing quality of health care.10 it’s the patient’s perspective that increasingly is being viewed as a meaningful indicator of health services quality and may, in fact, represent the most important perspective.11 this study was done to identify the contributing factors for perceived satisfaction with nursing care among inpatients in general wards of lumbini medical college teaching hospital, a 700 bedded referral centre in a developing country. methods: a descriptive cross sectional study was conducted in lumbini medical college teaching hospital throughout the month of august, 2015. a total of 60 inpatients from three different departments (medical, surgical, and orthopedics), who gave consent for participation and spent over night or more in the hospital wards were included using non-probability convenient sampling technique. newcastle satisfaction with nursing scale (nsns) was translated into its nepalese version by repeated forward and backward translation till a panel of expert in medical college was satisfied by the results.5,12 pretesting was done by another panel of expert from the nursing department. this scale consists of 19 items and each item was to be scored on a five point likert scale ranging from "very unsatisfied" carrying a value of one to "very satisfied" carrying a value of five. all the respondents were detailed about the nature and objective of the study and they were insured confidentiality of the information and also were allowed to leave any questions unanswered, if they had any doubts or were uncomfortable. then, they were asked to rate their degree of satisfaction on the scale. demographic data were collected in the same setting. data were entered into microsoft excel 2013 and then analyzed with spss 21. results was presented as mean, standard deviation, frequency and percentage. mean between variables was analyzed with t-test and correlation with karl pearson correlation coefficient. linear regression was applied to evaluate relationship between variables adjusted for other variables. results: there were a total of 60 respondents with a mean age of 30.08 yr (sd=9.72). mean age of male was 31.06 yr (sd=10.35) and female was 28.89 yr (sd=8.93) and the difference was not significant (t=0.86, df=58, p=0.4). majority of them (n=24, 40%) were of age group of 30 to 40 years. a pearson correlation coefficient was calculated for the relationship between participants age and satisfaction score. a weak negative correlation was found (r = -0.27, p=0.04) indicating a significant linear relationship between the two variables. younger patients tend to be more satisfied with the nursing care. there were 33 (55%) male and 27 (45%) female with m:f ratio of 1.22:1. the mean score of satisfaction in male was 3.16 (sd=0.11) and in female was 3.15 (sd=0.13) and this difference was not significant (t=0.3, df=58, p=0.76). there were 44 (73.3%) literate participants and the remaining 16 (26.7%) were illiterate. the mean score of satisfaction in literate was 3.14 (sd=0.11) and in illiterate was 3.19 (sd=0.13). this difference was not significant (t=1.48, df=58, p=0.15) mean hospital stay of the patients was 2.07 days (sd=3.1) with range of one to nine days. correlation between days of hospital stay and satisfaction score showed a negative significant linear relationship (r = -0.32, p=0.01). patients who stayed longer in hospital tend to be less satisfied with the nursing care. other results are shown in table 1. multi-linear regression was applied to estimate the relationship between several respondents' variables n (%) age 10 to 20 years 9 (15%) 21 to 30 years 22 (36.7) 31 to 40 years 24 (40%) >40 years 5 (8.3%) duration of hospitalization at lmcth <2 days 10 (16.7%) 2 7 days 36 (60%) >7 days 14 (23.3%) number of hospital admission 1st admission 46 (76.7%) 2nd or more admission 14 (23.3%) table 1: some variables of the respondents. 35 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 jlmc.edu.np koirala m. et al. contributing factors for perceived satisfaction with nursing care. independent variables with satisfaction score. relationship between none of the variables was statistically significant with the satisfaction score when adjusted for other variables. the result is shown in table 2. variables adjusted coefficient p age -0.002 0.38 gender male reference female -0.011 0.72 education illiterate reference literate -0.058 0.08 hospital stay -0.031 0.26 number of admission first reference reference second or more 0.038 0.15 table 2: adjusted coefficient of regression analysis discussion : patients' satisfaction is an important quality outcome indicator of health care in the hospital setting. the measurement of patients' satisfaction with nursing is particularly important since nursing service is often a primary determinant of overall satisfaction during a hospital stay.13 moreover, satisfied patients usually trust their health care providers, and as a return they comply with medical and nursing orders. eventually the patients' healing process is enhanced and at the same time, they disseminate their experiences to others which increase the number of patients who uses the services. if not satisfied, the opposite may happen.14 the finding of our study is in consistent with study done by jafar a. et al. in jordan and almost identical to another study done by amerbyoun a. et al. in iranian military hospitals.15,16 majority of the respondents (n=24, 40%) in our study were of age group 30 to 40 yr which is similar to the findings in other studies including the study conducted by thulung bk. et al. in tribhuwan university teaching hospital, kathmandu, nepal.15-18 while there was no significant correlation between gender and patient satisfaction in a study by wallin et al.,18 similar to our finding, another study by ottosson et al. reported higher satisfaction among male than female.19 moreover, these findings were also similar to that of mustard et al. who worked for improving patients' satisfaction through the consistent use of scripting by the nursing staff and pointed out that demographic characteristics such as sex and race seem to be unimportant.20 present study reveals that there is no significant relation between the education status of patients and their satisfaction score in contrast to that by wallin et al. who reported that less educated patients had higher satisfaction.18 in that study, 87% of respondents, who were illiterate, were fully satisfied compared to 56% who had diploma and above. this finding is also similar to the study by quinn et al. in which less educated patients tended to have higher satisfaction than the patients with higher education.21 in a study by wallin et al.,18 majority (66.7%) of respondents who had not had a history of previous hospital admission were fully satisfied compared to 10% of those who were admitted previously at least once to hospital. in our study, we found comparable satisfaction score in these two group of patients. conclusion: this study highlights the contributing factors that influence the patient's satisfaction with nursing care among inpatients. male, duration of hospital stay, and number of hospital stay had a significant relation with the satisfaction score when calculated individually. the nurses should know the factors influencing patients' satisfaction and work on those to improve the quality of nursing care. references: 1. comley al, demeyer e. assessing patient satisfaction with pain management through a continuous quality improvement effort. j pain symptom manage. 2001;21(1):27-40. 2. needleman j, buerhans p, mattke s, stewart m, zelevinsky k. nurse-staffing levels and the quality of care in hospitals. n engl j med. 2002;346(22):1715-22. 3. wagner d, bear m. patient satisfaction with nursing care: a concept analysis within a nursing framework. j adv nurs. 2009;65(3):692-701. doi: 10.1111/j.13652648.2008.04866.x. 4. aiken lh, clarke sp, sloane dm, sochalski j, silber jh. hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. jama. 2002;288(16):1987-93. 5. walsh m, walsh a. measuring patient satisfaction with nursing care: experience of using the newcastle satisfaction with nursing scale. j adv nurs. 1999;29(2);307-15. 36 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 koirala m. et al. contributing factors for perceived satisfaction with nursing care. jlmc.edu.np 6. lari ma, tamburini m, gray d. patients' needs, satisfaction, and health related quality of life: towards a comprehensive model. health qual life outcomes. 2004;2:32. doi: 10.1186/1477-7525-2-32. 7. crow r, gage h, hampson s, hart j, kimber a, storey l, et al. the measurement of satisfaction with healthcare: implications for practice from a systematic review of the literature. health technol assess. 2002;6(32):1-244. 8. delbanco tl. quality of care through the patient’s eyes. bmj. 1996;313(7061):832-33. 9. mcgee hm. patient satisfaction surveys: are they useful as indicators of quality of care? j health gain. 1998;2:5-8. 10. andaleeb ss. service quality perceptions and patient satisfaction: a study of hospitals in a developing country. soc sci med. 2001;52(9):1359-70. 11. o’connor sj, shewchuk rm, carney lw. the great gap. physician’s perceptions of patient service quality expectation fall short of reality. ,j health care mark. 1994;14(2):32-9. 12. mccoll e, thomas l, bond s. a study to determine patients’ satisfaction with nursing care. nurs stand. 1996;10(52):348. 13. fleischer s, berg a, zimmermann m, wüste k, behrens j. nursepatient interaction and communication: a systematic literature review. j public health. 2009;17(5):33953. doi:10.1007/s10389-008-0238-1. 14. dahlberg k, todres l, galvin k. lifeworld-led healthcare is more than patient-led care: an existential view of well being. med health care philos; 2009;12(3): 265–271. doi: 10.1007/s11019-008-9174-7. 15. alhusban ma, abualrub rf. patients’ satisfaction with nursing care in jordan. j nurs manag. 2009;17(6):746-58. doi: 10.1111/j.1365-2834.2008.00927.x. 16. ameryoun a, pourtaghi g, yahaghi e, heidari s, bahadori m, ebrahimnia m, et al. outpatient and inpatients services satisfaction in iranian military hospitals. iran red crescent med j. 2013;15(9);843-7. doi: 10.5812/ircmj.12665. 17. gupta bs, shrestha s, thulung bk. patient's perception towards quality nursing care .j nepal health res counc. 2014;12(27):83-7. 18. wallin e, lundgren po, ulander k. and holstein cs. does age, gender or educational background effect patient satisfaction with short stay surgery? 2000;8(2):79-88. 19. ottosson b, hallberg ir, axelsson k, loven l. patients’ satisfaction with surgical care impaired by cuts in expenditure and after interventions to improve nursing care at a surgical clinic. int j qual health care. 1997;9(1):43-53. 20. mustard lw. improving patient satisfaction through the consistent use of scripting by the nursing staff. jonas healthc law ethics regul. 2003;5(3)68-72. 21. quinn gp, jacobsen pb, albrecht tl, ellison ba, newman nw, bell m, et al. real-time patient satisfaction survey and improvement process. hosp top. 2004;82(3): 26-32. 37 lmc journal vol. 2.indd 86 ear nose throat (ent) disorders in government schools of far-western nepal acharya a1, singh mm1, shrestha a1 and pokharel b2 1department of ent head & neck surgery, 2school of nursing, lumbini medical college (lmc), tansen, palpa, nepal corresponding author: dr. acharya anup, lecturer, department of ent head & neck surgery, lumbini medical college (lmc), tansen, palpa, nepal; email: anupent@gmail.com, anupent@outlook.com. abstract background: ent disorders specially hearing impairment nega vely impacts students’ development of academic, language and social skills. if le undiagnosed, these condi ons may result in signifi cant irreversible damage such as varying degree of hearing loss that can aff ect the social or professional performance of the individuals in later stages of life. students going to government school in our country generally come from under privileged society. we inves gated the occurrence of ent diseases among various government school students in kailali district. methods: nine government school of kailai district were chosen at random. all students of those school present on the day of examina on went rou ne ent examina ons. brief history, if any, was recorded and fi ndings were noted. the study was done throughout the month of september, 2013. results: there were a total of 2256 students enrolled in the study. there were 1126 male and 1130 female students. mean age of the students was 9.88 years. forty one percent of students had ent problems. ear wax was the most common (17%) fi ndings followed by suppura ve ear diseases, o s media with eff usion as so on in decreasing frequency. conclusions: ent diseases and specially ear diseases are important health problems among school children of nepal. regular school health services, screening program, public awareness, improvement of socioeconomic status, mely referral to a specialist doctor can help to reduce the diseaserelated burden. introduction ent diseases may cause life-long or sometimes life-threatening problems. congenital or acquired hearing impairment hinders students’ development of academic, language and social skills.1 chronic o s media is an infl ammatory process of the middle ear and mastoid cavity, which may be related to several condi ons such as cholesteatoma and o s media with eff usion (ome) etc. it mostly presents with a tympanic membrane (tm) abnormality, like perforation or retrac on, and suppura ve discharge noted in the external ear canal. due to its insidious progress and irreversible damage, the disease is an important pediatric health topic especially in developing or underdeveloped countries.2 hearing loss is considered to be the main health issue that aff ects quality of life, aff ec ng approximately one-third of these popula ons. the world health report (1997) described hearing impairment as ‘a serious problem in young children because it retards language development and school progress, both of which have a signifi cant impact in later life’.3 school health program is an important aspect of any community health program. school health services provide an ideal pla orm to detect the health problems early and treat them.4 about 42% of the total popula on are children below the age of 16.5 there are no reliable data on the current prevalence of ent disorders in school children. there are few studies in nepal targe ng hospital based children or a certain disease only.6,7,8,9 the main goal of the current study was to determine the occurrence of ent disorders among schoolchildren in a district of far-west nepal. methods it was a cross-sec onal descrip ve study. the study was done throughout the month of september, 2013. nine government school of kailali district were chosen at random. all the students of those school present on the day of examina on were included in the study. a brief history, if any, was taken. general ent examina on was done. age, sex, complains, fi ndings and diagnosis were recorded. medical advice and counselling were given to those having posi ve fi ndings. prior to the study, consents were obtained from the principals or head-master of the schools, and families of the students. the occurrence was calculated by dividing the number of the students with posi ve fi nding by the total number of students and 95% confi dence interval (ci) was used. statistical analysis of the data was done using the sta s cal package for the social sciences (spss-17) program. results with a p value <0.05 were considered signifi cant. original article l m coll j 2013; 1(2): 86-88 87 table-1: age characteris cs of the students. total students 2256 minimum age 4 years maximum age 16 years mean age 9.88 years std. devia on 2.484 table 2: diagnosis with their frequencies sex total f m diagnosis 0 698 635 1333 1 432 491 923 total 1130 1126 2256 chi-square= 6.742, p= 0.009 table 3: diagnosis * sex crosstabula on condi on frequency percent normal 1333 59.0 wax 391 17.3 csom 138 6.1 ome 126 5.6 et dysfunc on 39 1.7 derma s pinna 33 1.5 o ts externs 33 1.5 csom as 31 1.4 otomycosis 17 .8 allergic rhini s 12 .5 aom 12 .5 ur 12 .5 epistaxis 9 .4 infected lobule 9 .4 chronic nasal ves buli s 7 .3 acute pharyngi s 6 .3 crs 6 .3 perichondri s 6 .3 asom 5 .2 chronic laryngi s 5 .2 dns 5 .2 fb ear 3 .1 post auricular lylmphadeni s 3 .1 pre auricular lymphadeni s 3 .1 acute nasal ves buli s 2 .1 chronic allergic pharyngi s 2 .1 pre auricular sinus (infected) 2 .1 suppura ve cervical lymphadeni s 2 .1 viral paro s 2 .1 cheek celluli s 1 .0 neck abscess (superfi cial) 1 .0 total 2256 100.0 results there were a total of 2256 students enrolled in the study. their age was as shown in table 1. there were 1126 male and 1130 female students with m:f ra o of 0.9964:1. of total, 1332 (59%) students had normal ent fi ndings. the rest 41% had posi ve fi ndings. the diagnosis based on the fi ndings are shown in table 2. it shows ear wax was the most common fi ndings (17.3%) in the school students. it was followed by chronic suppura ve o s media, tubotympanic variety (csom-tt), o s media with eff usion etc. in descending frequencies. rela onship between sex and normalcy was compared by chi-square test as shown in table 3. it showed males had signifi cantly more diseases than the females (p=0.009). discussion our study showed almost equal male and female students. in a study by adhikari p, there were nearly twice the number of male students than that of females.9 we found in the fi eld that there were various ngos working for the children, women and other classes of people. maybe it was due to these organiza ons that the a endance of female children were higher than in other studies. we have found that 41% of students had one or another ent diseases. it was higher than a study by maharjan m. et al which showed 33% of the school students had ent problems.6 ear wax was the most common diagnosis comprising of 17.3% of the total school popula on. wax was the most common diagnosis in many studies in our country and abroad.9,10,11,12 it was followed by csom-tt and ome. there has been a lot of studies showing ome as a major cause of hearing loss in children.6,9,12,13,14 there were 169 (7.5%) cases of csom of which 18.3 percent were a coantral variety. the occurrence of csom is comparable to a study done in bangladesh, but the a co-antral variety in our study is much higher.15 a co-antral csom has to be managed at earliest by surgical method due to high incidence of complica ons in this variety. there were 74 (3.28%) cases of non otogenic diseases comprising mainly of allergic rhini s, chronic rhinosinusi s, acute and chronic pharyngi s. there are very few studies which takes into account of non otogenic diseases in addi on to the ear diseases. we have found that the most common diseases are those which gives rise to hearing loss in children. adequate hearing is one of the main factors for good psychosocial development, by which individuals may express their thoughts, feelings, and wishes, and acquire life experience and knowledge. children require normal hearing or adequately corrected hearing to facilitate the formal educa on. conclusion ent diseases and specially ear diseases are important health problems among school children of nepal. regular school health services, screening program, public awareness, improvement of socioeconomic status, mely referral to a specialist doctor can help to reduce the disease-related burden. a acharya et al 88 journal of lumbini medical college references 1. khairi md daud m, noor rm, rahman na, sidek ds, mohamad a: the eff ect of mild hearing loss on academic performance in primary school children. int j pediatr otorhinolaryngol 2010; 74(1): 67-70. 2. gates ga, klein jo, lim dj, mogi g, ogra pl, pararella mm, paradise jl, tos m. recent advances in o s media. 1. defi ni ons, terminology, and classifi ca on of o s media. ann otol rhinol laryngol suppl. 2002; 188: 8-18. 3. the world health report 1997 – conquering suff ering, enriching humanity. world health forum 1997; 18(3-4): 248-60. 4. unicef, 2002. http://www.unicef.org/infobycountry/ nepal_sta s cs.html. 5. ministry of educa on and sports (moes), 2001, educa on informa on of nepal, moes, kathmandu, nepal. 6. maharjan m, bhandari s, singh i, mishra sc. prevalence of o s media in school going children in eastern nepal. kathmandu univ med j 2006; 4(4): 479-82. 7. rijal as, joshi rr, regmi s, malla ns, dhungana a, jha ak, rijal jp. ear diseases in children presen ng at nepal medical college teaching hospital. nepal med coll j 2011; 13(3): 164-8. 8. pandey s, dudani i, pradhan a. health profi le of school children in bhaktapur. kathmandu univ med j 2005; 3(3): 274-280. 9. adhikari p. pa ern of ear diseases in rural school children: experiences of free health camps in nepal. int j pediatr otorhinolaryngol 2009; 73: 1278-80. 10. nogueira jc, mendonça mda c. assessment of hearing in a municipal public school student popula on. braz j otorhinolaryngol 2011; 77(6): 716-20. 11. absalan a, pirasteh i, dash khavidaki ga, asemi rad a, nasr esfahani aa, nilforoush mh. a prevalence study of hearing loss among primary school children in the south east of iran. int j otolaryngol 2013; 2013: 138935. 12. chadha sk, sayal a, malhotra v, agarwal ak. prevalence of preventable ear disorders in over 15000 schoolchildren in northern india. j laryngol otol 2013; 127(1): 28-32. 13. mahadevan m, navarro-locsin g, tan hk, yamanaka n, sonsuwan n, wang pc, dung nt, restu rd, hashim ss, vijayasekaran s. a review of the burden of disease due to otitis media in the asia-pacific. int j pediatr otorhinolaryngol 2012; 76(5): 623-35. 14. chen y, li x, xu z, li z, zhang p, he y, wang f, qiu j. ear diseases among secondary school students in xi’an, china: the role of portable audio device use, insomnia and academic stress. bmc public health. 2011; 11: 445. 15. shaheen mm, raquib a, ahmad sm. prevalence and associated socio-demographic factors of chronic suppura ve o s media among rural primary school children of bangladesh. int j pediatr otorhinolaryngol 2012; 76(8): 1201-4. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 pokharel m, et al. a ten-year retrospective study of nasal bone fractures at a tertiary care hospital of nepal jlmc.edu.np ___________________________________________________________________________________ submitted: 24 march, 2021 accepted: 03 june, 2021 published: 20 june, 2021 aassociate professor, department of otorhinolaryngology and hns bassociate professor, department of radiodiagnosis and imaging cassistant professor, department of otorhinolaryngology and hns dlecturer, department of otorhinolaryngology and hns emedical officer, department of otorhinolaryngology and hns fkathmandu university school of medical sciences, dhulikhel hospital, dhulikhel, kavre, nepal. corresponding author: monika pokharel e-mail: monikapokharel2020@gmail.com orcid: https://orcid.org/0000-0002-9298-5534_______________________________________________________ abstract: introduction: nasal bone fracture occurs due to its vulnerable position and reduced biomechanical resistance to traumas. if not timely treated, it can result in permanent functional and esthetic damage. methods: a retrospective and cross-sectional study conducted in 91 patients above 17 years of age with nasal bone fractures in the department of otorhinolaryngology and head and neck surgery of a tertiary care hospital in kavre. results: road traffic accident was the most common cause of fracture (45.1%) followed by fall (36.3%), violence (13.2%), sports related accidents (4.4%) and occupational accidents (1.1%). class i fracture was seen in 70 (76.9%), class ii in 17 (18.7%) and class iii in 4 (4.4%). a closed reduction procedure was performed in 74 (81.30%) of the cases, closed reduction with septoplasty was done in 10 (11%), closed reduction with augmentation rhinoplasty was performed for 3 (3.3%), closed reduction with inferior turbinoplasty was required in 3 (3.3%) whereas closed reduction with debridement was done in 1(1.1%). conclusion: nasal bone fracture is a complex clinical issue which needs to be addressed early. violence prevention programs along with drinking and driving campaigns need to be more strengthened to decrease the alarmingly high frequency of nasal bone fracture in the current scenario. keywords: closed reduction; complication; nasal bone fracture original research articlehttps://doi.org/10.22502/jlmc.v9i1.426 monika pokharel,a,f subindra karki,b,f ashish dhakal,c,f abha kiran kc,d,f krishna sundar shrestha,d,f pradeep rajbhandari,d,f manish neupane e,f a ten-year retrospective study of nasal bone fractures at a tertiary care hospital of nepal how to cite this article:how to cite this article: pokharel m, karki s, dhakal a, kc ak, shrestha ks, rajbhandari p, neupane m. a ten-year retrospective study of nasal bone fractures at a tertiary care hospital of nepal. journal of lumbini medical college. 2021;9(1):5 pages. doi: https://doi.org/10.22502/jlmc. v9i1.426. epub: june 20, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: the nasal bone is commonly fractured due to its vulnerable position and reduced biomechanical resistance to traumas, fracturing even as a result of the action of wounding agents that develop low intensity kinetic energy.[1] nasal bone fracture is the most common facial fracture, accounting for approximately 40% of all facial fractures.[2] if not properly and timely treated, nasal bone fractures can result in permanent functional and esthetic damage, lead to complications in the upper airway,[3] and necessitate septoplasty or augmentation rhinoplasty. it can also affect social activities and may result in economic and psychological problems.[4] there is paucity of data relating to nasal bone fractures in our region. hence, the aim of this study is to analyze the sociodemographic factors, etiology and patterns of nasal bone fractures. understanding about the patterns, etiology and complications can help the health planners and policy makers to specifically address the burden of nasal bone fractures. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 pokharel m, et al. a ten-year retrospective study of nasal bone fractures at a tertiary care hospital of nepal jlmc.edu.np methods: this was a retrospective, cross-sectional study conducted in the department of otorhinolaryngology and head & neck surgery at the kathmandu university dhulikhel hospital between january 2010 to january 2020. the study population consisted of 91 adult patients more than 17 years with nasal bone fractures. patients were excluded if they were < =17 years, were pregnant or had undisplaced fractures which did not require correction. patients who had le fort fractures, zygomaticomaxillary complex fractures, dentoalveolar fractures or mandibular fractures, previous facial fractures or aesthetic surgeries were also excluded. similarly, patients with acute rhinosinusitis, malignancy of the nose and paranasal sinuses, soft tissue injuries were also not enrolled. the age, gender, etiology, associated injuries, type of fracture and treatment offered, alcohol intoxication, time elapsed after fracture until surgery, presenting symptoms, drug abuse were recorded. etiologies of fractures were grouped into road traffic collisions, fall, violence, sports accidents and occupational accidents. a detailed clinical data proforma was filled up. in addition, assessment was done by using plain radiographs of the nasal bone in lateral view. in 48 patients, computed tomography scan of the nose, paranasal sinuses and the facial skeleton were taken for effective preoperative evaluations and to confirm the clinical diagnosis. from the axial scan, a three dimensional reconstruction was performed using the syngo via software using a volume and surface rendering technique in siemens somatom perspective 128 slice computed tomography scanner. nasal fractures were classified according to the harrison’s classification system into three categories depending on the degree of damage as class 1, class 2 and class 3 fractures. depressed fracture of nasal bone where very little force is sufficient to cause a fracture was defined as class 1chevallet fracture. fracture causing significant amount of cosmetic deformity in which not only the nasal bones were fractured, but the underlying frontonasal process of maxilla was also fractured and the fracture line involved the nasal septum was defined as class 2.then orbitoethmoid fractures caused by high velocity trauma causing the most severe nasal injuries were defined as class 3 fractures.[5] in the current study, open reduction under general anesthesia was performed for more accurate nasal bone reduction and intraoperative pain reduction. all patients except for the type i group underwent closed reduction with external nasal splinting under general anesthesia. intravenous antibiotics were prescribed and antiseptic impregnated ribbon gauze packing was done for two days. external nasal splint was applied to all patients for a total of 10 days. statistical analysis was performed using the ibm spss software (version 22.0; ibm corp., armonk, ny, usa). ethical approval was granted by kathmandu university school of medical sciences institutional review committee (no.-139/20) results: of the 91 patients, 65 (71.4%)were males and 26 (28.6%)were females. the mean age of patients was 30.1±11.2 years (range:18-73 years). table 1 shows the socio-demographic characteristics of the patients. table 1. sociodemographic characteristics of the study population (n=91). variables frequency (%) sex male 65 (71.4) female 26 (28.6) alcohol intake at presentation yes 43(47.3) no 48(52.7) road traffic accident was the most common cause of fracture (45.1%) followed by fall (36.3%),violence (13.2%), sports related accidents (4.4%) and occupational accidents (1.1%) as shown in table 2. our findings showed that physical assault was the most common cause of nasal bone fracture among people in their twenties, with its frequency decreasing with increase in age. similarly, we also observed a striking decrease in the frequency of sports-related fractures among patients aged 40 years and above. in the age group analysis, the most j. lumbini. med. coll. vol 9, no 1, jan-june 2021 pokharel m, et al. a ten-year retrospective study of nasal bone fractures at a tertiary care hospital of nepal jlmc.edu.np common age group involved was 21-30 years. class i fracture was seen in 70 (76.9%), class ii in 17 (18.7%) and class iii in 4 (4.4%). altogether 43 (47.3%) of patients who presented with fractures were under the influence of alcohol as shown in table 2. sixty four (70.3%) patients presented in <3 days, 18 (19.8%) presented within 3 days to 1 week, 2 (2.2%) in more than 1 week to 2 weeks, 2 (2.2%) in >2 weeks to 3 weeks and 5 (5.5%) presented in >3 weeks. a closed reduction procedure was performed in 74 (81.3%) of the cases, closed reduction with septoplasty was done in 10 (11%), closed reduction with augmentation rhinoplasty was performed for 3 (3.3%), closed reduction with inferior turbinoplasty was required in 3 (3.3%) whereas closed reduction with debridement was done in 1(1.1%). the various complications that occurred in our patients are depicted in table 3. table 3. complications occurring in patients with nasal bone fractures. complication class 1 class 2 class 3 total hump nose 6 10 1 17 (18.7%) saddle nose 1 0 4 5 (5.4%) nasal widening 8 1 1 10 (10.9%) deviated nasal septum 13 3 0 16 (17.5%) hyposmia 12 2 1 15 (16.5%) pain 44 12 2 58 (63.7%) scar formation 18 15 3 36 (39.6%) discussion: the objective of this study was to analyze the socio-demographic factors, etiology and patterns of nasal bone fractures. in the present study, there was male preponderance in all age groups. this may be attributable to the fact that males are more exposed to activities such as drinking, driving, and physical assault which entail a high risk of fracture as compared to females. also, more social freedom given to men as compared to women may be a contributory factor for the same especially in a conservative country like ours. our findings are comparable to previous studies.[6,7] we found that patients in their twenties showed the highest incidence of fracture, with the frequency gradually decreasing with increase in age. this result is also consistent with the findings of a previous study.[7] people in the age group of 20–29 years are often exposed to trauma because of their high levels of physical and social activities thus resulting in increase in their chances of being exposed to trauma and hence nasal bone fracture. however, our findings are different from another study which has reported an increasing rate of fractures in the elderly.[8] our findings showed that physical assault was the most common cause of nasal bone fracture among people in their twenties, with its frequency decreasing with increase in age. similarly, we also observed a striking decrease in the frequency of sports-related fractures among patients aged 40 years and above. this may be explained due to the fact that younger aged individuals are more involved in physical and interpersonal activity under the influence of alcohol. surveys of facial injuries have shown that the etiology of fractures varies from one country to another and also within the same country depending on the prevailing socioeconomic, cultural and environmental factors.[9,10] in our study, road traffic accident was the most common cause of fracture followed by fall and violence. sports related accidents and occupational accidents constituted a minority.this is in accordance with other studies. table 2. relationship between etiology of fracture and alcohol consumption during the time of occurrence of fracture. alcohol intake etiology total road traffic collision fall violence sports related trauma occupational trauma yes 32 (74.4%) 4 (9.3%) 7 (16.3%) 0 (0%) 0 (0%) 43(47.3%) no 9 (18.8%) 29 (60.4%) 5 (10.4%) 4 (8.3%) 1 (2.1%) 48 (52.7%) total 41 (45.1%) 33 (36.3%) 12 13.2%) 4 (4.4%) 1 (1.1%) 91 (100%) j. lumbini. med. coll. vol 9, no 1, jan-june 2021 pokharel m, et al. a ten-year retrospective study of nasal bone fractures at a tertiary care hospital of nepal jlmc.edu.np [11,12,13] however, some other authors have reported the most common cause of facial fracture as assault or fall.[8,14,15] there may be many factors associated with increase in the rate of road traffic accidents in nepal like violation of the traffic rules, unsuitable road conditions, use of alcohol or other intoxicating agents. also, people in the villages climb mountains and trees to get leaves to feed their livestock which may be the reason for fall. other than these reasons, the violence between people is also common in many societies due to consumption of alcohol and drugs. our study also has some limitations.since it is a single centered study,our findings cannot be generalized. another potential limitation is the retrospective nature of study. moreover, this study excluded patients with a nasal bone fracture who received conservative treatment and were not admitted to the hospital. also, those who belonged to pediatric age groups were excluded which explains the moderate sample size in our study. conclusion: nasal bone fracture is a complex clinical issue which needs to be addressed early. reduction and alignment of nasal bone fracture should be carried out within 2-3 weeks time. acute saddling may require early surgical intervention in order to restore the septal height for good aesthetic purpose. our findings suggest that violence prevention programs along with drinking and driving campaigns need to be more strengthened to decrease the alarmingly high frequency of nasal bone fracture in the current scenario. acknowledgement: dr. laxmi khadka. conflict of interest: the authors declare that no competing interests exist source of funds: no fund was requested references: 1. hyman da, saha s, nayar hs, doyle jf, agarwal sk, chaietsr. patterns of facial fractures and protective device use in motor vehicle collisions from 2007 to 2012. jama facial plast surg. 2016;18(6):455-61.pmid: 27441732 doi: https://doi.org/10.1001/ jamafacial.2016.0733 2. kucik cj, clenney t, phelan j. management of acute nasal fractures. amfam physician. 2004;70(7):1315-20. pmid: 15508543 3. hashim h, iqbal s. motorcycle accident is the main cause of maxillofacial injuries in the penang mainland, malaysia. dent traumatol. 2011;27(1):19-22. pmid: 21244625 doi: https:// doi.org/10.1111/j.1600-9657.2010.00958.x 4. miloro m, ghali ge, larsen pe, waite pd. peterson’s principles of oral and maxillofacial surgery. vol. 1. 2nd ed. hamilton: bc decker inc; 2004. available from: 5. harrison dh. nasal injuries: their pathogenesis and treatment. br j plast surg. 1979;32(1):5764. pmid: 427309 doi: https://doi. org/10.1016/0007-1226(79)90063-8 6. maliska mc, lima júnior sm, gil jn. analysis of 185 maxillofacial fractures in the state of santa catarina, brazil.braz oral res. 2009;23(3):26874. pmid: 19893961 doi: https://doi. org/10.1590/s1806-83242009000300008 7. kang bh, kang hs, han jj, jung s, park hj, oh hk, et al. a retrospective clinical investigation for the effectiveness of closed reduction on nasal bone fracture.maxillofacplastreconstr surg. 2019;41(1):53. pmid: 3182489 doi:https://doi. org/10.1186/s40902-019-0236-y 8. jeon eg, jung dy, lee js, seol gj, choi sy, paeng jy et al. maxillofacial trauma trends at a tertiary care hospital: a retrospective study. maxillofacplastreconstr surg. 2014;36(6):2538. pmid: 27489843 doi: https://doi. org/10.14402/jkamprs.2014.36.6.253 9. hogg nj, stewart tc, armstrong je, girotti mj. epidemiology of maxillofacial injuries at trauma hospitals in ontario, canada, between 1992 and 1997. j trauma. 2000;49(3):42532. pmid: 11003318 doi: https://doi. org/10.1097/00005373-200009000-00007 10. gassner r, tuli t, hächl o, rudisch a, ulmer j. lumbini. med. coll. vol 9, no 1, jan-june 2021 pokharel m, et al. a ten-year retrospective study of nasal bone fractures at a tertiary care hospital of nepal jlmc.edu.np h. cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. j craniomaxillafac surg. 2003;31(1):51-61. pmid: 12553928 doi: https://doi.org/10.1016/ s1010-5182(02)00168-3 11. morris c, bebeau np, brockhoff h, tandon r, tiwana p. mandibular fractures: an analysis of the epidemiology and patterns of injury in 4,143 fractures. j oral maxillofac surg. 2015;73(5):951.e1-951.e12. pmid: 25883009 doi: https://doi.org/10.1016/j.joms.2015.01.001 12. vanbeek gj, merkx ca. changes in the pattern of fractures of the maxillofacial skeleton. intj oral maxillofac surg. 1999;28(6):424-8. pmid: 10609743 doi: https://doi.org/10.1034/j.13990020.1999.280605.x 13. ugboko vi, odusanya sa, fagade oo. maxillofacial fractures in a semi-urban nigerian teaching hospital. a review of 442 cases.intj oral maxillofac surg. 1998;27(4):286-9. pmid: 9698176 doi: https://doi.org/10.1016/s09015027(05)80616-2 14. brook im, wood n. aetiology and incidence of facial fractures in adults. int j oral surg. 1983;12(5):293-8.pmid: 6420354 doi: https:// doi.org/10.1016/s0300-9785(83)80016-7 15. ellis e, el-attar a, moos kf. an analysis of 2,067 cases of zygomatico-orbital fracture. j oral maxillofacsurg. 1985;43(6):41728.pmid: 3858478 doi: https://doi.org/10.1016/s02782391(85)80049-5 supernumerary nipples, congenital scoliosis, spina bifida, diastematomyelia, and crossed renal ectopia in a child: case report of a rare combination. kiran panthee,a,d kiran sharma,b,d balkrishna kalakhetic,d —–————————————————————————————————————————————— abstract: introduction: supernumerary nipples are common anomalies which may be associated with several systemic disorders, particularly urinary tract abnormalities. case report: here we report a case of a 4½ year old male presenting to the pediatric out patient clinic with fever for three days and recurrent sinopulmonary infections. the child had supernumerary nipples over the right side with deformed thoracic cage, congenital scoliosis, diastematomyelia, crossed renal ectopia, and spina bifida. all the conditions present together did not match any syndrome reported till date. conclusion: this was a rare syndrome and did not match fully with any known syndromes till date. this case warranted further investigation for its definite diagnosis but we do not have resources to that extent. keywords: ectopic • nipples • scoliosis • spina bifida • spinal cord ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, b resident c associate professor d department of pediatrics, lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. kiran panthee e-mail: keeranpanthee@gmail.com how to cite this article: panthee k, sharma k, kalakheti b. supernumerary nipples, congenital scoliosis, spina bifida, diastematomyelia, and crossed renal ectopia in a child: case report of a rare combination. journal of lumbini medical college. 2015;3(2):55-7. doi: 10.22502/jlmc.v3i2.74. ___________________________________________________________________________________ j. lumbini. med. coll. vol 3, no 2, july-dec 2015 case report jlmc.edu.np https://doi.org/10.22502/jlmc.v3i2.74 introduction: supernumerary nipples are common anomalies, and their significance is usually limited to cosmetic concerns. however, they are susceptible to hormonal changes and may signify internal disease. a high index of suspicion should be maintained during physical examinations, because any disease process that involves anatomically normal breasts may affect aberrantly located breasts or nipples. these anomalies may be associated with several systemic disorders, particularly urinary tract abnormalities.1,2 there is a higher prevalence for the left side and male gender.3 in addition, it has been shown that supernumerary nipples are also associated with several syndromes including a lethal type of popliteal pterygium syndrome,4 the simpson-golabi-behmel syndrome,5 and the char syndrome.6 becker nevus syndrome is also reported to be associated with supernumerary nipples.7 the association between supernumerary nipples, spina bifida, scoliosis and renal anomalies has been defined in many literatures.8,9 case report: a 4½ year old male child presented to paediatrics out patient clinic with fever for three days and recurrent history of sinopulmonary infections. on general examination, he had supernumerary nipple at the right chest, along the nipple line with deformed thoracic cage and prominence over lumbosacral region. the child’s anthropometry were as follows: head circumference 48 cm (3rd – 15th percentile), weight 13 kg (< 3rd percentile), height 81 cm (< 3rd percentile), upper segment (us): 37 cm, lower segment (ls): 44 cm and us:ls = 0.84. 55 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 jlmc.edu.np panthee k. et al. supernumerary nipples, congenital scoliosis, spina bifida, diastematomyelia, and crossed renal ectopia in a child. there was no consanguinity between the parents. the father was 26 years old and the mother was 22. the patient’s birth history were uneventful. he was the second child of the family, first pregnancy was aborted at 1½ months period of gestation due to young age of mother, seven years back. on physical examination, the child had normal facies, supernumerary nipple on the right side (figure 1), normal left nipple, scoliosis and lumbosacral prominence. extremities were normal. urogenital and rectal examinations were also normal. chest radiology revealed deformation at the second, fourth and fifth ribs and agenesis of the third rib (figure 2). ultrasonogram of abdomen and pelvis revealed both kidneys towards the left side with other viscera within the normal location. complete blood count, renal function test and liver function test were within normal limits. a karyotype of 46, xy was detected. cardiac findings were normal and so was the cranial mri. mri and ct images reveal crossed renal ectopia (figure 3), lumbar spina bifida with lipomyelocele and diastematomyelia (figure 4). discussion: solitary or multiple accessory nipples figure 1: supernumerary nipple on the right side. figure 2: chest radiology showing deformation at the second, fourth, and fifth rib and the scoliosis. figure 3: mri image showing renal ectopia. figure 4: mri image showing lumbar spina bifida with lipomyelocele and diastematomyelia. may occur in a unilateral or bilateral distribution along a line from the anterior axillary fold to the inguinal area. more common among africanamerican (3.5%) than white (0.6%) children. renal or urinary tract anomalies and hematologic abnormalities may rarely occur in children.10 several syndromes are reported that are associated with 56 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 panthee k. et al. supernumerary nipples, congenital scoliosis, spina bifida, diastematomyelia, and crossed renal ectopia in a child. jlmc.edu.np supernumerary nipples.4-7 it was not an autosomal dominant inheritance since none of the parents had similar anomalies. supernumerary nipples was not an isolated entity as it was associated with other anomalies too. supernumerary nipples and associated renal anomalies also has been identified in many literatures.8,11,12 conclusion: this was a rare syndrome and did not match completely with any known syndromes. this case warrants further investigation for its definite diagnosis but we do not have resources to that extent. references: 1. newman m. supernumerary nipples. am fam physician. 1988 aug;38(2):183-8. 2. brown j, schwartz ra. supernumerary nipples: an overview. cutis. 2003 may;71(5): 344-6. 3. schmidt h. supernumerary nipples: prevalence, size, sex and side predilection-a prospective clinical study. eur j pediatr. 1998 oct;157(10):821-3. 4. shafeghati y, karimi-nejad a, karimi-nejad r. supernumerary nipples in a bartsocas-papas patient in a consanguineous iranian family. clin dismorphol. 1999 apr;8(2):155-6. 5. hughes-benzie rm, hunter ag, allanson je, mackenzie ae. simpson-golabi-behmel syndrome associated with renal dysplasia and embryonal tumor: localization of the gene to xqcen-q21. am j med genet. 1992;43(1-2):428-35. 6. zannolli r, mostardini r, matera m, pucci l, gelb bd, morgese g. char syndrome: an additional family with polythelia, a new finding. am j med genet. 2000 nov;95(3):201-3. 7. urbani ce, betti r. supernumerary nipple in association with becker nevus vs. becker nevus syndrome: a semantic problem only. am j med genet. 1998 apr;77(1):76-7. 8. meggyessy v, mehes k. association of supernumerary nipples with renal anomalies. j pediatr. 1987 sep;111(3):412-3. 9. panigrahi i, saxena a, marwaha rk. congenital scoliosis, supernumerary nipples and spina bifida occulta. clin dysmorphol. 2008 jul;17(3):215-8. doi: 10.1097/ mcd.0b013e3282fc6fdc. 10. kliegman rm, stanton bf, st geme jw iii, schor nf, behrman re (eds). nelson textbook of pediatrics (20th ed). philadelphia: elsevier inc;2016.p.3119-20. 11. brown j, schwartz ra. supernumerary nipples and renal malformations: a family study. j cutan med surg. 2004;8(3):170-2. 12. grotto i, browner-elhanan k, mimouni d, varsano i, cohen ha, mimouni m. occurrence of supernumerary nipples in children with kidney and urinary tract malformations. pediatr dermatol. 2001;18(4):291-4. 57 evaluation of serum hdl and ldl levels in type ii diabetes mellitus kr joshi,a kk hiremath,a sp guptaa —–————————————————————————————————————————————— abstract: introduction: diabetes mellitus is a type of metabolic disorder characterized by hyperglycemia resulting from defect in insulin secretion, insulin action or both. this study intended to compare high density lipoprotein cholesterol (hdl) and low density lipoprotein cholesterol (ldl) profile between type ii diabetic and non-diabetic subjects and also find the correlation between hdl and ldl cholesterol in type ii diabetic. methods: the study was conducted on 100 total subjects out of which experimental group with 50 subjects of known type ii diabetes mellitus and control group with 50 subjects. results: the result of the present study suggests that fasting blood sugar and ldl cholesterol levels were increased but hdl cholesterol level was reduced in type ii diabetic subjects when compared to controls. conclusion: the estimation of hdl cholesterol and ldl cholesterol in type ii diabetes mellitus is very useful as it may serve as a useful parameter to monitor the prognosis of the patient. keywords: type ii diabetes • serum hdl • ldl • cholesterol ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer department of biochemistry, padmashree institute of medical lab. technology, nagarbhavi circle, bangalore, india corresponding author: dr. kr joshi e-mail: drkrjoshi@jlmc.edu.np how to cite this article: joshi kr, heremath kk, gupta sp. evaluation of serum hdl and ldl levels in type ii diabetes mellitus. journal of lumbini medical college. 2013;1(1):21-4. doi:10.22502/jlmc.v1i1.7. ___________________________________________________________________________________ j. lumbini. med. coll. vol 1, no 1, jan-june 2013 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v1i1.7 introduction: diabetes mellitus is a group of metabolic disorder characterized by hyperglycemia resulting from defect in insulin secretion, insulin action or both.1 diabetes mellitus is characterized by either the absence of insulin that is insulin dependent diabetes mellitus (iddm) type i or which is insensitive to the insulin that is non-insulin dependent diabetes mellitus (niddm) or type ii. it is a complex disease where the carbohydrate and fat metabolism is impaired.2 type ii diabetes is associated with a marked increased risk of cardiovascular disease (cvd). individuals with diabetes has an absolute risk of major coronary events similar to that of nondiabetic individuals with established coronary heart disease (chd).3 ldl cholesterol is the main lipid marker in cardiovascular risk estimation and the principle therapeutic target in diabetic subjects.4 high density lipoprotein (hdl) cholesterol is inversely correlated with cardiovascular events in all major epidemiological studies. strategies have demonstrated that increased hdl cholesterol is associated with decreased cardiovascular risk in high risk individuals such as patients with type ii diabetes.5 abnormal lipid profile is more common in diabetics and get aggravated with poor glycemic control. thus, the measurement of lipid profile is needed to investigate how their lipid metabolism especially hdl and ldl cholesterol is affected by diabetes. also, the correlation of hdl cholesterol and ldl cholesterol in diabetics and non-diabetics was observed in this study.6 high level of ldl cholesterol and low hdl cholesterol may be due to obesity, increased calorie intake and a lack of muscular exercise in the patients of diabetes mellitus.2 hence this study was designed where in hdl and ldl cholesterol levels have been correlated for diabetic and non-diabetic healthy subjects.7 21 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np joshi kr. et al. evaluation of serum hdl and ldl levels in type ii diabetes mellitus methods: a case-control study with 50 controls as non-diabetic cases and 50 cases as diabetic patients was undertaken to study the hdl and ldl profile. the present study was carried out on total 100 subjects, which were divided into two groups experimental group which consisted of 50 subjects with known type ii diabetes mellitus and control group which consisted of 50 healthy nondiabetic subjects with no present and past family history of diabetes mellitus. a total 50 type ii diabetic subjects were recruited in the study, among which 35 were males and 15 were females in the age group of 4070 years. non-insulin dependent diabetes mellitus patients were being treated by diet alone or diet combined with oral hypoglycemic agents. results: the study was a case control study where fasting plasma glucose, serum hdl cholesterol, serum ldl cholesterol was estimated, compared and correlated in type ii diabetic and non-diabetic subjects. table 1 and table 2 show that the mean age studied in type-ii diabetes mellitus patients was 54.34 yrs (sd=8.48) and 53.40 yrs (sd=7.95) in control subjects showing a suggestive significance p=0.57. whereas the percentage of gender study showed the control group with 54% male and 46% female when compared to case group male 68% and 32% female showing a non significant difference, p=0.15. hence, suggesting that the study comprised of equal distribution of age group and gender. table 3 shows that fasting plasma glucose and serum ldl cholesterol levels were elevated in case group with mean 164.56 mg (sd=51.17) and 121.42 mg (sd=27.89) respectively when compared to the control group mean of 95.48 mg (sd=10.09) and 103.64 mg (sd=30.67) respectively. a strong significance (p<0.001 and p=0.003) was found between case and control group’s mean fasting plasma glucose and serum ldl cholesterol levels respectively. whereas hdl cholesterol levels had fall in case group mean (39.22±7.96) when compared to the control group (44.06±10.57) showing a p value of 0.011. table 4 shows a comparison of hdl cholesterol in case and control. a strong significance is observed when compared with hdl cholesterol level <40mg/dl (p<0.001) and hdl cholesterol level is 40-60mg/dl (p<0.001). a significant lower incidence of hdl cholesterol levels is seen in case group than in controls (76% verses 32% respectively where hdl <40.0 mg/dl and 22% verses 60% respectively where hdl is in between 40-60 mg/ dl, p<0.001). whereas there was no significant in control and case group where hdl cholesterol levels where > 60mg/dl (p=0.36). table 1: age distribution table 2: gender distribution table 3: comparison of blood parameters table 4: comparison of hdl 22 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 joshi kr. et al. evaluation of serum hdl and ldl levels in type ii diabetes mellitus jlmc.edu.np table 5 shows a significant negative correlation between hdl and ldl cholesterol (r = -0.221) where in the ldl cholesterol levels are elevated whereas hdl cholesterol is reduced in case groups compared to control group which is significant. table 5: comparison of ldl discussion: the result obtained from present study has confirmed that the previous observations of an increased ldl and decreased hdl cholesterol levels in diabetic patients.8 type ii diabetes mellitus is chronic degenerative disease of epidemic proportion and is one of the major challenges to public health.9 the mean age studied in type ii diabetes mellitus patients control subjects was 54.34 yes (sd= 8.48) 53.40 yrs (sd=7.95) respectively. there appears to be no sex predilection for type ii diabetes mellitus according to this study. this is similar to other studies that reported no significant differences in the prevalence of type ii diabetes mellitus between males and females.10 the fasting blood glucose levels are elevated significantly (p<0.001) in niddm patients, when compared to the controls which is consistent with earlier reports by other researchers.11-13 the hdl cholesterol was low in type ii patients when compared to control. the decrease was found to be moderately significant (p= 0.01) in type ii patients. similar studies have been reported by harno k.14 the reduction of hdl cholesterol in type ii diabetic patients may be due to the increased activity of hepatic lipase, which plays an important role in hdl metabolism.14 however controversial studies also have been reported where no significant change in hdl cholesterol levels in diabetic patients reported.15 hdl cholesterol concentration are strongly and independently related to coronary artery disease, but the relationship is inverse; a low hdl cholesterol being an important predictor of coronary heart disease and whereas high levels of hdl cholesterol is protecting against coronary heart disease. a possible explanation for these finding is the role played by hdl cholesterol in reverse cholesterol transport as an acceptor of cellular free cholesterol.16 the ldl cholesterol is elevated significantly (p<0.003) in type i diabetic patients when compared to control. however, there was a small correlation between ldl cholesterol in type ii diabetic patients. the above findings are consistent with the observations by other researchers.17 metabolic reasons for lower hdl levels have not been fully documented. decreased synthesis of hdl has been found in one small study.18 schmitt jk suggested that ldl uptake by fibroblasts may be impaired in type ii diabetics. this may have led to increase in ldl cholesterol and decrease in hdl cholesterol in type ii diabetics.ii this is much similar to our study showing a negative correlation between ldl and hdl cholesterol (r = -0.221) in diabetics. conclusion: the estimation of hdl cholesterol and ldl cholesterol in type ii diabetes mellitus is very useful as it may serve as a useful parameter to monitor the prognosis of the patient. the detection of risk factor in the early stage of the disease will help the patients to improve and reduce the morbidity rate. the result of the present study suggests that fasting blood sugar and ldl cholesterol levels were found to be increased in type ii diabetic subjects when compared to controls. the hdl cholesterol level was reduced statistically in diabetics when compared to controls. a significant negative correlation was observed between hdl and ldl cholesterol in diabetic subject. confilict of interest declared: none financial support: none 23 j. lumbini. med. coll. vol 1, no 1, jan-june 2013 jlmc.edu.np joshi kr. et al. evaluation of serum hdl and ldl levels in type ii diabetes mellitus references: 1. process s, delrange e, vander burghs tv. minor alteration in thyroid function test associated with diabetes mellitus and obesity in outpatient without known thyroid illness. acta clin big. 2001. 2. suryawanshi np, bhutey ak, nagdeote an. study of lipid peroxide and lipid profile in diabetes mellitus. ind j clin biochem. 2006;21:126-30. 3. wagner am, sanchez-quesada jl, perez a, rigla m. inaccuracy of calculated ldl-cholesterol in type-2 diabetes: consequences for patient risk classification and therapeutic decisions. clin chem. 2000;46:1830-2. 4. solano mp, goldberg rb. lipid management in type-2 diabetes. am diabetes assoc clin diabetes. 2006;24:27-2. 5. nieuw drop m, vergeer m, bisoendial rj. reconstituted hdl infusion restores endothelial function in patients with type 2 diabetes mellitus. diabetologia. 2008;51:10814. 6. ugwa ce, ezeanyika lus, daikwo ma. lipid profile of a population of diabetic patients attending nigerian national petrolium corporation clinic, abuja. afr j biochem res. 2009;3:066-9. 7. kumar a, tewari p, sahoo ss. prevalence of insulin resistance in first degree relatives of type-2 diabetes mellitus patients: a prospective study in north indian popula_ on” ind j clin biochem 2005;20:10-7. 8. david m. initial management of glycemia in type-2 diabetes mellitus. n eng j med. 2002;347:1342-9. 9. bhalla k, shukla r, gupta vp, pugazhenthi s, prabhu km. glycated protein and serum lipid profile in complicated and uncomplicated niddm patient. ind j clin biochem. 1995;10:57-66. 10. idogun es, unuigbe ei, ogunuro ps, akinola ot. assessment of serum lipids in nigerians with type 2 diabetes mellitus complications. pak j med sci. 2007;23:708-2. 11. yegin a, ozben t. serum glycated lipoprotein in type 2 diabetic patients with and without complication. ann clin biochem. 1995;32:459-3. 12. panteghini m, cimino a, pagani f, girelli a. nonenzymatic glycation of apolipoprotein b in patients with insulin and non-insulin dependent diabetes mellitus. clin biochem. 1995;28:587-2. 13. freier bm, sudek cd. cholesterol in diabetes: the effect of insulin on kenetics of plasms squalene. j clin endocrine metab. 1979;49:824-8. 14. harno k, nikkila ea, kussi t. metabolism of cholesterol and post heparin plasma hepatic endothelial lipase activity: relationship to obesity and non-insulin dependent diabetes mellitus. diabetologia. 1980;19:28. 15. bhalla k, shukla r, gupta vp, puyazhenthi s, prabhu k m. glycosylated proteins and serum lipid profile in complicated and complicated niddm patients. ind j clin biochem. 1995;10:57-1. 16. glomset ja. the plasma lecithin: cholesterol acyl transferase reaction. j lipid res. 1968; 9: 15567. 17. yassin hdel, hasso nma, rubayi haal. lipid profile and lipid peroxidation pattern pre and post exercise in coronary heart disease. turk j med sci. 2005;53:223-8. 18. goolay a, zech l, shi mz. high density lipoprotein turnover in noninsulin dependent diabetes mellitus. diabetes. 1985;34:81. 19. schmitt jk, poole jr, lewis sb. hemoglobin a1 correlates with the ratio of low to high density lipoprotein in normal weight type 2 diabetics. metabol. 1982;31:1084-9. 24 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 7, no 1, jan-jun 2019 ___________________________________________________________________________________ submitted: 3 march, 2019, accepted: 21 may, 2019 published: 25 june, 2019 a-consultant ophthalmologist b-consultant optometrist, c-tilganga institute of ophthalmology, kathmandu, nepal d-dm resident, department of cardiology, national academy of medical science (nams), kathmandu, nepal e-sagarmatha choudhary eye hospital, siraha, lahan, nepal f-medical laboratory technologist g-kathmandu medical college and teaching hospital, kathmandu, nepal corresponding author: sharad gupta, e-mail: sharadgupta00839@gmail.com orcid: https://orcid.org/0000-0001-8654-5172 — – — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — abstract: introduction: central retinal artery occlusion (crao) is characterized by sudden obstruction of the arterial blood flow in the retinal circulation with consequent ischemic damage to the retina resulting in vision loss. an interesting case of unilateral crao associated with atrial septal defect (asd) in a young female is reported here. case: a young female presented to emergency department with history of sudden and painless loss of vision in her right eye for one day. her visual acuity at the time of presentation was perception of light in right eye and 6/6 in left eye. on examination, anterior segments of both the eyes were normal. however, relative afferent pupillary defect was positive in her right eye. on fundus examination, right eye showed pale retina and cherry red spot whereas left eye was unremarkable. findings were suggestive of right eye crao. ocular massage was done and oral carbonic anhydrase inhibitor was given. patient was referred to a cardiologist for further evaluation and establishment of the etiology. all tests were within reference limit except a large asd (secundum type with left to right shunt) with a diameter of 28 mm was revealed on transthoracic echocardiogram. conclusion: the association between asd and crao is rare. intracardiac shunts through defect may predispose the disease. detailed cardiac evaluation is mandatory to rule out possible causes to prevent ocular or systemic embolic events and associated morbidity. keywords: atrial septal defect, central retinal artery occlusion ——————————————————————————————————————————————— case reporthttps://doi.org/10.22502/jlmc.v7i1.281 sharad gupta, a, e manoj aryal, b, g yogita rajbhandari, a,c ajay adhikari, d vinit kumar kamble, a,e binod aryal,f, g central retinal artery occlusion associated with atrial septal defect: a case report introduction: central retinal artery occlusion (crao) is an ophthalmic emergency and is the ocular analogue of cerebral stroke. it was first described by von graefes in 1859.[1] an occlusion of the central retinal artery leads to sudden painless monocular loss of vision. the etiology remains unclear in many cases. probable causes are embolism (calcified, thrombotic, myxomatous, bacterial or cholesterol) of carotid or cardiac origin, vaso-obliteration (atherosclerotic plaques, giant-cell arteritis and vasculitis) and vascular compression mainly retrobulbar mass (hematoma, neoplasms, retrobulbar injections). atrial septal defect (asd) is a common congenital heart defect accounting for approximately 6–10%. it causes shunting of blood between the systemic and pulmonary circulations.[2] forty percent of patients may present with cryptogenic stroke at adulthood. paradoxical embolism has also been reported.[3] asd predisposes the individual to embolic events which may also involve the eye. here we report a unique case of unilateral crao associated with asd mainly due to paradoxical embolus. how to cite this article: gupta s, aryal m, rajbhandari y, adhikari a, kamble vk, aryal b. central retinal artery occlusion associated with atrial septal defect: a case report. journal of lumbini medical college. 2019;7(1):3 pages. doi: https://doi.org/10.22502/jlmc.v7i1.281 epub:2019 june 25. ______________________________________________________ gupta s. et al. central retinal artery occlusion associated with atrial septal defect: a case report jlmc.edu.npj. lumbini. med. coll. vol 7, no 1, jan-jun 2019 case report: a 32 years female presented to the emergency department with the chief complaint of sudden and painless loss of vision in her right eye for one day. she had no significant medical and surgical history. she did not give any history of trauma or other precipitating events and was not under any regular medication. on examination, her best corrected visual acuity was perception of light (lp) and 6/6 in right eye and left eye respectively. on slit lamp biomicroscopic examination, anterior segment of both eyes were normal except relative afferent pupillary defect was positive in right eye. right fundus showed pale retina and cherry red spot whereas left fundus was found to be unremarkable on posterior segment examination (fig.1 and fig.2). intraocular pressure were 22 mmhg and 16 mmhg in the right and left eyes respectively. ocular findings were suggestive of crao of the right eye. ocular massage for 15-20 minutes was done and oral carbonic anhydrase inhibitor 250 mg four times for a day was given as for the conservative management. patient was referred to cardiologist to establish the etiology and for further evaluation and management of crao. electrocardiogram showed right bundle branch block. transthoracic echocardiogram revealed acyanotic congenital heart disease, large asd (secundum type with left to right shunt) with a diameter of 28 mm, mild tricuspid regurgitation with mild pulmonary artery hypertension and dilated right atrium and right ventricle (fig. 3). fig 3.echocardiogram of the patient shows large ostium secundum asd with left to right shunt (yellow arrow) (a), dilated right atrium and right ventricle (b) by a transthoracic approach. rest of the tests including carotid artery doppler, complete blood count, random blood sugar and lipid profiles were within reference limits. discussion: central retinal artery occlusion (crao) results from the obstruction of central retinal artery; a major branch of the ophthalmic artery. crao is rare in patients younger than 25 years but if present, is often associated with underlying systemic or cardiac abnormality. in crao patients younger than 45 years, 45% have underlying cardiac abnormalities, of which 27% required anticoagulation or cardiac surgery.[4] optic nerve head drusen and peripapillary arterial loops are the common causes of crao in younger patients.[5] association between patent foramen ovale creating a right-to-left shunting of blood with central retinal artery occlusion had been reported in various literatures.[6,7] however, direct intra-cardiac communication between venous and arterial system can also occur with atrial septal defect, pulmonary artery venous malformation, ventricular septal defect, ebstein anomaly and patent ductus arteriosus. these cardiac entities under various conditions like right fig. 1. pale retina with cherry red spot on right fundus fig. 2. normal fundus of the left eye fig. 3. echocardiogram of the patient shows large ostium secundum asd with left to right shunt (yellow arrow) (a), dilated right atrium and right ventricle (b) by a transthoracic approach. arterial hypertension, right ventricular hypertension, positive pressure ventilation, positive end-expiratory pressure, pulmonary hypertension from hypoxemia, myocardial infarction of the right side of the heart and valsalva maneuvers can result into right-to-left shunt with formation of a paradoxical embolus.[8] although there are few articles about embolic stroke in cerebellum due to paradoxical embolus across asd [9] but crao associated with asd has not been reported till date. asd is essentially a left-to-right shunt; transient rise in right atrial pressure during valsalva or on a ventilator could predispose the migration of air or micro-emboli in the right atrium to the arterial circulation across the asd.[10,11] in this case there might be paradoxical embolus during valsalva maneuver (coughing, straining) which may have predisposed the migration of emboli from right atrium to systemic circulation leading to retinal artery occlusion. conclusion: the association between asd and crao is rare. despite the fact that asd is left to right shunt, paradoxical embolus from right atrium to systemic circulation due to transient rise in right atrium pressure can lead to embolic phenomena elsewhere in the body and sometimes in the eye. detailed cardiac evaluation is mandatory to rule out possible causes of cardiac disease to prevent ocular or systemic embolic events and associated morbidity. conflict of interest: none declared. 1. von graefes a. ueber embolie der arteria centralis retinae als ursache plotzlicher erblindung.  arch ophthalmol.  1859; 5(1):136–157. doi: https://doi. org/10.1007/bf02720764 2. bull c, deanfield j, de leval m, stark j, taylor jf, macartney fj. correction of isolated secundum atrial septal defect in infancy.  arch dis child.  1981; 56 (10):784–6. pmid: 7305418 3. rigby ml. the era of transcatheter closure of atrial septal defects.  heart.  1999; 81 (3):227–8. doi: http://dx.doi. org/10.1136/hrt.81.3.227 4. sharma s, sharma sm, cruess af, brown gc. transthoracic echocardiography in young patients with acute retinal arterial obstruction. reco study group. retinal emboli of cardiac origin group. can j ophthalmol 1997; 32 (1):38–4. pmid:9047032 5. newsom rs, trew dr, leonard tj. bilateral buried optic nerve drusen presenting with central retinal artery occlusion at high altitude.  eye 1995; 9(part 6): 806–808.  pmid: 8849557. doi :https://doi.org/10.1038/ eye.1995.202 6. t. nakagawa, a. hirata, n. inoue, y. hashimoto, and h. tanihara. a case of bilateral central retinal artery obstruction with patent foramen ovale.   acta ophthalmologica scandinavica, 2004: 82(1); 111–112. pmid: 14738497 7. l. clifford, r. sievers, a. salmon, and r. s. b. newsom. central retinal artery occlusion: association with patent foramen ovale.  eye, 2006; 20(6): 736–738.  pmid: 6701983 8. sunil v. furtado, prasanna k. venkatesh, ganesh k. murthy, arul d. furtado, and alangar s hegde. paradoxical embolus across atrial septal defect and posterior circulation infarct in neurosurgical patients international journal of neuroscience. 2010; 120(7):516–520. pmid: 20583906. doi: https://doi. org/10.3109/00207451003760072 9. laskowski, i. a., babu, s. c., osinuga, sr, o. a., lessnau, k. d., & menezes, n. s. (2018, october 02). paradoxical embolism. retrieved october 24, 2018, from https:// emedcine.medscape.com/article/460607-overview#a3t 10. fathi, a. r., eshtehardi, p., & meier, b. patent foramen ovale and neurosurgery in sitting position: a systematic review. british journal of anaesthesia, 2009; 102(5): 588– 596. . pmid: 19346525. doi : https://doi.org/10.1093/bja/ aep063 11. ozdemir, a. o., tamayo, a., munoz, c., dias, b., & spence, j. d. cryptogenic stroke and patent foramen ovale: clinical clues to paradoxical embolism journal of neurological sciences. 2008; 275(1-2): 121–127. doi : https://doi. org/10.1016/j.jns.2008.08.018 references: j. lumbini. med. coll. vol 7, no 1, jan-jun 2019 jlmc.edu.np gupta s. et al. central retinal artery occlusion associated with atrial septal defect: a case report doi: https://doi.org/10.1007/bf02720764 doi: https://doi.org/10.1007/bf02720764 doi: http://dx.doi.org/10.1136/hrt.81.3.227 doi: http://dx.doi.org/10.1136/hrt.81.3.227 doi :https://doi.org/10.1038/eye.1995.202 doi :https://doi.org/10.1038/eye.1995.202 doi: https://doi.org/10.3109/00207451003760072 doi: https://doi.org/10.3109/00207451003760072 https://emedcine.medscape.com/article/460607-overview#a3t https://emedcine.medscape.com/article/460607-overview#a3t https://doi.org/10.1016/j.jns.2008.08.018 https://doi.org/10.1016/j.jns.2008.08.018 https://doi.org/10.1016/j.jns.2008.08.018 https://doi.org/10.1016/j.jns.2008.08.018 j. lumbini. med. coll. vol 9, no 1, jan-june 2021 thapa p, et al. pregnant women’s mental health status and its related factors amidst covid-19: a cross-sectional study jlmc.edu.np ___________________________________________________________________________________ submitted: 12 april, 2021 accepted: 20 june, 2021 published: 30 june, 2021 alecturer, college of nursing bnursing officer ccollege of medical sciences, bharatpur, chitwan, nepal. dnobel college, kathmandu, nepal. egandaki medical college, pokhara, nepal. flumbini province hospital, rupandehi, nepal. corresponding author: pratima thapa e-mail: pratiimathapa@gmail.com orcid: https://orcid.org/0000-0003-2709-4986_______________________________________________________ abstract introduction: since the emergence of covid-19 pandemic, it has challenged the psychological aspect of everyone. pregnant women being the vulnerable group are most likely to be at increased risk. this study aimed to assess the mental health status of the pregnant women residing in nepal during covid-19. methods: a cross-sectional online study was carried out among 368 pregnant women during lockdown using perceived stress scale-10, generalized anxiety disorder-7 scale and edinburg perinatal depression scale. data were analyzed using descriptive and inferential statistics. results: the mean age of the participants was 27.06±4.64years. getting infected with the virus (71.7%) was the major fear and inadequate antenatal checkup (61.1%) was the major effect experienced by the participants. the prevalence of stress, anxiety and depression was 41%, 28.5% and 33.2% respectively. age, salary status of oneself and their husband, healthcare frontliner in the family and effect of social distancing were significantly associated with perceived stress. age, education, employment, monthly income, trimester and effect of social distancing were significantly associated with anxiety. salary status of husband, trimester, parity, being infected with covid-19 and effect of social distancing were associated with depression. conclusion: high prevalence of mental health disorders during covid-19 outbreak suggests the importance of special attention on monitoring the maternal mental health status during such public health emergencies. measures such as awareness program targeted to pregnant women and health education programs on how to cope during the pandemic situations should be made effective to rule down the mental health burden of covid-19. keywords: anxiety; covid-19; depression; pregnant women; stress original research articlehttps://doi.org/10.22502/jlmc.v9i1.428 pratima thapa,a,c binita dhakal,a,c upasana shrestha,a,d srijana gautam adhikari,a,e sunayana shrestha b,f pregnant women’s mental health status and its related factors amidst covid-19: a crosssectional study how to cite this article:how to cite this article: thapa p, dhakal b, shrestha u, adhikari sg, shrestha s. pregnant women’s mental health status and its related factors amidst covid-19: a cross-sectional study. journal of lumbini medical college. 2021;9(1):8 pages. doi: https://doi.org/10.22502/jlmc. v9i1.428. epub: june 30, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: with the emergence of coronavirus disease 2019 (covid-19), the world got desperately frazzled. the pandemic affected not only the physical but also the mental aspects. a study related to the covid-19 pandemic reported that women had a higher prevalence of mental health disorders than men.[1] in this scenario, the high-risk groups; pregnant women and postpartum mothers could undoubtedly be more susceptible to acquire mental health problems. pregnancy is usually a joyful time for most women, but it brings many negative emotions in a few of them. these emotions sometimes put pregnant women at risk of developing anxiety and depression.[2] as the world health organization (who) states, “virtually all women can develop mental disorders during pregnancy and in the first year after delivery; conditions such as extreme stress, emergency and conflict situations and natural disasters can increase risks for specific mental health disorders.”[3] therefore, pregnant j. lumbini. med. coll. vol 9, no 1, jan-june 2021 thapa p, et al. pregnant women’s mental health status and its related factors amidst covid-19: a cross-sectional study jlmc.edu.np women may be more in danger of developing mental illness in the covid-19 pandemic. the focus of the recent studies on pregnancies during the covid-19 pandemic has been mainly on therapeutic aspects. mental health and psychological needs are mentioned barely.[4,5] it is thus high time to recognize the possibility of a negative impact caused by the pandemic. necessary planning of the proper care to prevent any adverse effects has to be developed beforehand. mental health issues in this pandemic have to be considered as one of the critical public health concerns.[3] to manage the mental health consequences, it is first essential to identify the mental health status of pregnant women during this pandemic period. therefore, with this background, the researchers were interested in conducting this study to assess the mental health status of pregnant women and analyze the factors affecting their mental health status during the covid-19 pandemic. methods: a descriptive cross-sectional study was conducted (august-2020 to january-2021) among pregnant women residing in nepal. data was collected through an online survey as the people were advised to stay at home during the covid-19 outbreak. ethical clearance was obtained from the institutional review committee of college of medical sciences-teaching hospital (comsthirc), bharatpur-10 (ref. no. 2020-082). the required sample size for the study was calculated using the formula, n=z2pq/d2 based on a study conducted in china where the prevalence of poor mental health was 31.12%.[6] considering confidence level (z) = 1.96 for 95% confidence interval, desirable error (d) = 5% and non-response rate of 12%, the calculated sample size was 368. questionnaires were sent through google form (e-mail, viber, facebook, and whatsapp) to the targeted population. request to participate in the study was posted on social media with the links to the google form of questionnaire. purpose and objectives of the study were clearly explained. those who provided consent to participate in the study were asked to continue to fill the google form. the eligibility criteria included nepalese women residing in nepal who were pregnant, willing to participate in the study, and having no history of major stressors (divorce, death of a family member, and diagnosis of a family member with an incurable and life-threatening disease) in the last six months. research questionnaire: it consisted of six parts. part 1, 2 and 3 were self-developed questionnaire by the authors based on relevant literatures. part 4, 5 and 6 were internationally validated scalesperceived stress scale (pss-14), generalized anxiety disorder assessment scale (gad-7) and edinburg perinatal depression scale (epds) whose cronbach’s alpha values were 0.85, 0.89 and 0.74 respectively.[7,8,9] part 1: questions related to socio-demographic variables: age, religion, ethnicity, residence, marital status, education, husband’s education, occupation, occupation of husband, household income, salary status during lockdown and family type. part 2: questions related to obstetric factors: trimester, type of pregnancy, type of conception, parity, number of children, presence of any disease before pregnancy, history of abortion, timely antenatal checkups during lockdown and mode of antenatal checkups during lockdown. part 3: questions related to covid-19 measures: presence of family members working as covid-19 frontliner (health care worker), effect of social distancing on daily life activities, pregnant women’s fear during covid-19 and effects experienced by pregnant women during lockdown. part 4: perceived stress scale (pss-14) is a five point likert scale measuring perceived stress where 0 = never, 1 = low, 2 = moderate, 3 = much, 4 = very much. there are total 10 statements in the scale among which 4 items (4, 5, 7, 8) are of positive concepts for which reverse coding is done. scores range from 0 to 40.[10] participants with a score of 20 and above are regarded as stressed and below as non-stressed.[11] part 5: generalized anxiety disorder (gad-7) is a seven-item instrument that is used to measure the severity of generalized anxiety disorder (gad). response options scored as 0=“not at all,” 1=“several days,”2=“more than half the days” and 3=“nearly every day”. total score ranges from 0 to 21. a score of 10 and above is considered as cutoff point for identifying cases of gad.[8] part 6: edinburg perinatal depression scale (epds) has 10 multiple-choice questions; each question scored with a 0, 1, 2, or 3 (maximum score = 30). participants scoring 13 and above are categorized as depressed.[9] all collected data were checked, reviewed, coded and organized for its accuracy, completeness, and consistency and further analyzed via statistical j. lumbini. med. coll. vol 9, no 1, jan-june 2021 thapa p, et al. pregnant women’s mental health status and its related factors amidst covid-19: a cross-sectional study jlmc.edu.np package for social science (spss) version 16. data were analyzed and interpreted in terms of descriptive statistics (frequency, mean, range, percentage and standard deviation) and chi-square test was used to determine the statistical association of mental health status with the selected variables. statistical significance was assessed at level of <0.05. results: the mean age of the participants was 27.06 ± 4.64 years. majority (82.6%) of the participants were hindu. more than half (52.7%) of the participants were brahmin and chhetri and most (62.0%) of them were from urban area. almost half (43.5%) were educated up to secondary level. majority (64.7%) of the participants were unemployed and among the employed, only half (55%) of them were getting paid during the lockdown period. majority (65.5%) of the participants’ husband were educated up to higher secondary, most (85.3%) of them were employed and 77.9% were getting salary in the lockdown period. almost half (52.2%) of the participants had their monthly family income more than npr 25000. majority (68.5%) of the participants were from joint family. about two-thirds (66.6%) of the participants were in third trimester, the majority (87.8%) had planned pregnancy and almost all (98.9%) had natural conception. almost half (54.9%) of the participants were primigravidae and 55.2% had no children. majority (96.2%) of the participants did not have any disease before pregnancy and only 16% had a history of abortion. only 53.5% of the participants could continue their regular antenatal checkups during lockdown period, among which 71.7% had their checkups visiting hospital, 14.7% through phone calls and 0.3% through video call. participants infected with covid-19 accounted for 2.2% in this study. half (50.3%) of the participants stated that they were somewhat affected by social distancing whereas, 9.5% were extremely affected by social distancing. majority (71.7%) of the participants were afraid of getting infected with the virus followed by being unaware of the mode of delivery (64.4%) in this pandemic period. regarding the effect of covid-19 experienced by the participants, majority (61.1%) faced inadequate antenatal checkups followed by inadequate social support (57.1%) and transmission of vague and inaccurate information from different sources (50.5%). a very meagre portion (5.4%) of the participants faced domestic violence from family members. more details regarding the covid-19 related measures are presented in table 1 and 2. table 1. covid-19 related fears of the participants (n=368). fears* n (%) outcome of the unborn baby 232 (63.0) getting infected with the virus 264 (71.7) uncertainty regarding the mode of delivery 237 (64.4) probability of getting isolated from the baby if tested positive for covid-19 199 (54.1) not being able to be with the chosen ones at the time of delivery 155 (42.1) change of hospital 122 (33.2) unavailability of vehicles to reach hospital during emergency 146 (39.7) caregiver shortage 146 (39.7) missed antenatal appointment and visits 83 (22.6) *multiple response table 2: covid-19 related effects experienced by the participants (n=368). effects* n (%) inadequate social support 210 (57.1) inadequate antenatal check ups 225 (61.1) vague and inaccurate information from different sources 186 (50.5) reduced household finances 109 (29.6) being subjected to domestic violence from family members 20 (5.4) no proper arrangements of equipment and supplies needed for delivery and postnatal care 25 (6.8) lack of motivation to exercise/ physically inactive due to lockdown 122 (33.2) unavailability of choices for healthy foods 156 (42.4) over eating 81 (22.0) over resting 67 (18.2) *multiple response prevalence of stress, anxiety and depression among the pregnant women were found to be 41%, j. lumbini. med. coll. vol 9, no 1, jan-june 2021 thapa p, et al. pregnant women’s mental health status and its related factors amidst covid-19: a cross-sectional study jlmc.edu.np 28.5% and 33.2% respectively which is depicted in table 3. table 3. prevalence of stress, anxiety and depression among the participants (n=368). status stress n (%) anxiety n (%) depression n (%) yes 151 (41) 105 (28.5) 122 (33.2) no 217 (59) 263 (71.5) 246 (66.8) on bivariate analysis, age, salary status of the participant and their husband during lockdown, presence of family member working as covid-19 front liner, and effect of social distancing were significantly associated with perceived stress (p<0.05). furthermore, age, education, employment status of the participant, family monthly income, trimester and effect of social distancing were associated with anxiety (p<0.05). age, salary status of husband during lockdown, trimester, parity, being infected with covid-19 and effect of social distancing had significant association with depression (p<0.05). the details are represented in table 4. discussion: reproductive health and mental health are interwoven and a complete well-being cannot be obtained without their integration. mental health in pregnancy was never addressed to the extent of its necessity while this covid-19 pandemic has shown the ever present gap in maternal mental health worldwide.[12] the prevalence of stress, anxiety and depression in this study was found to be 41%, 28.5% and 33.2% respectively. the occurrence of depression is in agreement with the results of a study conducted in iran. however, in contrast, stress was higher and anxiety was lower in our study compared to the same study findings.[13] study conducted in china had higher prevalence of perceived stress, anxiety and depression.[14] this difference might be due to china being the epicenter of the emergence of covid-19. a turkish study which examined the same population of pregnant women prior and during the covid-19 pandemic found that depression and anxiety level were significantly increased in the latter period.[15] results of present study are in line with studies conducted in nepal before pandemic, showed the prevalence of stress, anxiety and depression to be table 4. association of perceived stress, anxiety and depression with selected variables. perceived stress anxiety depression variables no n (%) yes n (%) p value no n (%) yes n (%) p value no n (%) yes n (%) p value age (yrs) 0.01 0.03 0.07 15-25 77(51.7) 72(48.3) 96(64.4) 53(35.6) 101(67.8) 48(32.2) 26-35 127(62.3) 77(37.7) 154(75.5) 50(24.5) 139(68.1) 65(31.9) 36-45 13(86.7) 2 (13.3) 13(86.7) 2(13.3) 6(40.0) 9(60.0) salary status of husband < 0.001 0.86 0.04not paid 29(43.3) 38(56.7) 47(70.1) 20(29.9) 39(58.2) 28(41.8) paid 146(61.9) 90(38.1) 163(69.1) 73(30.9) 168(71.2) 68(28.8) trimester 0.15 0.04 0.03first 17(68.0) 8(32.0) 20(80.0) 5(20.0) 17(68.0) 8(32.0) second 64(65.3) 34(34.7) 78(79.6) 20(20.4) 55(56.1) 43(43.9) third 136(55.5) 109(44.5) 165(62.7) 80(32.7) 174(71.0) 71(29.0) effect of social distancing < 0.001 0.01 < 0.001 not at all 98(66.2) 50(33.8) 113(76.4) 35(23.6) 116(78.4) 32(21.6) somewhat 106(57.3) 79(42.7) 132(71.4) 53(28.6) 117(63.2) 68(36.8) extremely 13(37.1) 22(62.9) 18(51.4) 17(48.6) 13(37.1) 22(62.9) j. lumbini. med. coll. vol 9, no 1, jan-june 2021 thapa p, et al. pregnant women’s mental health status and its related factors amidst covid-19: a cross-sectional study jlmc.edu.np lesser than the finding of this study.[16,17,18] this shows the increment in the prevalence of mental health disorders after the emergence of covid-19. fear of unknown, fear of the outcome of the unborn child, disruption of routine prenatal care, inability to access reliable information and reduced daily routines and social interactions because of quarantine were the factors causing anxiety in turkish pregnant women during the covid-19 pandemic.[19] similar fears and effects were experienced by the pregnant women in this study. misinformation can lead to fear and anxiety. therefore reliable sources should provide accurate information in such a crisis period.[20] majority of the participants in this study also faced the inaccurate overflow of information regarding covid-19. antenatal visits were suspended except for critical situations, while in some countries, pregnant women were asked only to come at the time of birth.[21,22] likewise, in nepal, pregnant women were requested to postpone their regular antenatal checkups to reduce iatrogenic transmission.[23] in this study almost half of the participants were devoid of getting timely antenatal checkups during lockdown. mobilization of the female community health volunteers (fchv) for antenatal and postnatal checkups to identify any danger signs would benefit these crisis periods. necessary protocols of physical distancing and hand washing along with other preventive approaches must be briefed to the fchvs.[23] the results of the present study showed that women often felt lack of motivation to exercise and remained physically inactive due to lockdown as well as complained about over resting. these findings are in agreement with the study conducted among spanish pregnant women.[24] physical inactivity during pregnancy may result in complications such as obesity and gestational diabetes mellitus.the rcog (royal college of obstetricians and gynecologists) suggests that the covid-19 pandemic increases the risk of perinatal anxiety, depression, and domestic violence in pregnant women.[25] though a meagre proportion (5.4%) of the participants in this study suffered domestic violence from their family member. a study conducted in austria had 37.5% of the participants experiencing increased stress about conflict between household members.[26] this effect may be the most neglected consequence of lockdown but the important one that has to be addressed properly and timely. in this study, lower age group women had stress and anxiety in comparison to the other age groups. however in a study conducted in iran reported higher depression, anxiety and stress in women with more advanced age.[27] lower level of education was significantly associated with anxiety in this study. this finding is supported by various other studies suggesting that lower level of education have a tendency to elicit poor mental health status.[28,29] good mental health is successively related to her being educated to higher levels. being unemployed was associated with the presence of stress among the participants of this study, salary status of participants and their husband were also associated with anxiety and depression. those who had not got their salary during this lockdown period were presented with anxiety and depression than among those who were getting their salary in lockdown time. similarly those with lower monthly income were more anxious than the other with higher level of household income which is similar with findings of study conducted in iran.[30] in this study, women in second and third trimester were found to be anxious and depressed than in the first trimester which is similar to the findings of the iranian study.[30] the present study showed that primipara mothers were more depressed in comparison to the multipara which is in contrast to a finding of a systamatic review conducted by yan haohao et al.[31] the study conducted by moyer et al. showed family member being an essential frontline worker during covid-19 was significant driver of greater changes in pregnancy related anxiety which is in contrast with present study.[26] this may be because they are practising preventive measures very effectively and following the health care advices of covid-19 seriously. with the compliance, they could have developed more confidence in their practice of avoiding the virus and thus were less anxious in contrast to other group. effect of social distancing had a significant association with all the mental health status parameters in this study. those who were extremely affected by the social distancing protocol had more perceived stress, anxiety and depression. this finding is in agreement with the study conducted in jordan.[32] the limitation of the study is that data is collected through online so it ignores the pregnant women who do not have access to the internet and results are totally based on their self-declaration. hence, the results cannot be generalized. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 thapa p, et al. pregnant women’s mental health status and its related factors amidst covid-19: a cross-sectional study jlmc.edu.np conclusion: this study highlighted the high prevalence rate of stress, anxiety and depression among the pregnant women. therefore, it is very much essential to focus on mental health status of such high risks group. preparedness for maternal mental health care in such public health emergencies is the utmost necessity. measurements such as awareness programs targeting the pregnant women, provision of information flow on coping during the pandemic situations, screening of the antepartum mental health status and provision of tele-psychiatry services could be beneficial in 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perceived stress and associated factors among pregnant women attending antenatal care in urban thailand. psychol res behav manag. 2020;13:1115-22.pmid: 33293879 doi: https://doi.org/10.2147/prbm. s290196 12. aryal s, pant sb. maternal mental health in nepal and its prioritization during covid-19 pandemic: missing the obvious. asian j psychiatr. 2020;54:102281.pmid: 32653855 doi: https://doi.org/10.1016/j.ajp.2020.102281 13. effati-daryani f, zarei s, mohammadi a, hemmati e, ghasemiyngyknd s, mirghafourvand m. depression, stress, anxiety and their predictors in iranian pregnant women during the outbreak of covid-19. bmc psychol. 2020;8(1):99. pmid: 32962764 doi: https://doi.org/10.1186/s40359-020-00464-8 14. jiang h, jin l, qian x, xiong x, la x, chen w, et al. maternal mental health status and approaches for accessing antenatal care information during the covid-19 epidemic in china: cross-sectional study. j med internet res. 2021;23(1):e18722. pmid: 33347423 doi: https://doi.org/10.2196/18722 15. ayaz r, hocaoǧlu m, günay t, yardlmcl od, turgut a, karateke a. anxiety and depression symptoms in the same pregnant women before and during the covid-19 pandemic. j perinat med. 2020;48(9):965-70. pmid: 32887191 doi: https://doi.org/10.1515/jpm-2020-0380 16. aryal kk, alvik a, thapa n, mehata s, roka t, thapa p, et al. anxiety and depression among pregnant women and mothers of children under one year in sindupalchowk district. j nepal health res counc. 2018;16(2):195-204. pmid: 29983437 17. pantha s, hayes b, yadav bk, sharma p, shrestha a, gartoulla p. prevalence of stress among pregnant women attending antenatal care in a tertiary maternity hospital in kathmandu. journal of women’s health care. 2014;3(5):1000183. doi: http://dx.doi. org/10.4172/2167-0420.1000183 18. joshi d, shrestha s, shrestha n. understanding the antepartum depressive symptoms and its risk factors among the pregnant women visiting public health facilities of nepal. plos one. 2019;14(4):e0214992. pmid: 30947251 doi: https://doi.org/10.1371/journal.pone.0214992 19. mizraksahin b, kabakci en. the experiences of pregnant women during the covid-19 pandemic in turkey: a qualitative study. women birth.2021;34(2):162-69. pmid: 33023829 doi: https://doi.org/10.1016/j.wombi.2020.09.02 20. corbett ga, milne sj, hehir mp, lindow sw, o’connell mp. health anxiety and behavioural changes of pregnant women during the covid-19 pandemic. eur j of obstet gynecol reprod biol. 2020;249:96-7. pmid: 32317197 doi: https:// doi.org/10.1016/j.ejogrb.2020.04.022 21. walton g. covid-19. the new normal for midwives, women and families. midwifery. 2020;87:102736. pmid: 32414529 doi: https:// doi.org/10.1016/j.midw.2020.102736 22. furuta m. 2020 international year of midwiferyin the midst of a pandemic. midwifery. 2020;87:102739. pmid: 32389529 doi: https:// doi.org/10.1016/j.midw.2020.102739 23. aryal s, shrestha d. motherhood in nepal during covid-19 pandemic: are we heading from safe to unsafe? journal of lumbini medical college. 2020;8(1):128-9. doi: https:// doi.org/10.22502/jlmc.v8i1.351 24. biviá-roig g, la rosa vl, gómez-tébar m, serrano-raya l, amer-cuenca jj, caruso s, et al. analysis of the impact of the confinement resulting from covid-19 on the lifestyle and psychological wellbeing of spanish pregnant women: an internet-based cross-sectional survey. int j environ res public health. 2020;17(16):5933.pmid: 32824191 doi: https://doi.org/10.3390/ijerph17165933 j. lumbini. med. coll. vol 9, no 1, jan-june 2021 thapa p, et al. pregnant women’s mental health status and its related factors amidst covid-19: a cross-sectional study jlmc.edu.np 25. royal college of obstetricians and gynaecologists. coronavirus infection and pregnancy [internet]. london, uk: royal college of obstetricians and gynaecologists; 2021 [cited 2021 feb 21]. available from: https://www. rcog.org.uk/en/guidelines-research-services/ guidelines/coronavirus-pregnancy/ 26. moyer ca, compton sd, kaselitz e, muzik m. pregnancy-related anxiety during covid-19: a nationwide survey of 2740 pregnant women. arch womens ment health. 2020;23(6):757-65. pmid: 32989598 doi: https://doi.org/10.1007/ s00737-020-01073-5 27. keramat a, malary m, moosazadeh m, bagherian n, rajabi-shakib mr. factors influencing stress, anxiety, and depression among iranian pregnant women: the role of sexual distress and genital self-image. bmc pregnancy and childbirth. 2021;21:87. pmid: 33499805 doi: https://doi. org/10.1186/s12884-021-03575-1 28. kahyaoglusut h, kucukkaya b. anxiety, depression, and related factors in pregnant women during the covid-19 pandemic in turkey: a web-based cross-sectional study. perspect psychiatr care. 2021;57(2):860-8. pmid: 32989798 doi: https://doi.org/10.1111/ ppc.12627 29. taubman – ben-ari o, chasson m, abu sharkia s, weiss e. distress and anxiety associated with covid-19 among jewish and arab pregnant women in israel. j reprod infant psychol. 2020;38(3):340-8. pmid: 32573258 doi: https://doi.org/10.1080/02646838.2020.178603 7 30. saadati n, afshari p, boostani h, beheshtinasab m, abedi p, maraghi e. health anxiety and related factors among pregnant women during the covid-19 pandemic: a cross-sectional study from iran. bmc psychiatry. 2021;21(1):95. pmid: 33588794 doi: https://doi.org/10.1186/ s12888-021-03092-7 31. yan h, ding y, guo w. mental health of pregnant and postpartum women during the coronavirus disease 2019 pandemic: a systematic review and meta-analysis. front psychol. 2020;11:617001. pmid: 33324308 doi: https://doi.org/10.3389/ fpsyg.2020.617001 32. muhaidat n, fram k, thekrallah f, qatawneh a, al-btoush a. pregnancy during covid-19 outbreak: the impact of lockdown in a middle-income country on antenatal healthcare and wellbeing. int j womens health. 2020;16;12:1065-73. pmid: 33235516 doi: https://doi.org/10.2147/ijwh.s280342 knowledge on perimenopausal symptoms among women attending lumbini medical college teaching hospital parbati nepal paudyala, manju nepalb —–————————————————————————————————————————————— abstract: introduction: perimenopause is an unavoidable stage of a woman’s reproductive life that starts several years before menopause. due to declining estrogen level, women experience physiological and psychological changes during perimenopausal period and sometimes symptoms are very distressing that affect the women’s quality of life negatively. this study was done to assess the knowledge of women about perimenopausal symptoms. methods: a cross-sectional analytical study was done at lumbini medical college (lmc) throughout the months of november and december, 2013. women of age 40-60 years, attending various clinics in lmc and ready to take part in the study were included. a total of 142 women were selected purposefully. the data was collected using the semi structured interview schedule. results: the study revealed that half of respondents were between age group 40-44 years, 141 (99.3%) were married and 82 (57.7%) were literate. three quarter of respondents (74.6%) were menstruating women. the main source of information on perimenopausal symptoms was friends and relatives (81.2%). majority of respondents (n=90, 63.4%) had poor, 52 (33.8%) had fair and only 2.8% had good level of knowledge on perimenopausal symptoms. the respondents’ level of knowledge on perimenopausal symptoms was statistically significant with educational status (p<0.001), level of education (p=0.048) and economic status (p=0.02). conclusion: many women have poor knowledge on perimenopausal symptoms. the role of health care provider is that they should seriously discuss about mid-life women’s health problems including perimenopausal symptoms and treatment modality including hormonal replacement therapy so the quality of life of women can be improved. keywords: knowledge • perimenopause • quality of life —————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, college of nursing, lumbini medical college b lecturer, lalitpur nursing campus, sanepa corresponding author: parbati nepal paudyal e-mail: kirparu@gmail.com how to cite this article: paudyal pn, nepal m. knowledge on perimenopausal symptoms among women attending lumbini medical college teaching hospital. journal of lumbini medical college. 2014;2(2):41-4. doi: 10.22502/ jlmc.v2i2.56. ___________________________________________________________________________________ j. lumbini. med. coll. vol 2, no 2, july-dec 2014 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v2i2.56 perimenopause or menopausal transition, is the stage of a woman’s reproductive life that begins several years before menopause, when the ovaries gradually begin to produce less estrogen. it usually starts in a women’s forties. perimenopause lasts up until menopause, the point when the ovaries stop releasing eggs. in the last one to two years of perimenopause, the decline in estrogen accelerates. at this stage, many women experience menopausal symptoms.2 during perimenopause, ovarian activity declines (estrogenic activity is reduced), leads to different signs and symptoms in women. often, the first sign of the perimenopause is menstrual irregularity. vasomotor symptoms include hot flush, symptoms of palpitation, fatigue and weakness. “hot flush” is characterized by sudden feeling of heat by waves of vasodilatation affecting the face and neck and may last for one to ten minutes accompanied introduction: menopause is the permanent cessation of menstruation at the end of a woman’s reproductive life due to loss of ovarian follicular activity. it is the point of time when the last and final menstruation occurs. the clinical diagnosis is confirmed following stoppage of menstruation (amenorrhea) for twelve consecutive months in absence of any other pathology.1 41 j. lumbini. med. coll. vol 2, no 2, july-dec 2014 jlmc.edu.np paudyal et al. knowledge on perimenopausal symptoms among women attending lumbini medical college teaching hospital by profuse perspiration. they also tend to occur at night, interrupting sleep patterns and causing insomnia.1 other important physical changes during perimenopausal period are genital changes and sexual dysfunction vaginal dryness and loss of libido and vaginal atrophy and dyspareunia. urinary frequency, painful urination, uterine prolapse, and stress incontinence are also important symptoms of perimenopause.2 neurotic and psychotic changes of perimenopause include irritability, decreased concentration, nervousness, depression and memory loss. headaches are also common and there may be insomnia, paresthesia of the hand and feet, giddiness and tinnitus.3 perimenopause is a normal stage in a women’s life. however, it can be associated with health complaints, a decreased quality of life, and an increased risk for some illnesses such as osteoporosis and coronary heart disease. women can experience moderate or severe health effects that may persist for several years. these effects can have a large impact on women's physical and psychosocial health and wellbeing.4,5 assessing the perimenopausal knowledge base is very important. most importantly, there is a need for perimenopausal educational programs to be developed and implemented.6 there are very few studies conducted to assess the level of knowledge about perimenopausal symptoms in nepalese women. studies regarding knowledge on perimenopausal symptoms among nepalese women have not been reported. assessing the knowledge is preliminary action for taking appropriate intervention like health awareness program and campaign. so the was done to assess the knowledge regarding perimenopausal symptoms among the women in nepalese context. methods: an analytical cross-sectional study was done to assess the knowledge in which 142 women were selected purposefully. women visiting various clinics of lumbini medical college, aged between 40-60 years and ready to take part in the study were included. the data was collected throughout the months of november and december, 2013, using the face to face interview technique. a semi-structured questionnaire was developed to collect data. the questionnaire was tested by a panel of experts to reduce ambiguity, leading questions, emotive questions and stressful questions. ethical clearance was taken from the institutional review committee of lumbini medical college. special care was taken to maintain ethical issues during data collection. anonymity of all participants was maintained. data was entered in microsoft excel 2010 and analyzed by using spss version 17. various tests such as frequency distribution, chi-square were applied. results: table 1 shows the sociodemographic details of the women and table 2 shows the respondents knowledge on menopause. the mean age of the respondents was 45.4 years (sd=3.6 years, range 40-53 years). table 3 shows the respondents knowledge about physical sign and symptoms of perimenopause. table 4 shows the respondents knowledge about psychological sign and symptoms of perimenopause, which shows that majority (76.8%) of respondent answered that irritability was a perimenopausal symptom. table 5 shows the sources from where information on perimenopausal symptoms reached the respondents in which radio/ television was the commonest. table 6 shows the distribution of respondents according to their level variables n % age group in years 40-44 71 50 45-49 56 39.4 >49 15 10.6 marital status married 141 99.3 unmarried 1 0.7 religion hindu 137 96.5 buddhist 5 3.5 education status literate 82 57.7 illiterate 60 42.3 education level can just read and write 40 48.7 primary level 20 24.3 secondary level 16 19.5 higher secondary 3 3.6 graduate and higher 3 3.6 caste brammin/chhetri 79 55.6 newar 10 7.0 gurung/magar/tamang 31 21.8 b.k/nepali/dargi 22 15.5 economic status enough to full fill the basic need 82 57.7 not enough to full fill the basic need 49 34.5 extra saving 11 7.7 table 1: socio-demographic characteristics of respondents (n=142) 42 j. lumbini. med. coll. vol 2, no 2, july-dec 2014 paudyal et al. knowledge on perimenopausal symptoms among women attending lumbini medical college teaching hospital jlmc.edu.np variables n % accurate meaning of menopause 45 31.7 average age of menopause 65 45.8 menopause a natural process of aging 142 100 knowledge about surgical menopause 40 35.4 table 2: respondents’ knowledge on menopause (n=142) table 3: respondents' knowledge on physical sign and symptoms of perimenopause variables n % hot flushes 70 49.3 vaginal dryness & dyspareunia 91 64.1 loss of interest in sex 118 83.1 palpitation 73 51.4 stress incontinence 134 94.4 back pain and joint pain 124 87.3 table 4: respondents' knowledge on psychological sign and symptoms of perimenopause variables n % mood swing 73 51.4 lack of concentration 95 66.9 irritability 109 76.8 anxiety 87 61.3 sleep disturbance 103 72.5 sources of information n % radio/television 78 56.5 doctor/nurse 24 17.4 pamedical staffs 58 42.0 friends/relatives 112 81.2 internet books/magazine/leaflets 13 9.4 table 5: sources of perimenopausal information of respondents of knowledge regarding perimenopausal symptoms. majority (63.4%) of the respondents had poor level of knowledge, more than one quarter (33.8%) had fair and very few (2.8%) had good level of knowledge on perimenopausal symptoms. table 6 shows that the level of knowledge regarding perimenopausal symptoms among women is significantly higher in literates. the knowledge is similar in different age group, ethinic groups and in people with different marital status. discussion: this study revealed that the level of knowledge regarding perimenopausal symptoms variables level of knowledge p poor (%) fair(%) age group 0.49 45 years below 43(60.6) 28(39.4) 45 years above 47(66.2) 24(33.8) ethnicity 0.15 bramin/chhetri 46(58.2) 33(41.8) others 44(69.8) 19(30.2) education status <.001 literate 42(51.2) 40(48.8) illiterate 48(80) 12(20) level of education can read and write 26(65) 14(35) primary level 7(35) 13(65) secondary and higher 9 (40.9) 13(59.1) economic status fullfills basic needs 51 (62.2) 31(37.8) cannot fulfill basic needs 36(73.5) 13(26.5) extra saving 3(27.3) 8(72.7) marital status 0.39 having spouse 76(61.6) 47(38.2) having no spouse 13(72.2) 5(27.8) table 6: association between level of knowledge regarding perimenopausal symptoms and socio-demographic variables was statistically significant with education status (p<.001). the mean score of knowledge associated with perimenopause was 45.44 (sd= 6.2). this results is supported by the study conducted on taiwanese women which revealed that education level was statistically significant with level of perimenopausal knowledge (p=0.000) and mean score of knowledge associated with perimenopause was 46.31.7 concerning menopause as a natural processes of aging; this study reported that all the respondents accepted that it is a part of ageing. this result is supported by the study conducted in italian women which reported that more than 90% believed that menopause is a normal phase in women’s life.8 another study conducted by malik reported that 94% of the respondents considered that the menopause is a normal transition in women’s life.9 this study reported that 63.4% of respondents had poor, 33.8% had fair and only 2.8% had good level of knowledge regarding menopause. the reason behind the poor knowledge may be due to less appropriate source of information as majority of the women (81.2%) discuss their problems with their friends or relatives but not with doctors or nurses. concerning hot flushes as a perimenopausal 43 paudyal et al. knowledge on perimenopausal symptoms among women attending lumbini medical college teaching hospital jlmc.edu.npj. lumbini. med. coll. vol 2, no 2, july-dec 2014 symptom, this study revealed that, almost half of the respondents (49.3%) answered that it is a one of the perimenopausal symptom. this findings is supported by the study conducted in nigeria which reported that among the 533 women, 51% believed that hot flush was a menopausal symptom.10 similar findings was found in the study conducted by wong which reported that 67.6% of the respondents answered that hot flush is a menopausal symptom.11 our study reported that 94.4% of respondents answered stress incontinence as a perimenopausal symptom. joint pain and back pain is reported by 87.3%, decrease interest in sex by 83.1%, irritability by 76.8%, sleep disturbances by 72.55%, lack of concentration by 66.9%, vaginal dryness by 64.1%, anxiety by 61.3%, mood swing by 51.4% and pain during sexual intercourse by 40.1%. a study conducted in malaysia reported that out of 395 respondents, 86.5% had depression, 85.6% had irritability, 80.5% had vaginal dryness, 77.5% had forgetfulness, 63.5% had no sexual desire, 53.4% had urine leakage and 48.9% had painful intercourse as menopausal symptoms.11 conclusion: the study revealed that respondents’ knowledge regarding perimenopausal symptoms is poor. the reason behind the poor knowledge may be due to less appropriate source of information. though nearly half of the respondents were literate, they had only very basic level education so that education might be influencing factor for poor knowledge. none of the respondent referred internet as a source of information. this study revealed that the level of knowledge on perimenopause is statistically significant with education status, level of education and economic status. on this basis of facts, we concludes that there is a need to educate women so they can gain knowledge in different aspect of their life including perimenopause. references: 1. dutta dc. test book of gynaecology including contraception. 6th ed. calcutta: new central book agency; 2008. 2. lowermilk dl, perry se, bobak im. maternity & women’s health care.7th ed. st. louis, london: mosby; 2000. 3. kumar p, malhotra n, jeffcoate n. jeffcoate’s principles of gynaecology. 7th ed. new delhi: butterworths; 2008. 4. shaw w, padubidri v, daftary s, howkins j, bourne g. howkins & bourne; shaw’s textbook of gynaecology. noida, india: elsevier; 2008. 5. the women’s health council [ internet]. [updated 2012 sep 10]. available from: http://www.dohc.ie/about_us/divisions/whc_menopause/biomed_review.pdf 6. twiss jj, wegner j, hunter m, kelsay m, rathe-hart m , salado w. perimenopausal symptoms, quality of life, and health behaviors in users and nonusers of hormone therapy. j am acad nurs pract. 2007 nov;19(11):602-13. 7. tsao li, chang wy, hung ll, chang sh, chou pc. premenopausal knowledge of mid-life women in northern taiwan. j clin nurs. 2004 july;13(5):627-35. 8. donati s, cotichini r, mosconi p, satolli r, colombo c, liberati a, mele ea. menopause: knowledge, attitude and practice among italian women. maturitas. 2009 jul 20;63(3):246-52. 9. malik hs. knowledge and attitude towards menopause and hormone replacement therapy (hrt) among postmenopausal women. j pak med assoc. 2008 apr;58(4):164-7. 10. ande ab, omu op, ande oo , olagbuji nb. features and perceptions of menopausal women in benin city, nigeria. ann afr med. 2011 oct-dec;10(4):300-4. 11. wong lp, nur-liyana ah. (2007). a survey of knowledge and perceptions of menopause among young to middle-aged women in federal territory, kuala lumpur, malaysia. jummec. 2007;10(2):22-30. 44 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 nepal s, et al. reproductive health issues and use of family planning methods among married adolescent mothers. 244 jlmc.edu.np ___________________________________________________________________________________ submitted: 20 september, 2020 accepted: 1 december, 2020 published: 3 december, 2020 alecturer, department of community medicine, bassistant professor, department of obstetrics and gynaecology, clumbini medical college and teaching hospital, palpa, nepal. corresponding author: dr. samata nepal e-mail: samata.kool@gmail.com orcid: https://orcid.org/0000-0001-9189-4510_______________________________________________________ abstract: introduction: adolescent pregnancy is a major public health concern in lowand middle-income countries. nepal ranks among the twenty countries with the highest child marriage rates in the world. adolescent mothers are at higher risk for poorer maternal and neonatal outcomes. this study intended to find the reproductive health issues and use of family planning methods among married adolescent mothers at a tertiary care center in a western part of nepal. methods: this was a cross-sectional study conducted among adolescent mothers who attended the family planning counselling session at community medicine outpatient department at a tertiary care center. pre-tested semi-structured questionnaire was used for data collection and variables were entered in spsstm version 16. descriptive statistics were presented in terms of mean and percentage. results: among 235 adolescent mothers, the mean age of adolescent mothers was 18.02 years (sd = 1.13). almost 93.2% had not used any kind of contraceptive methods previously. limited knowledge, uncomfortable talking about contraception and spousal denial were common reasons for not using contraception. obstetric related complications were observed in 13.6% and one in ten neonates required neonatal intensive care unit admission during the study period. after the counselling session, six out of ten expressed current choice of long acting reversible contraceptives method in which jadelle implant was preferred. conclusion: our study among the adolescent mothers showed that use of family planning methods before pregnancy had been very low. policies need to focus on meeting the unmet need for family planning among married adolescent girls. keywords: adolescent mothers, family planning methods, reproductive health original research articlehttps://doi.org/10.22502/jlmc.v8i2.404 samata nepal,a,c shreyashi aryal b,c reproductive health issues and use of family planning methods among married adolescent mothers how to cite this article:how to cite this article: nepal s, aryal s. reproductive health issues and use of family planning methods among married adolescent mothers. journal of lumbini medical college. 2020;8(2):244-250. doi: https://doi. org/10.22502/jlmc.v8i2.404 epub: 2020 december 3. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: pregnancy in adolescents is a global health problem. globally, about 15 million adolescent pregnancies occur every year and accounts for 11% of total births.[1] the current adolescent birth rates per 1000 women (15-19 years) in nepal is 88[2] and nepal ranks among the twenty countries with the highest child marriage rates in the world. [3] the societal pressure to give birth soon after marriage, knowledge gaps regarding contraceptive use and limited autonomy put the newly married adolescent girls at risky pregnancy.[4] maternal and neonatal health outcomes are adverse in adolescent pregnancies when compared to pregnancy after 20 years of age. in addition, repeated pregnancies during adolescence risk for poorer maternal health, and socio-economic outcomes. pregnancy related complications and childbirth are major causes of mortality in 15-19-year girls worldwide.[5] j. lumbini. med. coll. vol 8, no 2, july-dec 2020 nepal s, et al. reproductive health issues and use of family planning methods among married adolescent mothers. 245 jlmc.edu.np according to the report from the world bank, contraception use among married adolescent girls is only 14% in nepal. increase in demand for contraceptive use among adolescents will help in delaying first births as well as healthy birth spacing can lead to healthy and productive life.[6] although policies are being implemented to end child marriage, addressing the adolescent’s reproductive health issues and meeting the need for family planning is equally important. the present study aimed to explore the reproductive health issues and use of family planning methods among adolescent mothers attending a tertiary care family planning unit in a western part of nepal. methods: this cross-sectional study was conducted at lumbini medical college and teaching hospital (lmcth), palpa, nepal over a period of six months from 1st january to 30th june, 2020. a questionnaire-based survey was carried out among adolescent mothers (10-19 years) who attended the out-patient department (opd) of family planning counselling unit. this study was approved by institutional review committee of lmcth (irc-lmc/07-j/019). sample size was calculated using the following formula: sample size (n) = z2pq/d2, where prevalence (p) = 0.17 [2], z = 1.96, standard normal variate for 95% confidence level, q = 1p = 1 0.17 = 0.83 d = 0.05. the minimum sample size calculated was 217. the participants were enrolled through a consecutive sampling technique. at the end of the counselling session participants were asked if they wanted to participate in the survey. informed consent was obtained for all the participants who wanted to participate in the study from their legal guardians. the study excluded unmarried adolescents, those with known mental health problems and those who refused to participate. data was collected through interviews using semi-structured questionnaires. the questionnaire used as the study tool in the present study was developed in nepali language in the department of community medicine after reviewing the published literature relevant to this study. the review and validation of questionnaire were done by a panel of experts from department of community medicine and department of obstetrics and gynaecology of lmcth. the questionnaire was pre-tested on adolescent mothers attending the family planning service comprising 10% of the sample size and they were not included in the present study proper. the questionnaire included demographic variables (current age, age at marriage, residence, ethnicity, education, occupation, continuity of education after marriage), husband’s information (current age, age at marriage, education, occupation), type of marriage, use of family planning methods after marriage and preference of family planning methods after delivery, reproductive health issues like parity, unintended pregnancy, antenatal care visits, mode of delivery, maternal and neonatal complications. each of the interview session lasted for 10-15 minutes. the participants were interviewed by the principal author and a nurse working in the community medicine opd. the family planning counselling unit of community medicine department of lmcth provides counselling to all the adolescent mothers using gather (greet, ask, tell, help, explain, and return) technique. gather is a client-centred counselling approach. this technique consists of six components; greet the client to build the rapport between counsellor and client; ask the client about the needs of family planning; tell the client about family planning methods suitable for her; help the client with her decision for using family planning methods; explain her about ways of using the methods; and return for follow-up.[7] the information about appropriate contraceptive methods, their advantages, disadvantages and adverse effects were explained during the sessions. every participant was allowed to choose the family planning methods of their choice. no any financial benefit was given to the participant. all the family planning methods were available at the department as per supply from government of nepal. if the adolescent mother chose any of the method, the service was given soon after. the data thus collected was entered and analysed in statistical package for social sciences (spsstm) version 16. continuous data were presented j. lumbini. med. coll. vol 8, no 2, july-dec 2020 nepal s, et al. reproductive health issues and use of family planning methods among married adolescent mothers. 246 jlmc.edu.np as mean and standard deviation; categorical data were presented as frequency and percentages. results: during the study period, 1234 clients attended the family planning counselling session, out of which 289 (23.41%) were adolescent mothers. among them 235 adolescent mothers gave consent to participate in the study.the mean age of adolescent mothers was 18.02 years (sd = 1.13), the mean age at marriage was 16.69 years (sd = 1.21) and the mean years of schooling was 8.28 years (sd = 2.31). more than half of the adolescent mothers were from janajati ethnicity. out of total, 224 (95.3%) of the participants were homemakers. almost 38.3% (90) of them had run away with their partners to marry. only 41 (17.4%) of the participants continued school after marriage and only 24 (10.2%) adolescent mothers were willing to continue school after delivery (table 1). the husband’s mean age at marriage was 21.51 years (sd = 2.8) with range of 14-31 years. almost 40% of the spouses had secondary level education and 28.9% of them were employed abroad and 40 (17.0%) were unemployed (table 2). table 2. demographic characteristics of spouse (n = 235). variables attributes n (%) spouse’s age at marriage < 20 years 56 (23.8) ≥ 20 years 179 (76.2) spouse’s mean age at marriage 21.51±2.8 years (range 14-31 years) spouse’s education primary and below 35 (14.9) lower secondary 74 (31.5) secondary 94 (40.0) higher secondary and above 32 (13.6) mean years of schooling 8.45 ± 2.34 years spouse’s occupation foreign employment 70 (29.8) technical job 54 (23.0) labourer 36 (15.3) shopkeeper/service 35 (14.9) unemployed 40 (17.0) around three fourth (74%) of the recent past pregnancies were not intended. the median anc visits was 4 where 79.2% of the adolescent mothers had completed their fourth ante-natal care (anc) visit. most of the participants had taken iron and calcium supplements (n= 216, 91.9%) and 220 (93.6%) adolescent mothers were immunized with td (tetanus diphtheria toxoid) during pregnancy. many of the adolescent mothers did not have obstetric complications (n= 203. 86.4%). more than two third had normal delivery and 94% (n=221) delivered full term babies. among the adolescent table 1. demographic characteristics of the study participants (n = 235). variables attributes n (%) age ≤ 17 years 59 (25.1) 18 – 19 years 176 (74.9) mean age 18.2 ± 1.13 years (range 1519 years) ethnicity dalit 63 (26.8) janajati 129 (54.9) madhesi 2 (0.9) muslim 2 (0.9) brahmin/ chettri 39 (16.5) address rural 200 (85.1) urban 35 (14.9) age at marriage ≤17 years 164 (69.8) 18 – 19 years 71 (30.2) mean age at marriage 16.69 ± 1.21 years (range 14 19 years) education level primary and below 34 (13.5) lower secondary 79 (33.6) secondary 93 (39.6) higher secondary and above 29 (12.3) mean years of schooling 8.28 ± 2.31 years occupation homemaker 224 (95.3) employed 11 (4.7) type of marriage arranged 73 (31.1) love 72 (30.6) ran away 90 (38.3) continuation of school after marriage yes 41 (17.4) no 194 (82.6) desired to continue school after delivery yes 24 (10.2) no 211 (89.8) j. lumbini. med. coll. vol 8, no 2, july-dec 2020 nepal s, et al. reproductive health issues and use of family planning methods among married adolescent mothers. 247 jlmc.edu.np mothers 34 (14.5%) had low birth weight (lbw) babies and seven (2.9%) were born dead. one in ten new born had complications at birth and needed neonatal intensive care unit (nicu) admission (table 3). table 3. reproductive health issues related to recent pregnancy (n = 235 unless specified otherwise). variables attributes n (%) pregnancy intended yes 61 (26.0) no 174 (74.0) no. of anc visits none 11 (4.6) 1-3 visits 38 (16.2) ≥4 visits 186 (79.2) antenatal supplements iron and calcium yes 216 (91.9) no 19 (8.1) tetanus diphtheria injection (both doses) yes 220 (93.6) no 15 (6.4) obstetric complication present 32 (13.6) absent 203 (86.4) complications observed* pregnancy induced hypertension 5 (15.6) eclampsia 2 (6.3) post-partum haemorrhage 7 (21.9) pre-labour rupture of membrane 5 (15.6) prolonged labour 4 (12.5) iufd** 5 (15.6) oligohydraminous 3 (9.4) retained placenta 1 (3.1) gestational age at delivery term 221 (94.0) pre-term 14 (6.0) mode of delivery vaginal delivery 181 (77.0) caesarean delivery 54 (23.0) outcome of the delivery normal birth weight 194 (82.6) low birth weight 34 (14.5) born dead 7 (2.9) neonatal intensive care admission yes 26 (11.1) no 209 (88.9) *(n = 32) **iufd: intra uterine fetal death table 4 illustrates the use of family planning methods among adolescent mothers. among the participants, 228 (97%) were primi-para and six out of 10 did not want to delay their first pregnancy. almost 93.2% (n = 219) did not use any kind of contraceptive methods previously. regarding the reason for not doing so, most of them (n= 94, 42.9%) stated that they had not known about using contraceptive methods. one fourth of them had not been comfortable talking about contraception and 17.8% of the participants had not been supported by their partners to use contraception. table 4. use of family planning methods (n = 235 unless specified otherwise). variables attributes n (%) parity first 228 (97.0) second 7 (3.0) wanted to delay 1stpregnancy yes 93 (39.6) no 142 (60.4) previous abortion yes 8 (3.4) no 227 (96.6) contraceptive methods used condom 11 (4.7) pills 4 (1.7) depot-medroxyprogesterone acetate 1 (0.4) never used 219 (93.2) reason for not using any contraceptive previously* didn’t know 94 (42.9) was not comfortable to discuss 55 (25.2) spousal denial 39 (17.8) others 31 (14.1) desired birth spacing ≥ 3 years 224 (95.3) < 3 years 11 (4.7) desire to use any contraceptive methods yes 187 (79.6) no 48 (20.4) contraceptive methods** larc*** 112 (59.9) nonlarc 75 (40.1) *(n = 219), **(n = 187), ***larc: long acting reversible contraceptive most of the adolescent mothers (n=224, 95.3%), after the counselling session, said that they wanted birth spacing for three years or more. six out of ten, chose long acting reversible contraceptive (larc) methods in which jadelle implant was most preferred (fig. 1). j. lumbini. med. coll. vol 8, no 2, july-dec 2020 nepal s, et al. reproductive health issues and use of family planning methods among married adolescent mothers. 248 jlmc.edu.np discussion: this study aimed to evaluate the reproductive health issues related to recent past pregnancy and contraception use in adolescent mothers. our results showed that more than nine in ten adolescent married women had not used any modern family planning methods to delay their first pregnancy. however, most of them now wanted to use family planning methods and delay their next pregnancy. they preferred using jadelle implant followed by depot-medroxyprogesterone acetate (dmpa) over other methods. about one in four clients attending the family planning counselling session were adolescent mothers. the average age at marriage in the adolescent mothers was 16.69 years. nepal demographic health survey (ndhs) 2016 showed that average age at marriage is 17.9 years (among 2549 years). on average, adolescent girls in the area of our study married five years earlier than men (16.69 years versus 21.54 years) compared to the ndhs 2016 where the difference was four years.[2] this may be due to the study in limited geographical area as compared to the national data. child marriage is still common and girls in rural part of nepal marry a year earlier than those from urban area. more than half of the adolescent mothers in our study were from janajati ethnic group. the study from rupandehi showed that teenage pregnancy was common among dalit but ethnicity had no direct contribution for pregnancy among adolescents.[8] at the initial stages of reproductive life, married adolescents are not aware of the need of contraception. bearing a child shortly after marriage, preference of a male child, limited decision-making on reproductive issues within marriage are still prevelent in nepalese society. so, the adolescent mothers are less likely to delay their pregnancy or child-birth.[6] sexual health and contraception are often regarded as a matter of privacy. adolescents are reluctant to discuss things related to reproductive health with family members, friends and even sexual partners. so, the stigma of getting recognised at local facility, age and gender of health care provider, negative attitudes towards the actual needs of adolescents, lack of privacy and confidentiality were some barriers faced by adolescents for seeking reproductive health care and contraception.[4,9] the contraceptive prevalence is low in adolescents and one of the reasons would be husband’s employment at abroad and these girls need contraception infrequently. our results show that many of these adolescent mothers had middle school education and 38.3% had run away marriages with their partners. their partners also had similar education level and mean age of 21.51 ± 2.8 years. the young couple, with low education level and immature enough to run away to get married are less likely to make rational decision on the use of contraception. the knowledge about consequences of early subsequent pregnancies is doubtful. firstly, education tends to postpone child marriage. even after marriage, education influences on their reproduction by increasing knowledge on reproductive health, socio-economic status, as well as autonomy on their reproductive rights.[10,11] family planning services are the part of essential health services. government of nepal has declared contraceptive free of cost to everyone. adolescent and sexual reproductive health program has been implemented to all level of health care services. but the utilization of these services is as low as 24.7%.[12] many women still are not aware of contraceptive methods despite the government spending a major budget on awareness through media. alternative methods are required specially those targeting young married women. government now needs to focus on policies regarding education and uptake of contraception, involving both the partners.[13] the mothers in our study had good anc and immunization coverage. the complications observed in the present study could have been checked by delaying the pregnancy or early intervention. other studies also observed that the frequencies of developing complications for teen mothers was relatively higher when compared to adult mothers. [14,15] unintended pregnancy was observed in fig. 1: choice of contraceptive methods made by adolescent mothers (n=187). ocp: oral contraceptive pills, iucd: intrauterine contraceptive device, dmpa: depotmedroxyprogesterone acetate j. lumbini. med. coll. vol 8, no 2, july-dec 2020 nepal s, et al. reproductive health issues and use of family planning methods among married adolescent mothers. 249 jlmc.edu.np 74% of adolescents. most of them did not desire to continue education after childbirth. this shows that they have fallen into a vicious cycle involving low education, wrong decision regarding contraception, childbearing and rearing, and getting pregnant again. many of the adolescent mothers wanted birth interval for more than three years. using larc would delay in subsequent pregnancies. one of the barriers for adolescent contraception is delay in initiation of contraceptive methods. if not pregnant, all contraceptive methods should be started anytime, even on the day of visit.[16] this holds true for both newly married adolescent girls as well as adolescent mothers. use of larc especially jadelle implants has shown good compliance, effectiveness and lower rate of second pregnancy when compared to the choice made for non-larc.[17,18] the present study is not without limitations. this study did not include the unmarried adolescent girls who are in need of contraception. the study was single centred and hospital based which may not represent the reproductive health issues and contraception use in the general population. conclusion: our study among the adolescent mothers in the remote area showed that the use of family planning methods before pregnancy had been very low. most of the adolescent mothers left school after delivery. these findings indicate the need of effective policies to postpone child marriage and immediate child birth after marriage by enhancing the use of contraceptive devices by the married adolescent girl population. it is also expected to lower maternal and neonatal complications. we recommend that reproductive health needs of this vulnerable population be prioritized by all of the concerned stakeholders. acknowledgement: mrs. geeta thapa. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available for the study. references: 1. rosen je. position paper on mainstreaming adolescent pregnancy in efforts to make pregnancy safer. department of making pregnancy safer. geneva: world health organization; 2010. available from: https://www. gfmer.ch/srh-course-2010/adolescent-sexualreproductive-health/who-mainstreamingadolescent-pregnancy-efforts-mps-2010.html 2. nepal demographic health survey 2016. ministry of health, ramshah path, kathmandu; nov 2017. available from: https://www. dhsprogram.com/pubs/pdf/fr336/fr336.pdf (accessed 2 sept 2020). 3. unfpa. marrying too young: end child marriage. available from: https://www. u n f p a . o r g / s i t e s / d e f a u l t / f i l e s / p u b p d f / marryingtooyoung.pdf (accessed 2 sep 2020). 4. maharjan b, rishal p, svanemyr j. factors influencing the use of reproductive health care services among married adolescent girls in dang district, nepal: a qualitative study. bmc pregnancy childbirth. 2019;19(1):152. doi: https://doi.org/10.1186/s12884-019-2298-3 pmid: 31053108 pmcid: pmc6500073. 5. who. adolescent pregnancy. factsheet in https://www.who.int/news-room/fact-sheets/ detail/adolescent-pregnancy (accessed 8 sept 2020). 6. aguilar am, cortez r. family planning : the hidden need of married adolescents in nepal. the world bank; 2015. available from: https://openknowledge.worldbank.org/ handle/10986/21464 (accessed 2 sept 2020). 7. rinehart w, rudy s, drennan m. gather guide to counseling. popul rep j. 1998;(48):131. pmid: 10096107. 8. devkota hr, clarke a, shrish s, bhatta dn. does women’s caste make a significant contribution to adolescent pregnancy in nepal? a study of dalit and non-dalit adolescents and young adults in rupandehi district. bmc womens health. 2018;18(1):23. doi: https://doi.org/10.1186/ s12905-018-0513-4 pmid: 29357853 pmcid: pmc5778648. 9. regmi pr, van teijlingen e, simkhada p, acharya dr. barriers to sexual health services for young people in nepal. j health popul j. lumbini. med. coll. vol 8, no 2, july-dec 2020 nepal s, et al. reproductive health issues and use of family planning methods among married adolescent mothers. 250 jlmc.edu.np nutr. 2010;28(6):619-27. doi: https://doi. org/10.3329/jhpn.v28i6.6611 pmid: 21261208 pmcid: pmc2995031. 10. pandey pl, seale h, razee h. exploring the factors impacting on access and acceptance of sexual and reproductive health services provided by adolescent-friendly health services in nepal. plos one. 2019;14(8):e0220855. doi: https:// doi.org/10.1371/journal.pone.0220855 pmid: 31393927 pmcid: pmc6687105. 11. who. adolescent pregnancy: issues in adolescent health and development. world health organization, geneva; 2004. available from: https://apps.who.int/iris/bitstream/ handle/10665/42903/9241591455_eng.pdf (assessed 2 sept 2020). 12. napit k, shrestha kb, magar sa, paudel r, thapa b, dhakal br, et al. factors associated with utilization of adolescent-friendly services in bhaktapur district, nepal. j health popul nutr. 2020;39(1):2. doi: https://doi.org/10.1186/ s41043-020-0212-2 pmid: 32041664 pmcid: pmc7011236. 13. mahato pk, sheppard za, van teijlingen e, de souza n. factors associated with contraceptive use in rural nepal: gender and decision-making. sex reprod healthc. 2020;24:100507. doi: https://doi.org/10.1016/j.srhc.2020.100507 pmid: 32200229. 14. kumar a, singh t, basu s, pandey s, bhargava v. outcome of teenage pregnancy. indian j pediatr. 2007;74(10):927-931. doi:10.1007/ s12098-007-0171-2 15. rexhepi m, besimi f, rufati n, alili a, bajrami s, ismaili h. hospital-based study of maternal, perinatal and neonatal outcomes in adolescent pregnancy compared to adult women pregnancy. open access maced j med sci. 2019;7(5):760-6. doi: https://doi.org/10.3889/ oamjms.2019.210 pmid: 30962834 pmcid: pmc6447330. 16. committee on adolescent health care. committee opinion no 699: adolescent pregnancy, contraception, and sexual activity. obstet gynecol. 2017;129(5):e142-e149. doi: https://doi.org/10.1097/aog.0000000000002045 pmid: 28426620. 17. rigsby dc, macones ga, driscoll da. risk factors for rapid repeat pregnancy among adolescent mothers: a review of the literature. j pediatr adolesc gynecol. 1998;11(3):11526. doi: https://doi.org/10.1016/s10833188(98)70130-5 pmid: 9704301. 18. winner b, peipert jf, zhao q, buckel c, madden t, allsworth je, et al. effectiveness of longacting reversible contraception. n engl j med. 2012;366(21):1998-2007. doi: https://doi. org/10.1056/nejmoa1110855 pmid: 22621627. lifestyle modification after diagnosis of hypertension in patients visiting lumbini medical college teaching hospital parbati nepal,a,c bina dhunganab,c —–————————————————————————————————————————————— abstract: introduction: lifestyle modifications is an important aspect of hypertension therapy. however, studies on this nonpharmacological approach of hypertension management and its impact is very limited in a developing country like nepal. the objective of the present study was to determine the life style of patients after diagnosis of hypertension. methods: a descriptive cross sectional study design was conducted in lumbini medical college teaching hospital (lmcth). a total of 63 patients attending medical outpatient clinic of lumbini medical college who were diagnosed as hypertensive at least two months before the interview were included. data were collected from 22nd february 2015 to 21st march 2015 by interview method using a questionnaire consisting of a combination of structured and semi structured questions. results: this study revealed that non-vegetarian decreased from 95.2% to 74.6% after diagnosis. lifestyle modification criteria like amount of salt intake, smoking, and alcohol consumption were significantly reduced whereas physical exercise and stress reduction activity were significant increased. conclusion: majority of respondents has changed their lifestyle after diagnosis of hypertension. keywords: healthy diet • healthy lifestyle • hypertension • lifestyle • sedentary lifestyle ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, department of nursing b nursing officer c lumbini medical college teaching hospital, palpa, nepal corresponding author: parbati nepal e-mail: kirparu@gmail.com how to cite this article: nepal p, dhungana b. lifestyle modification after diagnosis of hypertension in patients visiting lumbini medical college teaching hospital. journal of lumbini medical college, 2015;3(1):12-5. doi: 10.22502/jlmc.v3i1.62. ___________________________________________________________________________________ j. lumbini. med. coll. vol 3, no 1, jan-june 2015 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v3i1.62 introduction: hypertension is defined as a systolic blood pressure (sbp) greater than 140 mm hg and diastolic pressure greater (dbp) than 90 mm hg based on average of two or more accurate blood pressure measurements taken during two or more contacts with a health care provider.1 the world health organization (who) estimates that more than one billion population worldwide is affected by high blood pressure with prevalence of hypertension in one in every three adults. overall 26.4% adult world population was estimated to have hypertension in the year 2000, a number that was projected to increase to 29.2% by 2025.2 globally cardiovascular disease accounts for approximately 17 million deaths a year, nearly one third of the total deaths. of these, complications of hypertension account for 9.4 million deaths worldwide every year.3 hypertension is responsible for at least 45% of deaths due to heart disease (total ischemic heart disease) and 51% of deaths due to stroke.4 overweight, sedentary behavior, excessive alcohol intake, higher social class, additional salt intake, diabetes mellitus, and smoking are risk factors for hypertension in most of the countries of asia.5 lifestyle modification, previously termed nonpharmacologic therapy, has important roles in hypertensive as well as non-hypertensive individuals.6,7 in hypertensive individuals, lifestyle modifications can serve as initial treatment before the start of drug therapy and as an adjunct to medication in persons already on drug therapy. in hypertensive 12 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 jlmc.edu.np nepal p. et al. lifestyle modification after diagnosis of hypertension in patients visiting lumbini medical college teaching hospital. individuals with medication-controlled blood pressure (bp), these therapies can facilitate drug step-down and drug withdrawal in highly motivated individuals who achieve and sustain lifestyle changes. even an apparently small reduction in bp, if applied to an entire population, could have an enormous beneficial effect on cardiovascular events. for instance, a three mm hg reduction in systolic bp should lead to an eight percent reduction in stroke mortality and a five percent reduction in mortality from coronary heart disease.7 the dietary approaches to stop hypertension (dash) diet is a diet rich in fish, lean meat, low-fat dairy, fruits, vegetables, whole grains, legumes, nuts, and seeds. dash diet lowered sbp for hypertensive patients by an average of 11 mm hg and dbp by an average of 5.5 mm hg compared with the control group.8 reduction of three g/d in salt intake would lower blood pressure by 2.5/1.4 mm hg, which would reduce strokes by 12 to 14% and ischemic heart disease by nine percent to 10%.5 regular aerobic physical activity has been demonstrated to be beneficial both for prevention and treatment of hypertension.9 there are meager studies related to the change in pattern of lifestyle after diagnosis of hypertension in our part of world. thereby, this study was carried out to explore whether lifestyle modifications were implemented after the diagnosis of hypertension and to find out the relationships, if existed, between them. methods: a descriptive cross sectional study was conducted in medical outpatient clinic of lumbini medical college teaching hospital. a total of 63 hypertensive patients who were diagnosed more than two months back were included in the study. the study was done from 22nd of january 2015 to 21st of march 2015. data were collected by face to face interview technique. special care was taken for maintaining ethical issue during the time of data collection and anonymity of all participants was maintained. data were analyzed with spss 17. various tests such as frequency distribution, chisquare test were applied. results: socio-demographic profile of patient included in the study is shown in table 1. it shows that the majority (46%) of the respondents were above 60 years of age. both genders were almost equally affected. most (66.7%) of respondents were educated. table 2 shows frequency distribution of participants according to hypertension related variables. it depicts that majority (60.3%) of the respondents were suffering from hypertension for more than two years. fifty four percent of respondents had the habit of visiting hospital once in a month. before diagnosis, there were fewer vegetarian individuals (4.8%), but after they were diagnosed to have hypertension, the number of vegetarian rose to 74.6%. this difference was significant, x2 (n=63, df=1) = 10.47, p = 0.001. distribution of respondents according to type of meat consumed and frequency of consumption before and after the diagnosis of hypertension is shown in table 3. it shows that consumers of mutton, chicken, fish, and eggs all decreased after the diagnosis of hypertension. table 4 shows the distribution of respondents according to type of fats consumption before and after the diagnosis of hypertension. it shows that the users of ghee (saturated fat) were decreased. there was also a decrease in daily users of mustard oil, but there was increase in the uses of sunflower oil. amount table 1: socio-demographic profile of the participants variables n % age 30-40 years 5 7.9 40-50 years 11 17.5 50-60 years 18 28.6 above 60 29 46 gender male 32 50.8 female 31 49.2 educational status illiterate 21 33.3 literate 42 66.7 among literate primary 14 22.2 secondary 18 28.6 higher secondary 3 4.8 informal education 7 11.1 ethnicity brahmin 20 31.7 chhetri 12 19 janajati 21 33.3 dalit 10 15.9 13 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 nepal p. et al. lifestyle modification after diagnosis of hypertension in patients visiting lumbini medical college teaching hospital. jlmc.edu.np of salt taken before and after the diagnosis of hypertension is shown in table 5. it shows that there was decrease in the amount of salt consumed. table 6 shows the distribution of study population with lifestyle risk factors before and after the diagnosis of hypertension. there was significant reduction in frequency of smoking and alcohol consumption; whereas, there was significant increase in physical activities and stress reduction activities. discussion: the results of this study showed most of table 2: frequency distribution of participants according to hypertension related variables table 3: distribution of respondents according to type of meat consumed and frequency of consumption before and after diagnosis of hypertension the respondents (95.2%) were non-vegetarian and 4.8% were vegetarian before diagnosis, whereas after the diagnosis of hypertension vegetarian were found to have increased from 4.8 % to 25.4%. this finding is supported by the study done by acharya r. et al. in kathmandu, which also showed 90% were non-vegetarian and only 10% were vegetarian before diagnosis but after diagnosis the vegetarian increased from 10% to 20%.9 the consumption habit of non-vegetarian items such as mutton, buff, pork, chicken, fish and table 4: distribution of respondents according to type of fats consumption before and after diagnosis of hypertension table 5: amount of salt taken before and after the diagnosis of hypertension table 6: lifestyle risk factors before and after the diagnosis of hypertension variables n % duration of hypertension 2 month-1 year 11 17.5 1 year2 years 14 22.2 more than 2 years 38 60.3 duration of hospital visit once in a month 34 54 once in a three month 8 12.7 according to doctors instruction 13 20.6 while facing problem 8 12.7 frequency of consumption ty pe o f m ea t/ eg g d ai ly n (% ) w ee kl y n (% ) m on th ly n (% ) o cc as io na lly n (% ) mutton before 1(1.6) 25(39.7) 10(15.9) 22(34.9) after 0 6(9.5) 3(4.8) 25(39.7) pork before 1(1.6) 7(11.1) 4(6.3) 11(17.5) after 1(1.6) 0 2(3.2) 10(15.9) chicken before 5(7.9) 15(23.8) 7(11.1) 23(36.5) after 0 8(12.7) 3(4.8) 29(46) fish before 0 2(3.2) 5(7.9) 37(58.7) after 0 0 3(4.8) 28(44.4) egg before 18(28.6) 5(7.9) 1(1.6 19(30.2) after 1(1.6) 4(6.3) 1(1.6) 27(42.9) frequency of consumption n(%) ty pe o f g he e/ o il d ai ly w ee kl y m on th ly o cc asi on al ly n on -u se r ghee before 26(41.3) 5(7.9) 0 28(44.4) 4(6.3) after 2(3.2) 2(3.2) 0 16(25.4) 43(68.3) mustard oil before 56(88.9) 1(1.6) 1(1.6) 5(7.9) 0 after 33(52.4) 0 0 27(42.9) 3(4.8) soybean oil before 4(6.3) 1(1.6) 2(3.2) 45(71.4) 11(17.5) after 7(11.1) 0 1(1.6) 43(68.3) 12(19) sunflower oil before 0 0 0 43(68.3) 20(31.7) after 21(33.3) 1(1.6) 1(1.6) 29(46) 11(17.5) low normal additional before 5(7.9) 42(66.7) 16(25.4) after 54(85.7) 9(14.3) 0 alterations in lifestyle risk factors before n(%) after n(%) smoking 24(38.1) 8 (12.7) x 2=8, p=.005 alcohol consumption 29(46) 8 (12.7) x2=11.9, p<.001 physical activity 9(14.3) 29 (46) x2=10.53, p=.001 stress reduction activity 13 (20.6) 41 (65.1) x2=14.5, p<.001 14 j. lumbini. med. coll. vol 3, no 1, jan-june 2015 nepal p. et al. lifestyle modification after diagnosis of hypertension in patients visiting lumbini medical college teaching hospital. jlmc.edu.np eggs were taken into account while collecting the data in this study. this study showed that there was a reduction in the consumption of meat items after diagnosis of hypertension. there was decline in consumption of items like mutton, chicken, and eggs. this finding was supported by a similar study by acharya r. et al. in which there was also statistically significant decline in consumption of those items.2 finding of this study revealed that the number of respondents involved in smoking and drinking alcohol decreased significantly after diagnosis of hypertension which is consistent with other studies.9,10 physical workout has been taken as one of the associated factors for the hypertension. after the diagnosis of hypertension, the number of respondents doing physical exercise increased significantly from 14.3% to 46% which is supported by study done by who in 2006. that study revealed that very few respondents (14%) had gone through stress reduction activities before diagnosis but after that number increased to 39%.11 similarly, salt restriction, regular exercise, stress reduction, unsaturated oil reduction, alcohol moderation strategies has been adopted to control blood pressure by different hypertensive patients in different counties.9,11,12 conclusion: lifestyle modification strategies have been implemented by majority of the respondents after diagnosis of hypertension which is good sign of hypertension management. proper counseling by healthcare professionals regarding lifestyle modification is of utmost necessity to assure long normal life of the hypertensive patients. references: 1. smeltzer sc, bare b. brunner and suddarth’s textbook of medical surgical nursing. 12 ed. new delhi: wolter’s kluwer; 2012. 889-900 p. 2 vol. 2. who: high blood pressure a silent killer [internet]. who. 2013 – [cited 2015 jan 15]. available from http:// www.voanews.com/a/world-health-organizationhypertens ion/1636429.html 3. lim ss, vos t, flaxman ad, danaei g, adair-rohani h, amann m. et al. a comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010 : a systematic analysis for the global burden of disease study 2010. lancet. 2012;380(9859):2224-60. doi: 10.1016/s01406736(12)61766-8. 4. who. global status report on noncommunicable diseases 2010. world health organization. http://www.who. int/nmh/publications/ncd_report2010/en/. accessed february 17, 2015. 5. kim k, kang h, shin e, kim sh. prevention and management of hypertension for older adults. j community nutrition. 2004;6(1):26-34. 6. elmer pj, obarzanek e, vollmer wm, simons-morton d, stevens vj, young dr, et al. effects of comprehensive lifestyle modification on diet, weight, physical fitness, and blood pressure control: 18-month results of a randomized trial. ann intern med. 2006;144:485-495. doi: 10.7326/0003-4819-144-7-200604040-00007 7. appel lj. lifestyle modification as a means to prevent and treat high blood pressure. journal of american society of nephrology. 2003;14(2):99-102. 8. effects of comprehensive lifestyle modification on blood pressure control. jama. 2003;289(16). doi:10.1001/ jama.289.16.2083. 9. acharya r, chalise hn. lifestyle of patients before and after diagnosis of hypertension in kathmandu. health. 2011; 3(8);490-7. 10. neutel ci, campbell nr. changes in lifestyle after hypertension diagnosis in canada. the can j cardiol. 2008;24(3):199-204. 11. world health organization. focus in priorities, who report. 2005 [cited – january 26, 2015]. available at www. who.org. 12. okwuonu cg, emmanuel ci, ojimadu ne. perception and practice of lifestyle modification in the management of hypertension among hypertensives in south-east nigeria. international journal of medicine and biomedical research. 2014;3(2):122-30. 15 j. lumbini. med. coll. vol 8, no 2, july-dec 2020 bhandari s, et al. knowledge regarding blood donation among students of a college in western nepal 201 jlmc.edu.np ___________________________________________________________________________________ submitted: 12 september, 2019 accepted: 02 july, 2020 published: 10 september, 2020 alecturer, college of nursing, bassistant professor, college of nursing, cassociate professor, college of nursing, dlumbini medical college and teaching hospital, palpa, nepal. corresponding author: sita bhandari e-mail: sitapandey100@gmail.com orcid: https://orcid.org/0000-0001-7874-3451_______________________________________________________ abstract: introduction: blood can save millions of lives, and young people are the hope and future of safe blood supply worldwide. this study was conducted with an objective to assess knowledge level regarding blood donation among college students. methods: a cross sectional study was conducted at shree mandavya multiple campus, palpa, among all years of bachelor in business studies students. census sampling technique was used and the sample size was 78. a structured questionnaire was used for data collection. descriptive and inferential statistics (chi-square) was used for analysis. the level of significance (p) was set at 0.05. results: the mean age of the participants was 19.5 years. majority (67.9%) of the participants were male and the remaining 32.1% were female. most (87.2%) of them had never donated blood. few (38.5%) of them had history of blood requirement in the family whereas, 23.1% had blood donation in family. more than half (51.3%) of participants had inadequate level of knowledge regarding blood donation. the study showed that sex (p=0.04), history of self-blood donation (p=0.03) and history of blood requirement in the family (p=0.01) were found statistically significant with level of knowledge regarding blood transfusion. conclusion: this study showed that majority of the students had inadequate knowledge regarding blood donation. thus, it is very important to adopt strategies to sensitize and motivate them towards voluntary blood donation. keywords: blood donation, college students, knowledge original research articlehttps://doi.org/10.22502/jlmc.v8i2.302 sita bhandari,a,d parbati nepal,b,d bandana pokharel c,d knowledge regarding blood donation among students of a college in western nepal how to cite this article:how to cite this article: bhandari s, nepal p, pokharel b. knowledge regarding blood donation among students of a college in western nepal. journal of lumbini medical college. 2020;8(2): 5 pages. doi: https://doi. org/10.22502/jlmc.v8i2.302 epub: 2020 september 10. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: human blood is an essential component of human life which is universally recognized as the most precious element that sustains life of human and there are no substitutes to blood as yet.[1] voluntary blood donors are the major source of blood. there is a great need to create awareness of blood donation among the population.[2] blood can save millions of lives, and young people are the hope and future of a safe blood supply in the world. the theme of world health day on 2000 “blood saves life, safe blood starts with me” also encouraged donors voluntarily for this novel cause.[3] a loss of more than 30% of the total blood of the body could be fatal for which blood donations could play a pivotal role to save a life. moreover, various medical and surgical procedures could not be granted without blood and blood products. but many youths specially belonging from developing countries face ignorance, misperceptions and fears about the blood donation process, resulting in a limited numbers of voluntary blood donors.[4] to the best of our knowledge, limited studies have been conducted that have investigated the knowledge j. lumbini. med. coll. vol 8, no 2, july-dec 2020 bhandari s, et al. knowledge regarding blood donation among students of a college in western nepal 202 jlmc.edu.np regarding blood donation among younger people. thus, this study was conducted with an objective to assess the knowledge regarding blood donation among college students. methods: a cross sectional study was conducted at shree mandavya multiple campus palpa among all bachelor in business studies (bbs) students on 25th may 2019. ethical clearance was obtained from institutional review committee of the institute (irc-lmc 09-c/019) prior to data collection. census sampling technique was adopted to include all the students who were willing to participate. the sample size was 78. self-administered structured questionnaire in a simple understandable language was developed on the basis of objective of the study which consisted of two parts: part i: demographic variables part ii: self-administered structured questionnaire on knowledge regarding blood donation which consisted of: section a: introduction regarding blood donation section b: importance of blood donation section c: criteria for donating blood section d: preparation, procedure and donor recovery of blood donation section e: health benefits of donating blood section f: complications and risks of blood donation there were total 25 items and for each correct answer “one” score was given and “zero” score was given for wrong answer. based on a study conducted in india, those who had scored less than and equal to 60% of total score was classified as inadequate level of knowledge and those scoring more than 60% were having adequate level of knowledge.[5] the research questionnaire was pretested among 10% of the total sample among students of tansen multiple campus, palpa who were excluded from the actual study. the obtained reliability coefficient of the questionnaire was 0.90. the actual data was collected from all the bbs students of shree mandavya multiple campus, palpa. those students who did not give consent and were below 18 years of age were excluded from the study. rapport was established and the purpose of the study was clearly explained prior to data collection. informed consent was taken from each student. approximately, 30-35 minutes was provided for completion of the questionnaire. at the end, informal health education was provided regarding blood donation. the data thus collected was entered to and analyzed using statistical package for social sciences (spsstm) software version 16. all the data was kept in order for coding and editing. descriptive statistics (frequency, percentage, mean and standard deviation) and inferential statistics (chi-square test) were used for statistical analysis. the confidence interval was taken as 95% and probability significance (p) was set as less than 0.05. results: the mean age of the participants was 19.5 years. majority (91%) of the participants belonged to the age group less than 20 years and more than 20 years were seven (9%). two-third (67.9%) of participants were males and remaining 25 (32.1%) were females. regarding the history of previous blood donation, most (87.2%) of the participants had never donated whereas, only 10 (12.8%) had donated. forty-eight (61.5%) participants responded that there was no requirement of blood transfusion in the family but 30 (38.5%) had requirement of blood transfusion. majority (76.9%) of the participants had no history of blood donation in the family whereas, 18 (23.1%) had history of blood donation. the present study revealed that more than half (51.3%) of participants had inadequate level of knowledge regarding blood donation and remaining 48.7% had adequate level of knowledge (table 1). table 1. knowledge level of participants on blood donation (n=78). level of knowledge frequency (%) inadequate knowledge 40 (51.3) adequate knowledge 38 (48.7) sex (p=0.04), history of self blood donation (p=0.03) and history of blood requirement in the family (p=0.01) were found statistically significant with level of knowledge regarding blood donation. the results are depicted in table 2 and table 3. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 bhandari s, et al. knowledge regarding blood donation among students of a college in western nepal 203 jlmc.edu.np discussion: majority (67.9%) of participants in the study were male and the remaining (32.1%) were female which was similar with the study conducted in india. [6] regarding the history of previous blood donation, most (87.2%) of the participants had never donated blood whereas, only 12.8% had ever donated blood which was consistent with the findings of other studies conducted in saudi arabia and in india. [6,7,8] but another study revealed that more than 50% had history of previous blood donation which is inconsistent with present study.[9] this might be the result of lack of awareness regarding the need and importance of blood donation and related fear and anxiety to donate blood among young adults. the present study revealed that half of the participants had inadequate knowledge regarding blood donation. this finding was similar with the study conducted in a general college in india.[5] also, a comparative study conducted in nepal too revealed a low knowledge score among nonmedical students.[10] but this finding contradicted with study conducted in southern ethiopia.[11] the reasons behind it may be the curriculum of nonmedical studies does not include the information and also lack of mass awareness programme regarding blood donation. the study showed that sex (p= 0.04) had a significant association with the knowledge level. this finding was similar with the study conducted in karachi.[12] but contradicted with study conducted by hiremath p.[13] this might be due to a limited sample size in the study. the present study showed that history of previous blood donation (p=0.03) had a significant association with the knowledge level. this finding is similar with study conducted in north india.[14] the history of blood requirement in the family (p=0.01) had significant association with the knowledge level as the need of blood donation had made them aware about its importance. as youths are valuable assets for healthy donation, awareness is needed to be created among them for voluntary donation which could be achieved by organizing various educational packages for sensitization and awareness, designing curriculum about its importance specially for general colleges, and organizing voluntary blood donation camps time and often. the limitation of study was that the study table 2. association between level of knowledge and demographic variables (n=78). variables level of knowledge statistics inadequate adequate age ≤20 years 37 (52.1%) 34 (47.9%) x2 (1, 78)= 0.22, p= 0.64 > 20 years 3 (42.9%) 4 (57.1%) sex male 23 (43.4%) 30(56.6%) x2 (1, 78)= 4.12, p= 0.04 female 17 (68.0%) 8 (32.0%) table 3. association between level of knowledge and history of blood donation, history of blood requirement and blood transfusion in the family (n=78). variables level of knowledge statistics inadequate adequate history of previous blood donation yes 2(20.0%) 8(80.0%) p = 0.03 no 38(55.9%) 30(44.1%) history of blood requirement in the family yes 10(33.3%) 20(66.7%) x2 (1, 78) = 6.29, p = 0.01 no 30(62.5%) 18(37.5%) history of blood donation in the family yes 6(33.3%) 12(66.7%) x2 (1, 78) = 3.0, p = 0.08 no 34(56.7%) 26(43.3%) j. lumbini. med. coll. vol 8, no 2, july-dec 2020 bhandari s, et al. knowledge regarding blood donation among students of a college in western nepal 204 jlmc.edu.np was conducted at one setting with limited sample size; hence the results cannot be generalized. as well there are possibilities of recall bias that could hinder the results. conclusion: majority of bachelor level students of general college had inadequate level of knowledge regarding blood donation. sex, history of self blood donation and blood requirement in the family had an impact on overall knowledge. various educational packages, awareness programmes and blood camps could encourage for voluntary blood donation among young adults. acknowledgement: mr. prakash pangeni, principal, shree mandavya multiple campus, palpa. mr. prakash pandey, subnational manager, pallodium, kathmandu. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. j. lumbini. med. coll. vol 8, no 2, july-dec 2020 bhandari s, et al. knowledge regarding blood donation among students of a college in western nepal 205 jlmc.edu.np references: 1. sharma rk, verma s, sharma m, pugazhendi s. voluntary blood donation: attitude and practice among indian adults. journal of community medicine & health education. 2016;6(3):1000436. available from: https://www.omicsonline.org/open-access/ voluntary-blood-donation-attitude-and-practice-among-indian-adults-2161-0711-1000436. pdf 2. melku m, asrie f, shiferaw e, woldu b, yihunew y, asmelash d, et al. knowledge, attitude and practice regarding blood donation among graduating undergraduate health science students at the university of gondar, northwest ethiopia. ethiop j health sci. 2018;28(5):571-82. pmid: 30607072. doi: https://doi.org/10.4314/ejhs. v28i5.8 3. kanani an, vachhani jh, upadhyay sb, dholakiya sk. a study on knowledge and awareness about blood donation amongst government medical, para-medical and nursing undergraduate students in jamnagar, gujarat. global journal of transfusion icine. 2018;3(1):46-51. available from: https://www.researchgate.net/publication/324240771 4. shidam ug, lakshminarayanan s, saurabh s, roy g. knowledge and attitude regarding blood donation in rural puducherry, india. national journal of community medicine. 2015;6(1):64-8. available from: https://www. researchgate.net/publication/275154633 5. thakur a, chauhan hs, acharya b. knowledge and practices of blood donation among the undergraduate students of district una, himachal pradesh, india. global journal of medicine and public health. 2015;4(6):1-7. available from: http://www.gjmedph.com/uploads/o2-vo4no6. pdf 6. sahoo dp, patil c, dehmubed a. a study of knowledge, attitude and practice of voluntary blood donation among interns of a municipal medical college. international journal of community medicine and public health. 2017;4(4):1166-70. doi: http://dx.doi.org/10.18203/2394-6040.ijcmph20171343 7. almutairi at, alhatlan hm, albujays ia, almulhim as. blood donation among al-ahsa population in saudi arabia: attitudes, practice and obstacles. international research journal of public and environmental health. 2016;3(8):167-73. doi: http://dx.doi.org/10.15739/irjpeh.16.022 8. enawgaw b, yalew a, shiferaw e. blood donors’ knowledge and attitude towards blood donation at north gondar district blood bank, northwest ethiopia: a cross-sectional study. bmc research notes. 2019;12:729. doi: https://doi. org/10.1186/s13104-019-4776-0 9. atherley ae, taylor cg jr, whittington a, jonker c. knowledge, attitudes and practices towards blood donation in barbados. transfus med. 2016;26(6):415‐21. pmid: 27634655. doi: https://doi.org/10.1111/tme.12359 10. mamatya a, prajapati r, yadav r. knowledge and practice of blood donation: a comparison between medical and non-medical nepalese students. nepal med coll j. 2012;14(4):283-6. pmid: 24579535 11. shamebo t, gedebo c, damtew m, woldegeorgis t, girma e, terefe d. assessment of knowledge, attitude and practice of voluntary blood donation among undergraduate students in awada campus, hawassa university, southern ethiopia. journal of blood disorders & transfusion. 2020;11(1):431. available from: https:// www.longdom.org/archive/jbdt-volume-11-issue-1-year-2020.html 12. ahmed z, zafar m, khan aa, anjum mu, siddique ma. knowledge, attitude and practices about blood donation among undergraduate medical students in karachi. journal of infectious diseases & therapy. 2014;2(2):1000134. doi: https://www.researchgate.net/publication/262209239 13. hiremath p. to assess the knowledge of blood donation among voluntary blood donor at blood bank, krishna hospital karad (maharashtra, india). journal of nursing care. 2012;1(6):1000124. doi: http://dx.doi. org/10.4172/2167-1168.1000124 14. mishra sk, sachdev s, marwaha n, avasthi a. study of knowledge and attitude among college-going students toward voluntary blood donation from north india. j blood med. 2016;7:19-26. pmid: 27051326. doi: https:// doi.org/10.2147/jbm.s91088 clinical profile and outcome of asphyxiated newborn in a medical college teaching hospital kiran panthee,a,d kiran sharma,b,d balkrishna kalakheti,c,d kul thapab,d —–————————————————————————————————————————————— abstract: introduction: perinatal asphyxia, a major topic in neonatology, is a severe condition which has a high impact on neonatal mortality and morbidity and neurological and intellectual development of the infant. it is defined by who as"failure to initiate and sustain breathing at birth". it is estimated that around four million babies are born asphyxiated and among those one million die and an equal number of babies develop serious neurological consequences ranging from cerebral palsy and mental retardation to epilepsy. this study was done to identify the occurrence, clinical profile and, immediate outcome of perinatal asphyxia in lumbini medical college teaching hospital. methods: it was a retrospective study where 82 cases who fulfilled the inclusion criteria were included between december 2014 to november 2015. inclusion criteria included newborns with: a) apgar score equal to or less than six at five minutes, b) requirement of more than one minute of positive pressure ventilation, c) signs of fetal distress (heart rate of less than 100 beats per minute, late decelerations). results: out of total 425 neonatal intensive care unit (nicu) admissions, 82 (19.3%) cases were of asphyxia among which 56 were inborn and 26 were referred from outside. of those 82 cases, 47 (57.3%) cases developed hypoxic ischemic encephalopathy (hie); hie stage i had good outcome with survival rate of 95% and hie stage iii had poor outcome with survival rate of only 25%. conclusion: despite advances in management of neonates, perinatal asphyxia is still the leading cause of neonatal intensive care unit admission and mortality and morbidity in neonates. keywords: asphyxia neonatorum • brain hypoxia-ischemia • mortality • newborn • treatment outcome ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer b resident c associate professor d department of pediatrics, lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. kiran panthee e-mail: keeranpanthee@gmail.com how to cite this article: panthee k, sharma k, kalakheti b, thapa k. clinical profile and outcome of asphyxiated newborn in a medical college teaching hospital. journal of lumbini medical college. 2016;4(1):1-3. doi: 10.22502/jlmc.v4i1.78. ___________________________________________________________________________________ j. lumbini. med. coll. vol 4, no 1, jan-june 2016 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v4i1.78 introduction: perinatal asphyxia, a major topic in neonatology, is a severe condition which has a high impact on neonatal mortality and morbidity and neurological and intellectual development of the infant, despite many advances in perinatal care.1 hypoxemia may be defined as the "diminished amount of oxygen in the blood supply", while cerebral ischemia is defined as the "diminished amount of blood perfusing the brain".2 in term infants, 90% of insults occur in the antepartum or intrapartum periods as a result of placental insufficiency and the remaining occur in the postpartum period which may be secondary to pulmonary, cardiovascular or neurological abnormalities. the standard for defining an intrapartum hypoxic-ischemic event (hie) sufficient enough to produce moderate to severe neonatal encephalopathy which subsequently leads to cerebral palsy has been established in three consensus statements. the cornerstone of all these three statements is the presence of severe metabolic acidosis (ph < seven and base deficit equal to or more than 12 mmol/l) at birth in a newborn exhibiting early signs of moderate or severe encephalopathy.1 according to penela-velez de guevara et al., 703 cases, over 10 years' period, of perinatal asphyxia, 45% presented with evidence of hypoxicischemic encephalopathy on neonatal period. during the period of two years, 36% present neurologic sequelae, being psychomotor retardation the most 1 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 jlmc.edu.np panthee k. et al. clinical profile and outcome of asphyxiated newborn in a medical college teaching hospital. common.3 it is estimated that around four million babies are born asphyxiated per year among which 900,000 die and similar number i.e. one million develop serious neurological consequences like cerebral palsy, mental retardation, and epilepsy.4 perinatal asphyxia remains a major cause of global mortality which contributes to almost one quarter of the world's three million neonatal deaths and almost half of 2.6 million third trimester stillbirths. developing countries have the highest incidences of asphyxia, where sub-saharan africa and south asia, together, account for nearly 70% of worldwide stillbirths.5 outcome of birth asphyxia depends on apgar score at five minutes, heart rate at 90 seconds, time to first breath, duration of resuscitation, arterial blood gases, and acid-base status at 10 and 30 minutes of age.6 the neonatal mortality has decreased but morbidity after birth asphyxia in the form of neuro-developmental sequelae is same or even increased due to survival of asphyxiated babies.7 the aim of this study was to know the clinical profile and outcome of asphyxiated newborn in a tertiary center of nepal where patient are mainly from rural area. methods: this was a retrospective study done in lumbini medical college teaching hospital (lmcth) where 82 cases who fulfilled the criteria were included in the study between december 2014 to november 2015. inclusion criteria included newborns (term and preterm, hospital born or referred from outside within one hour) with: a) apgar score equal to or less than six at five minutes, b) requirement of more than one minute of positive pressure ventilation, c) signs of fetal distress (heart rate of less than 100 beats per minute, late decelerations). newborns with any congenital neuromuscular, cardiovascular, pulmonary, or central nervous system disorder were excluded from the study. detailed history and examination of babies was performed at the time of admission. detailed neurological examination of asphyxiated newborns including staging of hypoxic ischemic encephalopathy (hie) was done. hie was assessed according to sarnat and sarnat staging i.e. mild (hie stage i), moderate (hie stage ii), and severe (hie stage iii). neonates with hie show alteration in the level of consciousness and in the behavior ranging from irritability, hyperalertness to lethargy, obtundation, or coma. disorders of tone ranges from markedly increased to markedly decreased and a spectrum of abnormal movements ranges from tremors and jitteriness to frank seizures.8 results: there were 1972 live births at lmcth during the study period. a total of 425 neonates (including those referred from outside) were admitted in nicu. out of 425 admissions, 82 had perinatal asphyxia, 15 (3.5%) died and 6 (1.4%) left against medical advice. eighty-two (19.3%) of 425 nicu admissions were cases of perinatal asphyxia. of those 82 cases, 51 (62.2%) were male and 31(37.8%) were female; inborn were 56 (68.3%) and the rest 26 (31.7%) were referred from outside. similarly, 54 (65.85%) were delivered via normal vaginal delivery, 19 (23.17%) by cesarean section, and remaining nine (10.97%) by instrumental delivery. most common indication for cesarean section was meconium stained amniotic fluid (n=9) followed by fetal distress (n=7). of those 82 cases, 17 (20.7%) were preterm and 65 (79.3%) were term baby; 24 (29.3%) required ventilatory support. similarly, of these 82 cases, 47 cases (57.3%) developed hie of which 20 cases (24.4%) developed hie i, 19 (23.17%) developed hie ii and the remaining eight (9.75%) cases developed hie iii. one case of hie i died resulting in 95% survival rate of that group, two of hie ii died with survival rate of 89.5% and six died of hie iii resulting in survival rate of 25%. profile of asphyxiated babies is given in table 1. discussion: in last decade, neonatal mortality rate in variables n (%) male 51 (62.3) female 31 (37.7) inborn 56 (68.2) outborn 26 (31.7) normal vaginal delivery 54 (65.8) instrumental delivery 09 (10.9) cesarean section 19 (23.1) meconium stained fluid 28 (34.1) ventilator requirement 24 (29.3) term baby 65 (79.2) table 1: clinical profile of asphyxiated babies. 2 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 panthee k. et al. clinical profile and outcome of asphyxiated newborn in a medical college teaching hospital. jlmc.edu.np nepal has decreased from 33 to 23 per thousand live births.9 however, it has failed to meet the millennium development goal. birth asphyxia is major cause of nicu admission and neonatal mortality.4 any decrease in asphyxia related events would significantly decrease the overall neonatal mortality. recent advancements in neonatal care at delivery room and both invasive and non-invasive mechanical ventilations have revolutionized the outcome of asphyxiated newborns. in our study, 425 cases were admitted in nicu. of those, 82 cases (19.25%) were of perinatal asphyxia, which is similar to the study carried at dhulikhel hospital in which total asphyxiated babies were 14% of the total nicu admission.10 the rate of birth asphyxia in the present study was low in comparison to the study conducted by daga as et al. (27%) and azam in pakistan (48%).11,12 our study shows, male newborn (n=51) were admitted more frequently than female newborn (n=31). this may be because of the fact that male get more attention, in our region, and seek health services. this fact also explains the lower rate of asphyxiated babies admitted in nicu. asphyxia rate in this study was 28.4/1000 live births which was higher as compared to 5.4/1000 live births in the study conducted by thornberg e. et al. but similar to 26.9/1000 live births in the study conducted in dhulikhel hospital and a study from india which showed 22/1000 live births.10,13,14 this reflects the similar rate in developing countries like nepal and india. the majority of the babies were born via spontaneous vaginal deliveries. the major indications of cesarean section was fetal distress. timely recognition and intervention with caesarean section could be helpful in decreasing asphyxia related morbidity and mortality. in our study, out of the total 82 cases, 47 cases developed hie (57.31%). twenty babies (24.39%) developed hie stage i and one baby (5%) among them expired, 19 babies (23.17%) developed hie stage ii and two babies (10.52%) among them expired, and eight babies (9.75%) developed hie stage iii and six babies (75%) among them expired. overall mortality in our study in case of birth asphyxia is 10.9% which was similar to the study done by dongol s. and etuk sj.10,15 conclusion: despite advances in management of neonate, perinatal asphyxia is still the leading cause of nicu admission and mortality and morbidity. further prospective and case control studies are required to develop strategies for the prevention and management of asphyxiated babies and also to minimize the neuro-developmental sequele. limitation of the study: lack of arterial blood gas (abg) analysis, which is essential to define asphyxia, due to financial problem and technical difficulty. 1. antonucci r, porcella a, pilloni md. perinatal asphyxia in the term newborn. j pediatr neonat individual med. 2014;3(2):e030269. doi: 10.7363/030269. 2. volpe jj. neurology of the newborn. 4th ed. philadelphia: wb saunders company; 2001. 217-76 p. 3. penela-velez de guevara mt, gil-loper sb, martinpuerto mj. a descriptive study of perinatal asphyxia and its sequelae. revneurol. 2006;43(1):3-6. 4. lawn je, cousens s, zupan j.4 million neonatal deaths: when? where?why? lancet. 2005;365(9462):891-900 5. lawn je, manandhar a, haws ra, darmstadt gl. reducing one million child deaths from birth asphyxiaa survey of health systems gaps and priorities. health res policy syst. 2007;5:4. doi: 10.1186/1478-4505-5-4 pmid: 17506872. 6. begum ha, rahman a, anowar s, mortuza a, nahar n. long term outcome of birth asphyxiated infants. mymensingh med j. 2006;15(1):61-5. 7. bhutta za, ali n, hyder aa, wajid a. perinatal and newborn care in pakistan: seeing the unseen. bhutta za, ed. maternal and child health in pakistan: challenges and opportunities. karachi: oxford university press; 2004. 1946 p. 8. sarnat hb, sarnat ms. neonatal encephalopathy following fetal distress. a clinical and electroencephalographic study. arch neurol. 1976;33(10):696-705. 9. unicef. nepal multiple indicator cluster survey (nmics) 2014 key findings released. 14 january 2015. available from unicef.org.np. visited on 8 dec 2015. 10. dongol s, singh j, shrestha s, shakya a. clinical profile of birth asphyxia in dhulikhel hospital: a retrospective study. j nep paedtr soc. 2010; 30(3):141-6. 11. daga as, daga sr, patole sk. risk assessment in birth asphyxia. j trop pediatr. 1990;36:34-9. 12. azam m, malik f, khan p. birth asphyxia risk factors. the professional. 2004;11(4):416-23. 13. thornberg e, thiringer k, odeback a, milson i. birth asphyxia: incidence, clinical course and outcome in a swedish population. acta paediatr. 1995;84:927-32. 14. chandre s, ramji s, thirupurum s. perinatal asphyxia; multivariate analysis of risk factors in hospital birth. indian pediatr. 1997;34:206-12. 15. etuk sj, etuk is. relative risk of birth asphyxia in babies of booked women who deliver in unorthodox health facilities in calabor, nigeria. acta tropica. 2001;79(2):143-7. references: 3 importance of routine histopathological examination of gallbladder specimen in detecting incidental malignancies archana tiwari,a,c ramji rai,b,c surendra kumar jainb,c —–————————————————————————————————————————————— abstract: introduction: gallbladder carcinoma is the most common cancer of biliary tree and the 5th most common gastrointestinal malignancy. an early diagnosis is essential as this malignancy progresses silently with a late diagnosis and poor prognosis. epidemiological studies have identified striking geographic and ethnic variation with high occurrence in southeast asia, yet low elsewhere in the world. gallbladder carcinoma, in 15-30% of patients, show no preoperative or intraoperative evidence and are detected only on histopathological examination. they are called as incidental gallbladder cancer (igbc). the objective of this study was to find out the occurrence of igbc in cholecystectomy specimens received in our histopathology laboratory and to analyze their clinico-pathological features. methods: this was a prospective study carried out in the department of histopathology, lumbini medical college teaching hospital during a period of two years from may 2014 to april 2016. the study included 800 cases of cholecystectomized gall bladder specimens. result: ninety seven percent of the specimens (n=776) revealed benign pathology. malignancy was detected incidentally in 8 cases (1.25%). the mean age of patients with incidental gall bladder carcinoma was 69 years (sd=4.1) and f:m ratio was 9:1. out of 10 incidental malignancies, cholelithiasis was found in 8 (80%) cases. fundus was the most common location (n=5, 50%) and focal fragile necrotic area was most common (n=3, 30%) gross morphology. on pathological staging, all the incidentally detected malignancies (n=10) were found to be in surgically resectable stages. conclusion: igbc was found in 1.25% of the gallbladder specimen. detailed gross and histopathological examination of gallbladder specimen is mandatory for every cholecystectomy specimen, even for benign diseases, to detect incidental carcinoma at potentially curable stage. keywords: carcinoma • cholecystectomy • gallbladder • incidental ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, b professor c department of pathology, lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. archana tiwari e-mail: archana445@gmail.com how to cite this article: tiwari a, rai r, jain sk. importance of routine histopathological examination of gallbladder specimen in detecting incidental malignancies. journal of lumbini medical college. 2016;4(1):15-9. doi: 10.22502/jlmc.v4i1.76. ___________________________________________________________________________________ j. lumbini. med. coll. vol 4, no 1, jan-june 2016 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v4i1.76 introduction: gallbladder cancer is the most common cancer of biliary tree and the fifth most common gastrointestinal cancer.1 it is well known for its poor prognosis. the signs and symptoms of gallbladder carcinoma are not specific and often present late.2 diagnosis is, therefore, often made in the advanced stage with a poor prognosis; an overall mean survival of six months and a five-year survival rate of less than 5%. most gallbladder carcinoma cases are suspected preoperatively or intraoperatively. fifteen to thirty percent of patients with gallbladder carcinoma show no preoperative or intraoperative evidence of gallbladder cancer.3 these kind of carcinomas are called as incidental carcinoma. incidental gallbladder cancer (igbc) may be defined as a malignancy detected only on histopathological examination without prior preoperative or intraoperative suspicion of malignancy.4,5 with the introduction of laparoscopic surgery and the higher acceptance of this 15 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 jlmc.edu.np tiwari a. et al. importance of routine histopathological examination of gallbladder specimen in detecting incidental malignancies. technique, gallbladders are now removed much frequently than they used to be. with the increase of cholecystectomies, the diagnosis of incidental gallbladder carcinoma has become more frequent by histopathological examination.5 in nepal, histopathological examination of cholecystectomy specimens has become a routine practice.6-9 gallstone disease, porcelain gallbladder, and sclerosing cholangitis are the best known risk factors for gallbladder cancer apart from some nonmodifiable factors such as increasing age, ethnicity, female gender and family history or genetics.9,10 cholecystectomies performed with preoperative diagnosis of gallstone disease rarely results in a diagnosis of unexpected gallbladder cancer. however, at times, it is surprising to find occult malignancy among gallbladder specimens that are submitted with clinico-radiological diagnosis of benign diseases. surgical removal of gall bladder is common and cholecystectomized gallbladder specimens are one of the frequently received specimens in the histopathology department.11,12 however, not much is known about the rate of incidental carcinoma in such specimen in our population. objectives of this study were: 1) to find the proportion of incidental gall bladder carcinoma in cholecystectomy specimen and 2) analyze the different pathological entities of postoperative gall bladder specimen detected during routine histopathological examination. methods: this was a prospective study, carried out at department of pathology, lumbini medical college teaching hospital from may 2014 to january 2016. all gall bladder specimens submitted to the department of surgical pathology for histopathological examination were included in the study. routine gall bladder specimen with preoperative or intraoperative suspicion of malignancy and/or existence of gallbladder polyps detected during preoperative evaluation were categorized separately. the specimens were fixed in 10% formalin and were sectioned serially from the neck to the fundus. routine processing of tissue sections with hematoxylin and eosin staining was done and were reviewed by authors. tumor staging was based on the 7th edition of the american joint committee on cancer (ajcc) manual.13 data about patients’ demographic profile, preoperative and intraoperative findings, operative procedures performed, and histopathology findings were collected in microsoft excel 2007. data were analyzed with spss 17.0 for windows. descriptive statistics like frequency, percentage, mean, standard deviation were calculated. results: a total of 800 gall bladder specimens following open and laparoscopic surgeries were received during study period. of those 800 patients, 640 (80%) were women and 160 (20%) were men with m:f ratio of 1:4. mean age was 45 years (sd=13.7, range: 9–82 years). ninety seven percent (n=776) of the specimens revealed benign pathology. they were chronic calculus and acalculous cholecystitis with mild to severe non specific inflammation as well as with specific changes like eosinophilic cholecystitis, follicular cholecystitis, xanthogranulomatous cholecystitis, cholesterolosis, spongioid mucosal hyperplasia, adenomatous hyperplasia, pyloric metaplasia, and intestinal metaplasia. two cases of tubular adenoma were also detected in gallbladder submitted with surgical diagnosis of gallbladder polyp. eight cases of calcified/porcelain gallbladder were diagnosed; all needed decalcification before processing. three percent (n=24) of the specimen were diagnosed as gallbladder carcinoma on histopathological evaluation. twenty patients were female and 4 were male (m:f =1:5). out of 24 cases, malignancy was detected on histopathological evaluation incidentally in ten cases, which comprises 1.25 % of total cases. these cases were not suspected of malignancy clinically on preoperative evaluation and intraoperative evaluation. among them nine patients were female and one was male (m:f=1:9). their mean age was 69 years (sd=4.1). association with cholelithiasis was observed in 8/10 cases (80%) (table 1). out of ten incidental carcinomas, on gross examination, diffuse thickening of the gallbladder wall was seen in two cases and localized growth in the form of focal thickening in two cases, focal fragile necrotic area was found in three cases and mild mucosal irregularity in one case. two gallbladder specimens were filled with necro-hemorrhagic debris and had focal fragile elevated growth. fundus was the most common location (n=5) followed by body (n=2). three cases had multi-centric tumors 16 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 tiwari a. et al. importance of routine histopathological examination of gallbladder specimen in detecting incidental malignancies. jlmc.edu.np involving fundus, body, and neck of gallbladder. one case with focal thickening of gallbladder wall had in situ carcinoma and needed extensive re-sampling for confirmation of malignancy (table 1). histological variants of incidental carcinoma is presented in table 2. on pathological staging, all of the incidentally detected cases were found to be in surgically resectable stages; t2 (n=7, 70%), t1b (n=2, 20%), and t1a (n=1, 10%). perineural invasion was seen in five cases (fig 1). mucosal lesions thought to be premalignant (pyloric metaplasia and dysplasia) were detected in six cases. discussion: gall bladder is one of the commonest surgical specimen received in histopathology department and most common indications for cholecystectomies are variables value over all proportion of gall bladder carcinoma n (%) 24/800 (3%) m:f ratio 1:5 incidental carcinomas n (%) 10/800 (1.25%) m:f ratio 1:9 age in year (m, sd) 69 (sd=4.1) associated with gall stones n (%) 8 (80%) localized growth on gross examination 2 (20%) diffuse thickening of gall bladder wall 2 (20%) focal fragile necrotic area 3 (30%) lumen filled with necrotic debris with mucosal irregularity 2 (20%) mild mucosal irregularity 1 (10%) fundic site 5 (50%) multi-centric tumors 3 (30%) association of malignancy with porcelain gall bladder 0 precancerous lesion 6 (60%) peri-neural invasion 5 (50%) table 1: clinicopathological features of incidental gallbladder carcinoma. histological type of carcinoma n (%) adenocarcinoma, nos type 6 (60%) papillary adenocarcinoma 2 (20%) mucin secreting adenocarcinoma 1 (10%) poorly differentiated carcinoma 1 (10%) table 2: histological variants of incidental carcinoma (n=10) benign gallbladder diseases, such as symptomatic gallstone diseases and its complications (e.g. biliary colic, acute or chronic cholecystitis, gallstone pancreatitis, choledocholithiasis or gallbladder polyps).14 though diagnosis of benign disease is usually made preoperatively or intraoperatively, all specimens are routinely sent for histopathological examination to know the histopathological diagnosis and exclude malignancy even though the possibility of its incidental occurrence is rare.4,5 early detection of carcinoma of gb can save life due to its good prognosis when treated in early stage. the incidence of gall bladder cancer varies by geographic region and racial ethnic group. the highest gallbladder cancer incidence rates worldwide have been reported in women from india, chile, pakistan, and japan and in american indians.15 therefore, nepal is an appropriate place to study for incidence of gallbladder carcinoma being a south asian country and as it shares geographical, environmental and cultural similarities with those countries. shukla et al. have shown that the high incidence of carcinoma gall bladder along the gangetic belt of northern india which is probably due to the presence of heavy metals like cadmium, mercury and lead in gall bladder specimens of patients.16 the incidence of incidentally diagnosed gallbladder cancer has been reported to vary from 0.35% up to 2.85% in different studies worldwide. 4-8 in recent years, the incidence of incidental diagnosis has increased, probably because of an increase in the number of elective cholecystectomies for benign diseases in the present era of laparoscopic cholecystectomy.17,18 in the present study, the rate of fig 1: h and e stained sections of perineural invasion in adenocarcinoma (color picture available online) 17 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 tiwari a. et al. importance of routine histopathological examination of gallbladder specimen in detecting incidental malignancies. jlmc.edu.np study year n % weinstein et al. 2002 1697 0.35 % khan et al. 2007 428 1.86 % deguara et al. 2009 2577 1.0 % shrestha et al. 2010 668 1.4 % ghimire et al. 2011 783 1.28 % kalita d et al. 2013 4115 0.44 % yi x et al. 2013 14073 0.18 % sharma et al. 2014 863 1.9 % present study 2016 800 1.25 % table 3 : comparison of occurrence of incidental gallbladder carcinoma with different studies. incidental gallbladder cancer was found to be 1.25% of total cholecystectomized specimen and 41.66% of total cases of gallbladder carcinoma. similar incidence is observed in different other studies (table3). deguara et al. had also reported one percent cases of incidental gallbladder carcinoma in their study of 2577 cholecystectomies.19 khan et al. reported 1.86% of incidental gallbladder carcinomas, whereas weinstein et al. reported 0.35%.20,21 the rate of incidental primary carcinoma of gallbladder was 1.4% in the study of 668 cases of cholecystectomies specimens in the study of shrestha et al. and 1.28% in the study of 783 cases by ghimire et al., which is similar to our study. 6-7 sharma et al. found 1.9% of incidental carcinoma in cholecystectomy specimen.22 in the present study incidental carcinoma of gallbladder showed a female preponderance (m:f=1:9). majority of patients in our analysis with incidental carcinoma of the gall bladder were seen in the age group of 55-85 years and mean age was 69 years. similar results were observed in other studies from india (pandey et al., 2001; kapoor et al., 2003), nepal and other asian countries.6-8,23,24 an association of gallstones has been found in 75% to 98% of cases of incidental gallbladder carcinoma in other studies.8-10 in present study 80% (n=10) of patients with incidental carcinoma had coexisting cholelithiasis. this study showed a very high proportion of incidental gall bladder carcinoma in a relatively small sample size, which underscores the high risk of gallbladder in our population. most of the incidentally detected carcinoma are in surgically resectable stage, with a good survival rate (mitrovik et al. 2010; mazer et al. 2012; yi et al., 2013).25-27 this study showed incidental carcinomas in pathological t1a, t1b and t2 stage. though simple cholecystectomy is said to be sufficient in stages tis (intra-mucosal carcinoma or carcinoma in situ.) and t1a carcinomas (tumor grown into lamina propria), radical re-resection is strongly recommended for patients with and onwards pt1b stage (tumor has grown into the muscularis propria).13,27 the reoperation should be performed as soon as possible, preferably within 10 days after the initial operation.27 this reflects the importance of histopathological study of all cholecystectomy specimens, irrespective of clinical impression and pathologists can provide useful information to stage the tumor and help to determine the best form of therapy. histopathological examination of the tumors revealed morphological findings similar to other studies.6-9,11,12,22,23 adenocarcinoma, not otherwise specified (with mild and moderate differentiation), was found to be most common histological type (fig 2). porcelain gallbladder (calcification of gallbladder) is said to be associated with10-25% cases of carcinoma.28 in our case 5 out of 24 cases of gallbladder malignancy were associated with porcelain gall bladder. however, we could not find this association in incidental cases of malignancies. stephen et al. reported that a calcified gallbladder is associated with an increased risk of gallbladder cancer, but at a much lower rate than previously estimated.28 conclusion: gallbladder carcinoma is well known for its poor prognosis when diagnosed in advanced stage. fig 2: h and e stained sections from adenocarcinoma, not otherwise specified, 4x. (color picture available online) 18 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 tiwari a. et al. importance of routine histopathological examination of gallbladder specimen in detecting incidental malignancies. jlmc.edu.np 1. rakic m, patrlj l, kopljar m, kliček r, kolovrat m, loncar b, et al. gallbladder cancer. hepatobiliary surg nutr. 2014 oct;3(5):221-6. 2. ake andren-sandberg. diagnosis and management of gallbladder cancer . n am j med sci. 2012 jul;4(7):293–9. 3. smith gcs, parks rw , madhavan kk, and garden oj. a 10-year experience in the management of gallbladder cancer. hpb. 2003;5(3):159-66. 4. ashwin r, cherukuri sd, sathyanesan j, palaniappan r, and govindan m. incidental gall bladder cancers: are they truly incidental? world j gastrointest oncol. 2014 dec 15;6(12): 441–3. 5. isambert m, leux c, métairie s, paineau j. incidentallydiscovered gallbladder cancer: when, why and which reoperation? j visc surg. 2011;148:e77–e84. 6. shrestha r, tiwari m, ranabhat sk, aryal g, rauniyar sk and shrestha hg. incidental gallbladder carcinoma: value of routine histological examination of cholecystectomy specimens. nepal med coll j. 2010;12(2):90-4. 7. ghimire p, yogi n, shrestha bb. incidence of incidental carcinoma gall bladder in cases of routine cholecystectomy. kathmandu univ med j. 2011;34(2):3-6. 8. baidya r, sigdel b, baidya nl. histopathological changes in gallbladder mucosa associated with cholelithiasis. journal of pathology of nepal. 2012;2(3):224-5. 9. jayasundara jasb, de silva wmm. histological assessment of cholecystectomy specimens performed for symptomatic cholelithiasis: routine or selective? ann r coll surg engl. 2013 jul;95(5):317-22. 10. stinton lm, shaffer ea. epidemiology of gallbladder disease: cholelithiasis and cancer. gut liver. 2012 apr;6(2):172–87. 11. matthyssens le, ziol m, barrat c, champault gg. routine surgical pathology in general surgery. br j surg. 2006;93(3):362-8. 12. lohsiriwat v, vongjirad a, lohsiriwat d. value of routine histopathologic examination of three common surgical specimens: appendix, gall bladder, and hemorrhoid. world j surg. 2009;33(10):2189-93. 13. edge sb, byrd dr, compton cc, fritz ag, greene fl, trotti a, eds. ajcc cancer staging manual. new york: springer; 2010. 14. potts jr 3rd. what are the indications for cholecystectomy? cleve clin j med. 1990 jan-feb;57(1):40-7. 15. hundal r, shaffer ea. gallbladder cancer: epidemiology and outcome. clin epidemiol. 2014;6:99–109. 16. shukla vk, prakash a, tripathi bd, reddy dcs, singh s. biliary heavy metal concentrations in carcinoma of the gall bladder: case-control study. br med j. 1998;317:1288-9. 17. panebianco a, volpi a, lozito c, prestera a, lalongo p, palasciano n. incidental gallbladder carcinoma: our experience. g chir. 2013 may-jun;34(5-6):167-9. 18. varsheney s, buttirini g, gupta r. incidental carcinoma of the gallbladder. ejso. 2002;28:4-10. 19. deguara j, borg cm, laferia g. incidental gallbladder carcinoma in the maltese archipelago. malta med j. 2003;15(suppl 1):1728-9. 20. khan ma, khan ra, siddiqui s, maheshwari v. occult carcinoma of gallbladder: incidence and role of simple cholecystectomy. jk pract. 2007;14:22-3. 21. weinstein d. incidental finding of gallbladder carcinoma. isr med assoc j. 2002;4(5):334-6. 22. sharma jd, kalita i, das t, goswami p, krishnatreya m. a retrospective study of post-operative gall bladder pathology with special reference to incidental carcinoma of the gall bladder. int j res med sci. 2014;2(3):1050-3. 23. pandey m, pathak ak, gautam a, aryya nc, shukla vk. carcinoma of the gallbladder: a retrospective review of 99 cases. digest dis and sci. 2001;46:1145-51. 24. kapoor vk, mcmichael aj. gallbladder cancer: an ‘indian’ disease. natl med j ind. 2003;16(4):209-13. 25. 28. mitrović f, krdzalić g, musanović n, osmić h. incidental gallbladder carcinoma in regional clinical centre. acta chir iugosl. 2010;57:95-7. 26. mazer lm, losada hf, chaudhry rm, donohue jh, kooby da, nagorney dm, et al. tumor characteristics and survival analysis of incidental versus suspected gallbladder carcinoma. j gastrointest surg. 2012;16(7):1311-7. 27. yi x, long x, zai h, xiao d, li w, li y. unsuspected gallbladder carcinoma discovered during or after cholecystectomy: focus on appropriate radical reresection according to the t-stage. clin transl oncol. 2013;15(8):652-8.. 28. stephen ae, berger dl. carcinoma in the porcelain gallbladder: a relationship revisited. surgery. 2001;129(6):699-703. importance of routine histopathological evaluation of gallbladder specimens even in benign conditions of gallbladder is well justified and supported by this study as this study has detected incidental gallbladder carcinoma in 1.25% cases. though this value of incidental carcinoma is low, early detection of malignancy at potentially curable stage can be life saving as early diagnosis and pathological staging can guide best and appropriate management. emphasis should be given to careful, detailed and thorough sampling of all gallbladder specimens with high degree of suspicion to detect focal neoplastic changes irrespective of clinical impression. references: 19 computed tomography findings in patients with seizure disorder sumnima acharya,a,c awadesh tiwari,b,c amit shrestha,a,c rupesh sharma,a,c raju shakyad —–————————————————————————————————————————————— abstract: introduction: seizure occurs in up to 10% of the population, whereas epilepsy is a chronic disease characterized by recurrent seizures that may affect up to 2% of the population. modern neuroimaging is useful in diagnosis of abnormalities underlying the epilepsies, but the information provided by imaging techniques can also contribute to proper classification of certain epileptic disorders and can delineate the genetics of some underlying syndromes. neuroimaging is even more important for those patients who have medically intractable seizures. this study was carried out to establish different etiologies of seizures, to correlate the clinical data and radiological findings in cases of seizure, and to identify the common etiologies in different types of seizures. methods: this was a retrospective hospital-based study conducted in the department of radiodiagnosis of lumbini medical college teaching hospital. records of patients of past two years, admitted in any department of the hospital with history of seizure disorder and underwent a computed tomography (ct) of brain were included. the ct patterns were assessed and the data were tabulated and statistically analyzed. results: there were a total of 480 cases out of which 263 (55%) were male and 217 (45%) were female with m:f ratio of 1.2:1. generalized seizure was more frequent than partial seizure in both gender. in 274 cases of generalized seizures, ct scan findings were abnormal in 151 cases and normal finding observed in 123 cases. in 206 cases of partial seizures, 125 cases were abnormal and 81 having normal ct scan findings. age wise distribution showed highest number (n=218) of cases in young group (<20 yr) and least number (n=45) in eldest group (>60 yr). the most common cause of seizure was calcified granuloma (n=79, 16.5%) followed by neurocysticercosis (ncc, n=64, 13%). diffuse cerebral edema, sub-arachnoid hemorrhage, and hydrocephalus was seen only in lower age group particularly among 1-20 years. infarct and diffuse cortical atrophy were most common cause of seizure in older age group. ncc and tuberculoma are the most common cause of partial seizure whereas cerebral infarcts, hemorrhage, malignancy, diffuse cortical atrophy are the most common cause of complex seizure. few rare diseases like fahr disease and tuberous sclerosis were also found in ct scan of seizure patients. conclusion: ncc and tuberculoma are the most common cause of partial seizure whereas cerebral infarcts, hemorrhage, malignancy, and diffuse cortical atrophy are the most common cause of complex seizure. ct scan plays an important role as a preliminary tool in radiological assessment of patients presenting with seizures. keywords: computed tomography • epilepsy • neurocysticercosis • seizure • tuberculoma ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, b associate professor and head c department of radiodiagnosis, lumbini medical college teaching hospital, palpa, nepal d senior consultant family physician, lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. sumnima acharya e-mail: doctorsumnima@gmail.com how to cite this article: acharya s, tiwari a, shrestha a, sharma r, shakya r. computed tomography findings in patients with seizure disorder. journal of lumbini medical college. 2016;4(1):7-10. doi: 10.22502/jlmc.v4i1.86 ___________________________________________________________________________________ j. lumbini. med. coll. vol 4, no 1, jan-june 2016 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v4i1.86 introduction: a seizure is a finite event of altered cerebral function because of excessive and abnormal electrical discharges of the brain cells. epilepsy is a chronic condition predisposing a person to recurrent seizures. the clinical manifestation consists of sudden and transitory abnormal phenomena which may include alterations of consciousness, motor, sensory, autonomic or psychic events, perceived by the patient or by an observer.1 seizures are classified into different types. the classification is important because etiologic diagnosis, appropriate treatment, and 7 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 jlmc.edu.np acharya s. et al. computed tomography findings in patients with seizure disorder. accurate prognostication all depend on the correct identification of seizures and epilepsy. there are two main types of seizures: generalized and focal. focal seizures are those arising within networks of a single cerebral hemisphere and may remain localized or subsequently become more widely distributed. generalized seizures rapidly affect both hemispheres as well as both sides of the body even when caused by a "focal" lesion. generalized seizures are further subdivided into tonic-clonic, absence, myoclonic, clonic, tonic, and atonic.2 seizures may occur in up to 10% of the population, whereas epilepsy is a chronic disease characterized by recurrent seizures that may affect up to 2% of the population. modern neuroimaging is useful in the diagnosis of the abnormalities underlying the epilepsies, but the information provided by imaging techniques can also contribute to the proper classification of certain epileptic disorders and can delineate the genetics underlying some syndromes. neuroimaging is even more important for those patients who have medically intractable seizures.3 computed tomography (ct) uses ionizing radiation and can generate excellent hard tissue imaging contrast with moderately good soft tissue resolution. ct has a number of advantages, and those include lower cost, scan speed, ready accessibility, and easy use, which provide a relatively reliable imaging modality for most patients.4 although the use of ct for patients with epilepsy has been greatly diminished by magnetic resonance imaging (mri), ct is still the technique of choice for the investigation of patients with seizures and epilepsy under certain conditions. in the neonate and young infant, ct is often of secondary or adjunctive importance, but it serves as a significant backup role to ultrasound.5,6 ct can accurately detect hemorrhage, infarctions, gross malformations, ventricular system pathologies, and lesions with underlying calcification. in older children and adults, ct is the technique of choice in the perioperative state because it can rapidly detect recent hemorrhage, hydrocephalus, and major structural changes.7 methods: this was a retrospective hospital-based study conducted in department of radiodiagnosis of lumbini medical college teaching hospital, palpa, nepal. the secondary data collection was done throughout the month of march, 2016. medical records of patients admitted in any department of the hospital with history of seizure disorder and underwent a ct scan of brain from first of march, 2014 to 28th of february, 2016 were included. ct scan was done using siemens somatom emotion and regular ct protocols were followed. ct protocols included supine position with head first and axial section of head. plain ct scan with 10 mm slice thickness were taken and thin sections of two to five mm were also done in particular aspects. contrast enhanced ct was also carried out whenever required. points in history and clinical examination were noted. the ct patterns were then noted. this study didn’t involve traumatic skull or brain injuries. the data was tabulated in microsoft excel 2013 and analyzed by spss-21. descriptive statistics like frequency and percentage were calculated. chi-square test was applied to see relation between categorical data. p value <0.05 was considered significant. results: there were 480 cases in total out of which 263 (55%) were male and 217 (45%) were female with m:f ratio of 1.2:1. frequency of generalized and partial seizure and their relation to gender is shown in table 1. it shows that partial and generalized seizure were equally distributed in both gender. out of 274 cases of generalized seizure, ct scan findings were abnormal in 151 (55%) cases. out of 206 cases of partial seizures, 125 (61%) cases had abnormal ct scan findings. this difference was not statistically significant, x2(n=204, df=1) = 1.49, p = 0.22. table 2 shows the ct scan findings of patients with seizure and their age-group wise distribution. most common finding was calcified granuloma (n=79, 16.5%) and was most common in young age (<20 years). the second most common finding was neurocysticercosis which was found in 64 (13%) cases. neurocysticercosis was also most common in young group (<20 years). other findings in decreasing order were diffuse cortical atrophy which was common in elderly (>60 years) group, tuberculosis, granulomatous lesion, infarct gender partial seizure generalized seizure statistics male 112 151 x2=0.026 df=1, p=.87female 94 123 total 206 (43%) 274 (57%) table 1: relation between gender and type of seizure (n=480) 8 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 acharya s. et al. computed tomography findings in patients with seizure disorder. jlmc.edu.np findings ≤ 20 21-40 41-60 >60 n normal 111 64 23 6 204 neurocysticercosis 32 15 13 4 64 tuberculosis 11 5 2 2 20 granulomatous lesion 10 6 0 1 17 calcified granuloma 31 28 17 3 79 infarct 1 2 2 8 13 hemorrhage 1 0 5 1 7 diffuse cortical atrophy 6 6 11 14 37 arachnoid cyst 4 3 1 0 8 gliotic changes 2 2 3 2 9 malignancy 0 0 2 4 6 arterio-venous malformation 0 1 1 0 2 tuberous scalerosis 0 2 0 0 2 scizencephaly 2 0 0 0 2 hydrocephalous 2 0 0 0 2 focal cortical atrophy 0 1 0 0 1 focal cerebral edema 1 0 0 0 1 diffuse cerebral edema 2 0 0 0 2 sah 2 0 0 0 2 fahr disease 0 2 0 0 2 total 218 137 80 45 480 table 2: ct scan findings of patients with seizure according to age group (years). ct findings partial seizure generalized seizure n ncc 60 4 64 tuberculosis 17 3 20 granulomatous lesion 16 1 17 calcified granuloma 9 70 79 infarct 3 10 13 hemorrhage 0 7 7 diffuse cortical atrophy 7 30 37 malignancy 0 6 6 tuberous scalerosis 0 2 2 hydrocephalous 0 2 2 focal cortical atrophy 1 0 1 focal cerebral edema 1 0 1 diffuse cerebral edema 0 2 2 sah 0 2 2 fahr disease 0 2 2 table 3: ct scan findings in patients with seizure according to the type of seizure. among others. scizencephaly, hydrocephalous, focal cerebral edema, diffuse cerebral edema, and sub-arachnoid hemorrhage (sah) were exclusively present in young (<20 years) age group. table 3 shows the distribution of ct scan findings according to the type of seizure. calcified granuloma, diffuse cortical atrophy, infarct, and malignancy were the common findings in patients with generalized seizure. neurocysticercosis, tuberculosis, and granulomatous lesions were frequent findings in patients with partial seizure. discussion: hospital admissions with history of seizures are common. almost 3-9 per 1000 population of total hospital emergencies are seizure cases. epilepsy is an important health problem in developing countries, where its prevalence can be up to 57 per 1000 population.8 singh a. et al. conducted five years retrospective study which involve 915 cases of seizures including both generalized and partial. out of total 915 cases 515 were male and 400 were female. generalized seizure observed little more in male and female. this study had high prevalence of seizures in first, second, third and fourth decades with decreasing pattern with increasing age. prevalence in first decade was low as compared to second and third decades. tuberculoma (9.39%) and neurocysticercosis (3.60%) had highest prevalence in partial seizures followed by focal cerebral edema (6.22%) whereas diffuse cerebral edema (4.91%) seen with generalized seizures. cerebral infarct was equally seen in both types of seizures. brain tumor presented mostly with generalized seizure (2.07%) than in partial seizures (0.98%). in our study, out of total 480 cases, 263 were male and 217 were female with m:f ratio of 1.2:1. generalized seizure was observed more as compared to partial seizure in both males and females. seizure was more common in first, second, third and fourth decades. in ncc and tuberculoma, the commonest finding was partial seizure whereas in cerebral infarct, hemorrhage, malignancy, diffuse cortical atrophy, complex seizure was common. both studies are comparable. in 274 cases of generalized seizures, ct scan findings were abnormal in 151 cases. in 206 cases of partial seizures, 125 cases had abnormal ct findings. similar studies were done by different researchers in different places of india i.e. bangalore, mumbai, chennai.9,10,11 study done at these places showed high ratio of ct scan abnormalities in partial seizure. highest prevalence occurred in the second decade of life in sri lanka.12 study done at south india by venkateswara mn. et al. showed high prevalence 9 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 acharya s. et al. computed tomography findings in patients with seizure disorder. jlmc.edu.np rate of seizure in second and third decades.13 computerized tomography (ct) of the brain has been used routinely to study patients with epilepsy. in patients with the various electro-clinical types of epilepsy i.e. primary, secondary, and partial, it gave accurate information about the frequency, topography, and severity of morphological abnormalities. in various types of organic lesion like tumor, post-traumatic, post ischemic, post infectious, etc., it markedly increased the ability to establish etiology.14 contrast enhanced images are very valuable in making a diagnosis. although ct gives ionizing radiation to the patient, but its increasing wide spread availability, patient affordability, and short scan time makes it very valuable tool in diagnostic work up of a seizure patient. its benefit outweighs the risk. ct scan plays a very important role as a preliminary tool in radiological assessment of patients presenting with seizure. in about half of the seizure patients, it is able to diagnose or suggest the abnormality. it is valuable in making a diagnosis particularly in developing country like nepal, where infections like ncc and tb are most important causes of seizures. conclusion: computerized transverse axial tomography is one of the important investigations to rule out the etiological causes of seizures. in nepal, there is high prevalence of ncc followed by tuberculosis, which are commonly found in cases of partial seizures. malignancy, cerebral edemas, calcifications, cerebral atrophy, hydrocephalus, sub arachnoid hemorrhage, intracerebral hemorrhage, infarction of basal ganglion, tuberous sclerosis are other common ct scan findings in patients with seizure disorder. references: 1. lowenstein dh. seizures and epilepsy. in: kasper dl, braunwald e, fauci as, hauser sl, longo dl, jameson jl. (eds). harrison’s principles of internal medicine (18 ed.). new york: mc grawhill professional publishing; 2008. chapter 369. 2. berg at, berkovic sf, brodie mj, buchhalter j, cross jh, van emde boas w, et al. revised terminology and concepts for organization of seizures and epilepsies: report of the ilae commission on classification and terminology, 2005-2009. epilepsia. 2010;51(4):676-85. doi: 10.1111/j.1528-1167.2010.02522.x. epub 2010 feb 26. 3. kuzniecky ri. neuroimaging of epilepsy: therapeutic implications. neurorx. 2005;2(2):384–93. 4. sa de camargo ec, koroshetz wj. neuroimaging of ischemia and infarction. neurorx. 2005;2:265–76. 5. hankey g, davies l, gubbay ss. long term survival with early childhood intracerebral tumours. j neurol neurosurg psychiatry. 1989;52:778–81. 6. wyllie e, rothner ad, luders h. partial seizures in children: clinical features, medical treatment, and surgical considerations. pediatr clin north am. 1989;36:343–64. 7. gastaut h, gastaut jl. computerized transverse axial tomography in epilepsy. epilepsia. 1976;17:325–36. 8. senanayake n, roman gc. epidemiology of epilepsy in developing countries. bull world health organ. 1993;71(2):247-58. 9. mani ks, rangan g. epilepsy in the third world-asian aspects. in: dam m, gram l. (eds.). comprehensive epileptology. new york: raven press; 1991.p. 781-93. 10. joshi v, katiyar bc, mohan pk, misra s, shukla gd. profile of epilepsy in a developing country: a study of 1000 patients based on the international classification. epilepsia. 1977;18(4):549-54. 11. koul r, razdan s, motta a. prevalence and pattern of epilepsy (lath/mirgi/laran) in rural kashmir, india. epilepsia. 1988;29(2):116-22. 12. baheti r, gupta bd, baheti r. a study of ct and eeg findings in patients with generalized or partial seizures in western rajasthan. jiacm. 2003;4(1):25-9. 13. venkateswara mn, anusha b. a study on trends in prescribing pattern of antiepileptic drugs in teritiary care teaching hospital. ijcp sciences. 2012;3(2):25-31. 14. gastaut h, gastaut jl. computerized transverse axial tomography in epilepsy. epilepsia. 1976;17(3):325–36. 10 pattern of severe acute maternal morbidity in a tertiary care institute narinder kaur,a shreyashi aryala —–————————————————————————————————————————————— abstract: introduction: maternal mortality traditionally has been the indicator of maternal health all over the world. more recently review of the cases of severe acute maternal morbidity (samm), also termed as "near miss obstetrics events", has been found to be a useful supplementary indicator to investigate maternal health care. cases of near miss are those in which women present with potentially fatal complication during pregnancy, delivery, or the puerperium and survive merely by chance or by good hospital care. this study was done with the objective to analyze cases of samm at lumbini medical college teaching hospital (lmcth), nepal. methods: a retrospective study of all cases meeting the who criteria for samm, during may 2015, was done. cases meeting the who eligibility criteria for near miss cases were included in the study. medical record of such cases in past one year was reviewed. their sociodemographic variables, parity, gestational age, associated organ dysfunction, icu and hospital stay, management, and fetal and maternal outcome were noted. results: during the study period, there were total of 28 cases of samm and two maternal mortality out of 2735 live births. thus rate of samm was 1.02%, and maternal mortality rate was 0.07%. majority of patients were unbooked (n=18, 64.28%) and 10 (35.71%) were illiterate. commonest causes for admission to icu was hemorrhage (n=10, 35.71%) followed by hypertensive disorders (n=9, 32.06%), sepsis (n=2, 7.14%), and obstructed labour (n=2, 7.14%). laparotomy was performed in six (21.42%) women, obstetric hysterectomy in four (14.28%), and pelvic devascularization in two (10.71%). conclusion: samm is a useful adjunct to maternal mortality to assess maternal health care. improving facility based care and prompt referral, education of primary health care (phc) staff can be a short term measure to quickly reduce the number of maternal deaths. facility based monitoring and reporting of samm outcome is an important step for scaling up such efforts. keywords: maternal death • maternal mortality • morbidity • near miss • obstetric complications ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, department of obstetrics and gynecology lumbini medical college, palpa, nepal corresponding author: dr. narinder kaur e-mail: dr.kaurnarinder@gmail.com how to cite this article: kaur n, aryal s. pattern of severe acute maternal morbidity in a tertiary care institute. journal of lumbini medical college. 2015;3(2):45-9. doi: 10.22502/jlmc.v3i2.72. ___________________________________________________________________________________ j. lumbini. med. coll. vol 3, no 2, july-dec 2015 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v3i2.72 introduction: each year nearly 289,000 women die globally due to pregnancy associated causes.1 for each maternal death, nearly 118 women suffer from life threatening event of "severe acute maternal morbidity" (samm).2 samm is also known as "near miss" and is described as a very ill pregnant (antenatal, intrapartum or 42 days after termination of pregnancy) women who would have died had it not been the good luck and good care on her side.3,4 maternal mortality is one of the important indicator of maternal health care but during the 1990s, the concept of samm emerged in response to the need for a more sensitive marker of quality of obstetric care.3,5-9 the prevalence of samm is more in developing countries and causes are mainly hemorrhage, hypertensive disorders, sepsis, and obstructed labour, which are the same as that for maternal mortality.4 near miss is an indicator of maternal health and maternal care at any institution.1,3,4 good antenatal care, timely referral and diagnosis, availability of blood in time, and maintenance of asepsis can go long way in improving the samm.8 systematic reviews have shown that there are many inconsistencies in classification of maternal deaths, standard definition and criteria for 45 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 jlmc.edu.np kaur n. et al. pattern of severe acute maternal morbidity in a tertiary care institute. identifying samm, and near miss.4,9-11 in this study, world health organization near miss guideline was used.6,12 a survivor of a near miss event is an indicator of the quality of care provided. an audit of samm can help identify factors leading to maternal morbidity and its complications and assess the quality of care within the health care facility which will help in making improvements in these areas of health care. methods: this is a retrospective study done at lumbini medical college teaching hospital, nepal which is a 700 bedded tertiary care referral center in hilly mid western nepal. all cases who met the who criteria for samm from 1st may 2014 to 31st of july 2015 were included in the study.9,13 those patients were analyzed for the following information: booking, literacy and socio-economic status, gestational age, parity, disease responsible for critical illness, complication that prompted for icu admission, number of stay days in icu and hospital, management, requirement of blood and blood products and complications prompting referral to other centers. data were entered and analyzed in spss version 21. results were interpreted as mean, sd and percentages, wherever applicable. results: during the study period, there were 2735 deliveries out of which 624 patient required lower segment caesarean section (lscs) giving a lscs rate of 22.8%. twenty eight (1.02%) were admitted to icu which met the who criteria for samm. table 1 shows the demographic detail of these 28 women. the mean age was 23.4 yrs (sd = 3.9). most women were of age less than 25 years and with parity less than two, a common trend in this region. eighteen (64.28%) of these pregnancies were unbooked and were admitted in emergency. literacy level was low and majority was from low socio-economic group. table 2 summarizes the causes, occurrences, complications, and management of samm. haemorrhage was the most common cause of samm followed by hypertensive disorders of pregnancy. disseminated intravascular coagulation occurred in four subjects. primary pph was the leading cause variables n % age of mother (years) 15-25 19 (67.85) 26-35 7 (25) >35 2 (7.24 ) parity 0 2 (7.24) 1 13 (46.42) 2 8 (28.57) >2 5 (17.98) gestational age <12 weeks 2 (7.24) 13-28 wks 0 29-36wks 6 (21.42) 37-40wks 15 (53.57) >40 wks 5 (17.85) booking status booked 10 (35.71) unbooked 18 (64.28) literacy illiterate 10 (35.71) literate 18 (64.27) socioeconomic status low 19 (67.85) middle 9 (32.15) high 0 table 1: socio-demographic variables, parity and gestational age of participants present in 11 (39.28%) patients. table 3 shows the causes for hemorrhage and their management with blood and blood products. blood and blood products were required in all cases of hemorrhage. circulatory support was needed in 10 and mechanical ventilation in seven subjects. surgical management was required in eight cases as shown in table 2. one woman developed deep vein thrombosis and had paresis on left side of the body. there were three women with sepsis, two were admitted within 10 days of puerperium with breathlessness and pulmonary congestion, were kept on ventilator support for 3 and 7 days respectively. the third patient was in 26 wks pregnancy with suspected meningitis and was referred outside due to unavailability of mechanical ventilator. total icu stay was <24 hrs in two (7.24%), 24-72 hour in 19 (67.85%) and >72 hours in 7(25%) cases of samm. two women with obstructed labour (cpd and neglected impacted shoulder presentation) were found to have referred late from 46 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 kaur n. et al. pattern of severe acute maternal morbidity in a tertiary care institute. jlmc.edu.np group near miss criterion n % 1 severe post partum hemorrhage 10 35.71 2 severe preeclampsia+ hypertension 5 17.78 3 eclampsia 4 14.28 4 postpartum sepsis 2 7.14 5 obstructed labour 2 7.14 6 rupture uterus 1 3.5 7 severe complication of abortion 1 3.5 8 ruptured ectopic pregnancy 1 3.5 9 pregnancy with fever? meningitis 1 3.5 10 lscs(quadruplets for intraopera-tive hypotention) 1 3.5 total number admitted to icu (n) 28 100 critical interventions 11 laparatomy 6 21.42 12 interventional radiology 0 0 13 use of blood and blood products 12 39.28 life threatening conditions 14 cardiovascular dysfunction 10 35.71 15 respiratory dysfunction 7 25 16 renal dysfunction 1 3.5 17 coagulation/hematological dysfunction 4 14.28 18 hepatic dysfunction 0 0 19 neurological dysfunction 1 3.5 20 uterine dysfunction(hysterectomy) 4 14.28 21 devascularization, internal iliac ligation, uterine and ovarian artery ligation, b-lynch suture 3 10.7 table 2: study group according to who near miss criteria. cause n(%) primary pph 11(39.28) uterine atony 7 (25) cervical laceration and broad ligament hematoma 1 (3.50) cervical laceration extending into lower segment 1 (3.5) cervical and vaginal laceration 1 (3.5) uterine rupture 1 (3.5) other causes ruptured ectopic pregnancy 1 (3.5) inevitable abortion 1 (3.5) blood and blood products transfused 1 4 units whole blood 4(14.28) ≤ 4 fresh frozen plasma (ffp) 2(7.14) ≤ 8 ffp + cryopecipitate 2(7.14) ≤ 8 ffp + platelets rich plasma 1(3.5) 5 8 ffp 2(7.5) >8 ffp 1(3.5) table 3: causes of hemorrhage and requirement of blood and blood products (n=28) health institutes in the periphery. there were two maternal mortality during this period which were both unbooked and referred cases of eclampsia and obstructed labour leading to pph and dic. regarding the neonatal outcome amongst women with samm, there were 3 stillbirths and two neonatal deaths. during that period the rate of perinatal mortality was 1.82/1000. nine babies required nicu admission, six for prematurity, one for meconium aspiration and two for neonatal asphyxia. one woman amongst samm had acute kidney injury following severe pph and hysterectomy and was referred to other centre for dialysis. one antenatal woman with acute respiratory distress syndrome was referred for the want of ventilator support. discussion: progress in reduction of maternal mortality has been slow. over 1000 women still die from pregnancy related causes around the world and vast majority of these deaths occur in developing countries.10 severe obstetric morbidity and its relation to mortality may be a more sensitive measures of pregnancy outcome than mortality alone.3,7,9,13 including samm in maternal death audit increases the rapidity with which health system problems can be identified. but the criteria currently used to identify a near miss vary greatly.1,4,6,12,14 there is a clear need to set uniform criteria to classify patients as samm.9,15 comparing the rate over time and across region, it is clear that different approaches are needed to lower the rate of near miss and that interventions must be developed with the local context in mind.9,13 the incidence of samm ranges from 0.07 to 8.23% and the case fatality ratio from 0.02 to 37%.16 in the present study, occurrence of samm was 1.02% and maternal mortality rate was 0.07 % (70/100000) respectively. in nepal maternal mortality is reported as 229/100000 in 2008-2009.17 low maternal mortality in our institute may be due to a small size reported from a single institution only. comparable incidence of samm are reported by other institutions in nepal as 2.23% and 3.5%.18,19 hemorrhage and hypertensive disorder in pregnancy are the most common cause of direct obstetric deaths being disproportionately higher among the poor, less educated, at the extremes of reproductive period and 47 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 kaur n. et al. pattern of severe acute maternal morbidity in a tertiary care institute. jlmc.edu.np the women with higher parity.4,13 this is the same as reported in the current series. worldwide, the leading causes of severe morbidity are hemorrhage, pregnancy related hypertension, sepsis, and obstructed labour.1,2,4-6,9,13 in current study, findings are comparable being 46.42%, 32.06%, 10.62%, and 7.14% respectively. regardless of geographical factors, hemorrhage is the largest contributor accounting for one-fifth to half of the cases.4,20-22 hypertensive disease and its consequences account for 10% to 45% of cases of samm.21,22,26 in our series hemorrhage and hypertensive disorders were responsible for 46.42% and 35.14% respectively. the reported incidence of haemorrhage in this study (35.71%) is higher than that reported by upadhyaya i. et al. (14.6%) but comparable to that reported by shrestha ns. et al. (41.66%) in other institutes in nepal.18,19 however the incidence of hypertensive disorders were higher in the study by upadhyaya et al. (50%) as compared to 32.06% in our study.18 good antenatal services with aggressive management of preeclampsia, particularly during labour are to be encouraged. the provision of an icu for eclamptic patients especially in certain designated areas of labour suits with excellent nursing care would be helpful.23 similarly hemorrhage should be diagnosed in time and managed aggressively. untoward are the result of too little or too late management. good blood bank services are necessary round the clock; severe morbidity usually results, for the lack of availability of blood and blood products, delayed referral and delayed diagnosis. shortage of micu beds and lack of high dependency units in obstetrics departments are responsible for high mortality ratio.24 strengthened health system and effective maternal health care particularly with acute pregnancy related complications are considered the key factors for reducing maternal mortality.21 basic antenatal care cannot be over emphasized as ample evidence shows that antenatal follow up decreases a woman's risk when it comes to labour and delivery.12,25 in this study majority of the women were unbooked (64.28%). this emphasizes the need of antenatal counseling. screening for anemia and complicating diseases during anc, hygiene during labour, presence of skilled birth attendant and active management of third stage of labour are the basic requirement advocated by who.8,13 some factors for late presentation include awareness, level of weak referral system, financial constrains, gender discrimination, constrains on mobility, health seeking behavior during illness and acceptable norms related to physiologic phenomenon i.e. menstruation, pregnancy and child birth. additionally the absence of medical facilities also results in amplified morbidity and mortality in these women,same is seen in the present series.26 poor antenatal care, coverage and awareness, delayed diagnosis of severe morbidity, untimely often delayed referral and transfer and unavailability of resources might have been the cause of avoidable severe maternal morbidity and mortality in our study as 64.28% were unbooked and admitted in emergency. most maternal morbidities and mortalities could have been avoided with the help of government funded policies including early referrals, quick, efficient and well equipped transport facilities, availability of adequate blood and blood products and promoting safe motherhood. conclusion: the leading causes of severe maternal morbidity in this institute were hemorrhage and hypertensive disorders of pregnancy. it is a good indicator for designing, monitoring, follow-up and evaluation of safe motherhood. regular auditing on regular basis for improvement in management is necessary. maternal mortality and samm can be reduced by meticulous adaptation of safe motherhood initiative, provision of separate icu for obstetric patients, early assessment and aggressive interventions through team management involving obstetrician, anesthetist, other specialties as and when required. efforts geared towards improvements in the management of near miss morbidities would definitely go a long way in reducing the present maternal mortality ratio and long term pregnancy complications. references: 1. world health statistics 2014: fact sheets. geneva: world health organization; 2014. 2. waterstone m, bewley s, wolfe c. incidence and predictors of severe obstetric morbidity: case-control study. bmj. 2001;322(7294):1089-93. 3. stones w, lim w, al-azzawi f, kelly m. an investigation of maternal morbidity with identification of life threatening 'near miss' episodes. health trends. 1991;23(1):13-5. 4. mantel gd, buchmann e, rees h, pattison rc. severe acute maternal morbidity: a pilot study of a definition for near-miss. br j obstet gynaecol. 1998; 105(9):985-90. 48 j. lumbini. med. coll. vol 3, no 2, july-dec 2015 kaur n. et al. pattern of severe acute maternal morbidity in a tertiary care institute. jlmc.edu.np 5. khan ks, wojdyla d, say l, gulmezoglu am, van look pf. who analysis of causes of maternal deaths: a systematic review. lancet. 2006;367(9516):1066-74. doi: 10.1016/ s0140-6736(06)68397-9. 6. say l, souza jp, pattison rc, who working group on maternal mortality and morbidity classifications. maternal near miss--towards a standard tool for monitoring quality of maternal health care, best pract res clin obstet gynaecol. 2009;23(3):287-96. doi: 10:1016/j.bpobgn.2009.1.007. 7. lewis g. confidential enquiry into maternal and child healthimproving care for mothers, babies and children why mothers die 2000-2002, executive summary and key findingsthe sixth report of the confidential enquiries into maternal deaths in the united kingdom. london; rcog press. 2004. 8. lazarus jv, lalonde a. reducing postpartum hemorrhage in africa. int j gyanecol obstet. 2005;88(1):89-90. 9. tuncalp o, hindin mj, souza jp, chou d, say l. the prevalence of maternal near miss: a systematic review. bjog. 2012;119(6):653-61. 10. moody j. confidential enquiry into maternal and child healthimproving care for mothers, babies and children why mothers die 2000-2003, executive summary and key findingsreport of the confidential enquiries into maternal deaths in the united kingdom. london; rcog press. 2004.p.234-4. 11. gandhi mn, wiez t, ronsmans c. severe acute maternal morbidity in rural south africa. int. j gynaecol obstet. 2004; 87(2):180-7. 12. pattison r, say l, souza jp, broek nv, rooney c, who working group on maternal mortality and morbidity classifications. who maternal death and near-miss classification. bulletin of the world healthh organization 2009;87:p.734. doi: 10.2471/blt.09.071001. 13. world health organization, department of reproductive health and research. evaluating the quality of care for severe pregnancy complications: the who near-miss approach for maternal health. who guide; geneva: 2011. 14. world health organization. maternal mortality in 2005: estimates developed by who, unicef, unfpa and the world bank. switzerland; world health organization; 2010. p.15-6. 15. ostermann m, raimundo m, williams a, whitely c, beale r. retrospective analysis of outcome of women with breast or gynaecological cancer in the intensive care unit. jrsm short rep. 2013 jan;4(1):2. doi: 10.1258/ shorts.2012.012036. 16. minkauskiene m, nadisauskiene r, padaiga z, makari s. systematic review on the incidence and prevalence of severe maternal morbidity. medicina (kaunas). 2004;40(4):299309. 17. barnett s, sharma sk, poudel p, chitrakar sr, k.c np, hulton l. nepal maternal mortality and morbidity study 2008/09. kathmandu: family health division, government of nepal; 2010. 18. upadhyaya i, chaudhary p. severe acute maternal morbidity and intensive care in paropakar maternity and womens' hospital. njog. 2013;8(2):38-41. 19. shrestha ns, saha r, karki c. near miss maternal morbidity and maternal mortality at kathmandu medical college teaching hospital. kathmandu univ med j. 2010;8(30):222-6. 20. bouvier-colle mh, salanave b, ancel py, varnoux n, fernandez h, papiernik e, et al. obstetric patients treated in intensive care units and maternal mortality. regional team for the survey. eur j obstet gyaecol reprod biol. 1996;65(1): 121-5. 21. prual a, bouviier-colle mh, de bernis l, breart g. severe maternal morbidity from direct obstetric causes in west africa: incidence and case fatality rates. bull world health organ. 2000;78(5):593-602. 22. brace v, penney g, hall m. quantifying severe maternal morbidity: a scottish population study. br j obstet gynaecol. 2004;111(5):481-4. 23. wilson re, salihu hm. the paradox of obstetrics 'near misses": converting maternal mortality into morbidity. int j fertil womens med. 2007;52(2-3):121-7. 24. bibi s, memon a, sheikh jm, qureshi ali. severe acute maternal morbidity and intensive care in a public sector university hospital of pakistan. j ayub med coll abbottabad. 2008:20(1):109-12. 25. the mother-baby package: who's guide to saving women's and infant’s lives. safe mother. 1994;15:4-7. 26. ostermann m, raimundo m, williams a, whitely c, beale r. retrospective analysis of outcome of women with breast or gynaecological cancer in the intensive care unit. jrsm short rep. 2013 jan;4(1):2. doi: 10.1258/ shorts.2012.012036. 49 outcomes of pediatric supracondylar fractures of humerus treated by posterior triceps splitting approach rajeev dwivedi,a ruban raj joshi,a subin byanjankar,a rahul shresthaa —–————————————————————————————————————————————— abstract: introduction: close reduction and percutaneous pinning is the gold standard treatment for supracondylar fracture of humerus. open reduction and internal fixation is indicated in patients with unacceptable closed reduction, neurovascular compromise, and open fractures. open reduction can be performed through various approaches. every approach has their advantages and limitations. the aim of this study was to assess the functional and cosmetic outcome of pediatric supracondylar fracture of humerus treated by posterior triceps splitting approach. methods: this was a prospective evaluation of 20 consecutive patients with displaced pediatric supracondylar humeral fractures operated by triceps spitting posterior approach in our institution for two years. at initial presentation, 19 cases were gartland iii and one was flexion variant of injury. complications such as reduction loss, pin migration, infection, osteonecrosis of any part of the elbow, bone healing, and functional results were evaluated. flynn criteria were used to evaluate the final results. results: twenty patients underwent open reduction and internal fixation by triceps splitting approach. thirteen patients were male and seven were female with m:f ratio of 1.86:1. the mean age was 6.8 yr (sd=2.74, range 2-14). all the fractures united by six weeks; mean time for union was 4.5 wk (sd=0.94). all patients were assessed at six months using flynn clinical and radiological criteria. results were satisfactory in all patients. conclusion: posterior triceps splitting approach is simple, safe and has good functional and radiological outcome. we recommend this approach for open reduction and internal fixation in pediatric supracondylar fracture. keywords: humeral fractures • internal fixation • open reduction • pediatric ——————————————————————————————————————————————— ___________________________________________________________________________________ a lecturer, department of orthopedics and traumatology lumbini medical college teaching hospital, palpa, nepal corresponding author: dr. rajeev dwivedi e-mail: rd172002@gmail.com how to cite this article: dwivedi r, joshi rr, byanjankar s, shrestha r. outcomes of pediatric supracondylar fractures of humerus treated by posterior triceps splitting approach. journal of lumbini medical college. 2016;4(1):28-31. doi: 10.22502/jlmc.v4i1.83. ___________________________________________________________________________________ j. lumbini. med. coll. vol 4, no 1, jan-june 2016 original research article jlmc.edu.np https://doi.org/10.22502/jlmc.v4i1.83 introduction: in children, supracondylar fractures are the most common elbow fractures that account for about 70% of fractures around the elbow.1,2 these fractures are divided into two types; extension (98%) and flexion (2%) type; the extension type is further is classified by gartland into type i (without displacement), type ii (with displacement but intact posterior cortex) and type iii (with displacement and disruption of both cortices).1,2 displaced supracondylar fracture in children is usually treated by closed reduction and percutaneous k-wires fixation (crif). there are certain indications for open reduction and internal fixation (orif) like unacceptable closed reduction, pucker sign, vascular insufficiency, and compound fractures.1,3,4 outcome of supracondylar fracture mainly depends upon reduction of fracture fragments and surgical approach used to open the fracture. open reduction can be performed through a posterior, lateral, medial, or anterior approach or a combination of these approaches. every approach has their own advantages and limitations. complications like reduction of range of motion, failure to perfectly reduce the fragments, and nerve injury following open reduction of supracondylar fracture may be 28 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 dwivedi r. et al. outcomes of pediatric supracondylar fractures of humerus treated by posterior triceps splitting approach. jlmc.edu.np approach related. the ideal approach should give appropriate exposure of the fracture site, should be safe and quick and be associated with minimal complications. the aim of this study was to review the advantages and disadvantages of posterior triceps splitting approach and to assess the functional outcome of supracondylar fracture of humerus in children treated by this approach. methods: this prospective study was conducted from april 2014 to march 2016 in the department of orthopedics, lumbini medical college teaching hospital, papla, nepal. all cases of supracondylar fracture of humerus in children, less than 15 years of age, not able to be reduced by closed method were included. the ethical clearance for this study was taken from the institution review board. written informed consent was taken from patients' relative. all fractures were classified according to gartland classification.2 operative technique: all surgeries were done under general anesthesia. patients were placed in lateral position on unaffected side. tourniquet was used. midline incision was given on posterior aspect of elbow starting few centimeter above tip of olecranon, curved around it and carried distal to it. subcutaneous tissue was dissected and ulnar nerve was identified and isolated. triceps muscle was vertically split to expose fracture site. hematoma was evacuated and saline wash was done to visualize the fracture site. fracture was reduced after clearing the interposed soft tissue and hematoma. reduction was assessed by visualizing the medial and lateral pillar anatomy. after reduction, the fracture was fixed with cross k-wires starting simultaneously from medial and lateral epicondyle area, across the fracture site, to engage the opposite cortex of the proximal fragment. the fractures were secured with 1.5-2.0 mm k-wires depending upon the age of the patient and at least two cross k-wires were used. number of wires depended on surgeon's preferences, pattern of fracture, and final stability of the fracture. stability of fracture reduction was checked. the k-wires were bent and cutoff outside the skin to allow removal in the outpatient department without anesthesia. tourniquet was released. hemostasis was achieved and wound was closed in layers. postoperatively, the extremity was immobilized in posterior splint with elbow flexed to 90° and patients were transferred to the ward after recovery from anesthesia. patients were usually discharged from hospital on third day after first wound inspection; called for follow-up after one week, three week, six week, 12 wk and 24 wk. the plaster of paris (pop) slab and k-wires were removed after fracture union was seen in x-ray. active range of motion exercises was started after removing the slab and k-wires. the patients were examined clinically and radiologically; range of motion of elbow and carrying angle were noted. the final results obtained were evaluated by flynn criteria (table 1).5 the results were graded as excellent, good, fair and poor according to loss of range of motion and loss of carrying angle of elbow. results: ninety children, less than 15 years of age, underwent surgery for supracondylar fracture of humerus during the study period. seventy nine cases grading loss of carrying angleof elbow loss of rom of elbow excellent 0-5° 0-5° good 6-9° 6-9° fair 10-15° 10-15° poor >15° >15° table 1: flynn criteria were gartland type iii, ten cases were gartland type ii fractures and one case was flexion type injury. twenty (22.2%) cases required open reduction and internal fixation. there were 19 gartland type iii injuries and one patient with flexion type injury. all were closed fractures and none of the patients had vascular compromise. all 20 patients underwent open reduction and internal fixation by triceps splitting approach. thirteen patients were male and seven were female with m:f ratio of 1.86:1. the mean age was 6.8 yr (sd=2.74, range 2-14). the commonest cause of injury was fall while playing in 10 (50%) patients, fall from tree in five (25%), fall from height in three (15%), and fall from bicycle in two (10%) patients. there was a right-sided predominance (n=14, 70%) compared to the left side (n=6, 30%). however, the difference was not statistically significant (x2[n=20, df=1] = 3.2, p=0.07). there were 12 patients with posteromedial displacement and seven with posterolateral displacements. one 29 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 jlmc.edu.np dwivedi r. et al. outcomes of pediatric supracondylar fractures of humerus treated by posterior triceps splitting approach. flexion type was medially displaced. patients underwent surgery between 24 to 72 hr of injury. postoperative hospital stay averaged 3.75 days (sd=1.16, range 3-7). the skin incision healed in all patients without problems by second week and then sutures were removed. radiographs were performed prior to removal of the k-wires and the plaster slab. all the fractures had united by six week; mean time for union was 4.5 wk (sd=0.94). among postoperative complications, one patients had pin site infection that improved with wound care and oral antibiotics. there was no complication like permanent nerve palsy, k-wire loosening, and failure of reduction. radial nerve palsy was seen in two cases and median nerve palsy in other two cases; all recovered without intervention by three months. all patients were assessed at six months using flynn clinical and radiological criteria.5 all 20 cases had satisfactory results (table 2). discussion: supracondylar fracture is the most common fracture in children around elbow.1,2 anatomical reduction is the main requirement to prevent malunion. inadequate reduction can produce grading loss of carrying angle loss of rom of elbow n (%) excellent 0-5° 0-5° 16 (80%) good 6-9° 6-9° 3(15%) fair 10-15° 10-15° 1(5%) poor >15° >15° 0 table 2: patients grading according to flynn criteria. deformities such as cubitus varus (the most common), cubitus valgus, malrotation, angulation (in sagittal plane), or translation. these deformities can cause functional disability.6 close reductions and percutaneous pinning is the gold standard treatment for supracondylar fracture of humerus in children.3 open reduction and internal fixation is indicated in patients with unacceptable closed reduction, neurovascular compromise, open fractures, severe displacement, pucker sign, or severe ecchymoses on anterior surface of the elbow.1,4,6 range of motion (rom) of elbow is another important factor with respect to outcome. rom of elbow depends on reduction of the fracture, surgical approach used to open the fracture site, and post operative complications like myositis ossificans and infections. there are various surgical approaches for orif. each approach has its merit and demerits. type of approach is also surgeon's choice. anterior approach gives good exposure to neurovascular bundles but it is a demanding approach and all orthopedic surgeons may not be familiar with this approach.7,8 medial and lateral approaches are limited approach with respect to exposure; visualization of other side of the pillar is not adequate and xray is required to see the reduction of fracture fragments and position of k-wires.9 there is a chance of ulnar nerve injury in all approaches except posterior approach because in all other approach medial k-wire is inserted blindly. all orthopedic surgeons are familiar with posterior approach as it is an easy and safe approach. the ulnar nerve is isolated in this approach so that iatrogenic ulnar nerve injury is avoided. both the pillars are visualized for prefect anatomical reduction. better manipulation of fracture fragment is possible and no x-rays are required to see the position of wires intraoperatively. posterior approach is standard approach for treatment in adults. it has been reported to have a high rate of loss of motion and the risk of osteonecrosis secondary to the disruption of the posterior end arterial supply to the trochlea of the humerus but in our study, only one patient had limitation of motion of elbow that is less than 15 degree.4,10,11 no complication like osteonecrosis was found. there are studies where posterior approach was used to operate the supracondylar fracture in children. these studies have similar outcomes as our study. in the study from iran, omidi-kashani et al. reported about thirty six children with displaced gartland type iii supracondylar fractures who underwent open reduction and internal fixation over six years period.12 they divided into three groups on the basis of surgical approach; group a (n=14) posterior approach with triceps splitting, group b (n=10) posterior approach with tongue shape flap, and group c (n=12) lateral, anterolateral, or medial approach. loss of range of motion was not more than 12° in any group. there was no deformity noted in group a triceps splitting approach. they advocated and recommended the posterior approach, particularly posterior triceps splitting approach, in surgical treatment of supracondylar fracture with normal neurovascular state in children, due to its simplicity, greater exposure, lack of interference with vital structures, and better surgical outcome. 30 j. lumbini. med. coll. vol 4, no 1, jan-june 2016 dwivedi r. et al. outcomes of pediatric supracondylar fractures of humerus treated by posterior triceps splitting approach. jlmc.edu.np study from india by gowada et al. reported, among 30 patients who underwent triceps splitting approach, that the functional results based on flynn grading were satisfactory in 28 patients (excellent in 18 (60%), good in seven (23.3%), and fair in three (10%) patients). they reported loss of carrying angle more than 15° in two patients and loss of rom more than 15° in one patient.13 karibasappa ag. et al. used posterior approach in 30 patients in their study. excellent results were obtained in 22 (73.3%), good in six (20%), and fair and poor in one (3.3%) each.14 in study from pakistan, haziqdad khan et al. used posterior campbell approach, which is an extensive approach then triceps splitting approach, to treat 30 gartland type iii supracondylar fracture. according to the flynn criteria, results were excellent in 16 (53.3%), good in six (20%), fair in five (16.7%), and poor in three (10%) patients.15 in our study, according to flynn criteria, results were excellent in 16 (80%) patients, good in three (15%), and fair in one case. the later patient had a loss of elbow motion of more than 10°. there was no poor result. short comings of this study was small number of cases and short term follow up. we need long term follow up to better understand about osteonecrosis of distal humerus, one of the complication mentioned in literature associated with posterior approach. another weakness is that we did not perform any measurements on last x-rays. humeral-ulnar angle, baumann angle, and lateral humero-capitellar angle are among the measurements that could be used to evaluate accuracy of reduction and alignment of the extremity. conclusion: to conclude, posterior triceps splitting approach is simple, exposure is sufficient to visualize both pillars, ulnar nerve is safe because it is isolated, intraoperative x-ray is not needed, there is no interference with anterior neurovascular structure, and functional and radiological outcome is good. so, we recommend this approach for open reduction and internal fixation of pediatric supracondylar fractures. references: 1. mangwani j, nadarajah r, paterson jm. supracondylar humeral fractures in children: ten years’ experience in a teaching hospital. j bone joint surg br. 2006;88(3):362-5. 2. mihrano tachdjian. pediatric orthopedics. 3rd ed. philadelphia: w saunders co; 2008. 3. milbrandt ta, copley lab. common elbow injuries in children: evaluation, treatment and clinical outcomes. curr opin orthop. 2004;15(4):286-94. 4. omid r, choi pd, skaggs dl. supracondylar humeral fractures in children. j bone joint surg am. 2008 may;90(5):1121-32. doi: 10.2106/jbjs.g.01354. 5. flynn jc, matthews jg, benoit rl. blind pinning of displaced supracondylar fractures of the humerus in children. sixteen years' experience with long-term followup. j bone joint surg am. 1974 mar;56(2):263-72. 6. rockwood c, buchols r, court-brown c. rockwood and green's fractures in children. 6th ed. william and wilkins: lipincott; 2006. 564-6 p. 7. otsuka ny, kasser jr. supracondylar fractures of the humerus in children. j am acad orthop surg. 1997 jan;5(1):19-26. 8. ay s, akinci m, ercetin o. the anterior cubital approach for displaced pediatric supracondylar humeral fractures. tech hand up extrem surg. 2006;10(4):235–8. 9. ersan o, gonen e, arik a, dasar u, ates y. treatment of supracondylar fractures of the humerus in children through an anterior approach is a safe and effective method. int orthop. 2009;33:1371–5. 10. yang z, wang y, gilula la, yamaguchi k. microcirculation of the distal humeral epiphyseal cartilage: implications for post-traumatic growth deformities. j hand surg am. 1998 jan;23(1):165-72. 11. bronfen ce, geffard b, mallet jf. dissolution of the trochlea after supracondylar fracture of the humerus in childhood: an analysis of six cases. j pediatr orthop. 2007;27(5):547-50. 12. omidi-kashani f, hassankhani eg, hasankhani gg. surgical outcomes of pediatric humeral supracondylar fractures treated by posterior approach and triceps splitting. j trauma treat. 2013;s4:007. doi:10.4172/21671222. 13. gowda pm, mohameed n. a study of supracondylar fractures of humerus in children by open reduction and internal fixation with kirschner wires. indian journal of clinical practice. 2014 nov;25(6):572-6. 14. karibasappa ag, venkata rm, manjunath j, nelvigi as. gartland type-iii supracondylar fracture humerus in children-treated by open reduction and internal fixation after failed closed reduction:a prospective clinical study. journal of international academic research for multidisciplinary. 2014 feb;2(1):1-5. 15. khan hd, shah fa, ullah k. outcome of supracondylar fractures of humerus in children treated with open reduction and internal stabilization with cross kirschner wires. journal of surgery pakistan. 2011 oct-dec;16(4):1-4. 31 j. lumbini. med. coll. vol 9, no 1, jan-june 2021 karki n, et al. assessment of prescription errors in the internal medicine department of a tertiary care hospital in nepal: a cross-sectional study jlmc.edu.np ___________________________________________________________________________________ submitted: 09 january, 2021 accepted: 18 may, 2021 published: 25 may, 2021 aassistant professor, department of pharmacology blecturer, department of pharmacology clumbini medical college & teaching hospital, palpa nepal dinstitute of medicine (tu), maharajgunj, kathmandu, nepal corresponding author: naresh karki e-mail: karki007naresh@gmail.com orcid: https://orcid.org/0000-0002-8788-6443_______________________________________________________ abstract: introduction: prescription errors are common problems in hospitals that lead to increase in morbidity, mortality and treatment cost. they also reduce faith towards healthcare providers. they are avoidable and their adverse outcomes can be reduced if assessed and recognized earlier. this study was conducted to assess prescription errors occurred in a tertiary care hospital in nepal. methods: a cross-sectional study was conducted in the internal medicine department of lumbini medical college over five months of duration. patients who were prescribed at least one drug in the prescription form were included. results: out of 425 patients, prescription errors were seen in 168 (39.5%) cases. among the prescription errors, 160 (37.6% of all prescriptions) were the errors of omission. errors of omission, due to missed dose of the drug were observed in 111 prescriptions (26.1%). regarding the severity of medication errors, category b errors were the most common (21.6%). prescriptions to patients with one diagnosis were less likely to have prescription errors compared to those with more than one diagnosis (p = 0.0002). observed frequency of prescription errors was higher among patients with polypharmacy (p < 0.001) and fixed-dose drug combination (p < 0.001). the observed frequency of errors of omission was also higher among patients with more than one diagnosis (p = 0.0002), patients with polypharmacy (p < 0.001) and patients who were prescribed fixeddose drug combinations (p < 0.001). conclusion: about one-third of the patients had prescription errors. among them, errors of omission were the most common. keywords: error of omission, medication error, prescriptions, tertiary hospital original research articlehttps://doi.org/10.22502/jlmc.v9i1.414 naresh karki,a,c kamal kandel,b,c pravin prasad a,d assessment of prescription errors in the internal medicine department of a tertiary care hospital in nepal: a cross-sectional study how to cite this article:how to cite this article: karki n, kandel k, prasad p. assessment of prescription errors in the internal medicine department of a tertiary care hospital in nepal: a cross-sectional study. journal of lumbini medical college. 2021;9(1):8pages. doi: https://doi.org/10.22502/jlmc.v9i1.414. epub: may 25, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: national coordinating council for medication error reporting and prevention (ncc merp) defined medication errors (mes) as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use”.[1,2] many factors are responsible for generating mes such as health worker’s workload, poor knowledge about drugs, irrational use of drugs, poor communication between healthcare providers and patients, pressure of time management, inadequate knowledge of disease and complexity of disease.[2] according to data of who, mes generally produce adverse j. lumbini. med. coll. vol 9, no 1, jan-june 2021 karki n, et al. assessment of prescription errors in the internal medicine department of a tertiary care hospital in nepal: a cross-sectional study jlmc.edu.np effects of drugs in approximately one million people every year worldwide including lowand middleincome countries.[3] among mes, prescription errors are common which are of two types; errors of omission and errors of commission.[4] if essential information is missed in the prescription, it is called error of omission, while errors of commission occur if wrong information is written in the prescription. [4] prescription errors lead to increase in adverse effects of drugs, morbidities, mortalities and burden of treatment costs. beside this, they also lead to reduced faith of patients towards healthcare providers and increased wastage of public money.[4,5] if assessments of those errors are made by authorized healthcare professionals in regular interval, they can be identified and corrected. so, in future, the harmful outcomes of those errors can be prevented and minimized.[6,7] these regular assessments also reduce existing gap of belief between healthcare providers and patients. many studies related to prescription error rates have been conducted in hospitals worldwide, but sufficient studies are not available for low-and middle-income countries, despite those countries have increased practice of using medications. moreover, only few studies have been found in tertiary level hospitals of nepal.[4,6] thus, this study was conducted with general objective to provide the understanding of prescription errors in internal medicine department of lumbini medical college and teaching hospital (lmcth). while the specific objectives were to evaluate prevalence of prescription errors that include errors of omission as well as errors of commission, to assess the level of severity of medication errors and to study their association with socio-demographic/clinical characteristics of the patients. methods: a cross sectional study was conducted in internal medicine department of lmcth, tansen, palpa after an approval letter was received from institutional review committee (protocol no: irc-lmc 14-g/020). an approval letter was also received from the head of the department of internal medicine to conduct the study. the study was conducted for the duration of five months from august, 2020 to january, 2021. the study included the data of: patient who visited the internal medicine out-patient department (opd) irrespective of age, gender and diagnosis, patient encountered first time by researchers, follow up patient encountered first time by researchers and patient prescribed at least one drug in opd prescription form. while, follow up patient encountered previously during first visit, patient prescribed no drug in opd prescription form and patient treated in internal medicine in-patient department were excluded. the sample size was calculated using the following formula (when population was unknown) as demonstrated in the articles published by sheikh et al. and degu et al.[7,8]: n = z2 p (1-p) / d2 where, n = minimum sample size required for accuracy in estimating proportions z = standard normal value for 95 % confidence interval (1.96), p = proportion of population possessing characteristics of interest, 0.5 (50%), 1-p = proportion of population that do not possess the characteristics of interest, d = margin of sampling error tolerated, 0.05 (5%) hence, the minimum sample size required was 384. a convenience sampling technique was used for collection of the data. the primary data were collected from health insurance section of lmcth and recorded in pre-designed case-proforma. the case-proforma consisted of information about socio-demographic profile of patients, diagnosis of disease and findings related to prescription errors. each prescription was checked two times to find if prescription contained any error. all the processes were done by researchers themselves. all the data were kept confidential and anonymous by keeping code numbers in place of name and address of the patient. however, hospital numbers were recorded for the proof that data were original. prescription errors namely errors of omission and errors of commission were included in caseproforma as found in the study conducted by ansari et al., sheikh et al., and sapkota et al.[6,7,9]: 1. errors of omission (essential information is j. lumbini. med. coll. vol 9, no 1, jan-june 2021 karki n, et al. assessment of prescription errors in the internal medicine department of a tertiary care hospital in nepal: a cross-sectional study jlmc.edu.np missed in the prescription form.): related to prescriber • patient name not mentioned • age not mentioned • prescription date not mentioned • diagnosis not mentioned • prescriber name not mentioned • department not mentioned • prescriber signature not mentioned related to drugs per total medicine dispensed • dose not mentioned • frequency not mentioned • dosage form not mentioned • quantity to supply not mentioned 2. errors of commission (wrong information is written in the prescription form, some examples of which are given below.): the possible causes for this type of errors are high workload of doctors, distraction of mind due to multiple duties of doctors, time pressure because of increased numbers of patients visiting to the opd and interruption by patients, patient’s relatives and other hospital staffs while prescribing the drugs). • wrong strength (example: dose of thyroxine is written in milligram in place of microgram) • wrong drug name (example; metoprolol is written in place of metronidazole) • wrong dosage form • potential drug-drug interaction both errors of omission and errors of commission made in the act of writing the prescription form were analyzed. the treatment guidelines for the disease or medical decisions were not taken into consideration during assessment of errors. further, level of severity of the medication errors was assessed by using internationally validated nccmerp index.[2,10] this index contains nine categories from category a to category i as described below: • category a: circumstances that have potential to cause medication errors. this circumstance causes no harm to the patients. • category b: an error occurs but does not reach the patient. this error causes no harm to the patient. • category c: an error occurs and reaches the patient but does not cause any harm to the patient. • category d: an error occurs that reaches the patient and needs monitoring to confirm that the error causes no harm to the patient. this error also requires intervention to prevent harm. • category e: this category includes error that may contribute or result in temporary harm. these errors may require intervention to prevent them. • category f: an error occurs that may contribute to or result in temporary harm and requires initial or prolong hospitalization of patient. • category g: an error occurs that may contribute to result in permanent harm to the patients. • category h: an error occurs that requires intervention necessary to sustain life. • category i: an error occurs that contributes or causes the patient’s death. once data were collected, they were entered in and analyzed by statistical package for social sciences (spss), version 18. basic socio-demographic variables (age, sex, ethnicity of the patients), clinical characteristics (presence of multiple illnesses, prescription of five or more drugs i.e. polypharmacy, prescription of fixed-dose drug combinations) were described. prescription errors and their associations with various sociodemographic and clinical characteristics were then analyzed. categorical variables were expressed as frequency and percentage. continuous variables were reported in terms of mean and standard deviation (sd). for inferential statistics, independent t-test and chi-square test were used as appropriate. p value less than 0.05 was considered as statistically significant. results: a total of 425 prescription forms were observed. of them, 53.4% were of males and 69.2% patients were above 50 years of age (table 1). mean age ± sd of patients was 57.4 ± 16.9 years. moreover, 56.2% of patients were found with more than one diagnosis and 46.8% of total patients were prescribed five or more than five drugs (polypharmacy) as shown in table 1. fixeddose drugs combinations (fdc) were found to be prescribed to 49.2% of the patients (table 1). the most common fdc was salmeterol + fluticasone (12%) followed by amlodipine + losartan (10.1%) j. lumbini. med. coll. vol 9, no 1, jan-june 2021 karki n, et al. assessment of prescription errors in the internal medicine department of a tertiary care hospital in nepal: a cross-sectional study jlmc.edu.np table 1. socio-demographic and clinical characteristics of patients (n = 425). characteristics numbers (%) statistics age group (in years) 1-10 4 (0.9) 11-20 5 (1.2) 21-30 24 (5.7) 31-40 37 (8.7) 41-50 61 (14.3) >50 294 (69.2) mean age ± sd (in years) 57.4 ± 16.9 gender female 198 (46.6) male 227 (53.4) mean age of female ± sd (in years) mean age of male ± sd (in years) 56.3 ± 17.3 58.4 ± 16.5 t = -1.29, df = 409.71, p = 0.198 ethnic groups brahmin 145 (34.1) chhetri 129 (30.4) newar 37 (8.7) others 114 (26.8) number of diagnosis one 186 (43.8) more than one 239 (56.2) polypharmacy five or more than five drugs 199 (46.8) less than five drugs 226 (53.2) fixeddose drugs combination (fdc) yes 209 (49.2) no 216 (50.8) average number of drugs prescribed per encounter 4.4 ± 2.2 in 168 (39.5%) patients prescription errors were seen. among prescription errors, 160 (37.6%) patients were found with error of omission and 13 (3.1%) patients with errors of commission. five patients were found with both errors of omission and errors of commission. average number of medication errors per prescription was 1.60 ± 0.48. furthermore, among errors of omission, dose of the drug was not mentioned in 111 (26.1%) patients, while among error of commission wrong dose was prescribed in 12 (2.8%) patients (table 2). the level of severity of medication error, according to ncc merp index, was analyzed and it showed category b in 92 (21.6%) patients, category a in 74 (17.4%) and category c in 2 (0.5%). patients with only one diagnosis were less likely to be found with prescription errors compared to the patients with more than one diagnosis (x2[n = 425, df = 1] = 13.72, p = 0.0002) as demonstrated in table 3. the prescription errors were more likely presented among patients with polypharmacy compared to patients without polypharmacy. this association was found statistically significant (x2[n = 425, df = 1] = 25.37, p < 0.001). patients who were prescribed fdc were more likely found with prescription errors compared to patients who were not prescribed fdc (x2[n = 425, df =1] = 43.89, p < 0.001) as shown in table 3. similarly, errors of omission were more likely presented among patients with more than one diagnosis compared to one diagnosis (x2[n = 425, df =1] = 13.23, p = 0.0002), among patients with polypharmacy compared to patients without polypharmacy (x2[n = 425, df =1] = 23.34, p < 0.001) and among patients who prescribed fdc compared to patients without prescribing fdc (x2[n = 425, df =1] = 41.88, p < 0.001) as demonstrated in table 3 discussion: the aim of this study was to provide the understanding of prescription errors in internal medicine department of a tertiary care hospital. in our study, about two-third of the patients were above 50 years of age. the reason behind this might be that the data were collected during the covid-19 pandemic and the majority of the patients were the follow up patients with the diagnosis of chronic health conditions like hypertension, diabetes, chronic obstructive pulmonary diseases etc. who visited the hospital to refill the drugs under their health insurance scheme. our study demonstrated almost equal distribution of the genders with male to female ratio 1.1:1. the average number of drugs prescribed per encounter was 4.4 ± 2.2. this finding was higher than the average number of drugs prescribed per j. lumbini. med. coll. vol 9, no 1, jan-june 2021 karki n, et al. assessment of prescription errors in the internal medicine department of a tertiary care hospital in nepal: a cross-sectional study jlmc.edu.np table 2. distribution of prescriptions errors among patients (n = 425) error of omission related to prescriber related to drugs per total medicine dispensed variables n (%) variables n (%) patient name not mentioned 0 (0) dose not mentioned 111 (26.1) age not mentioned 0 (0) frequency not mentioned 0 (0) prescription date not mentioned 0 (0) dosage form not mentioned 23 (5.4) diagnosis not mentioned 0 (0) quantity to supply not mentioned 0 (0) prescriber name not mentioned 21 (4.9) department not mentioned 0 (0) prescriber signature not mentioned 5 (1.2) errors of commission variables n (%) wrong strength or dose 12 (2.8) wrong drug name (not spelling) 0 (0) wrong dosage form 0 (0) drug-drug interaction 1 (0.2) table 3. association of socio-demographic and clinical characteristics with prescription errors, errors of omission and errors of commission characteristics medication errors errors of omission errors of commission yes no statistics yes no statistics yes no statistics age (in years) ≤ 50 38 93 x2 = 8.77, df = 1, p = 0.003 35 96 x2=9.63 df = 1, p = 0.002 5 126 p = 0.550 >50 130 164 125 169 8 286 gender female 80 118 x2 = 0.11, df = 1, p = 0.731 77 121 x2 = 0.24, df = 1, p = 0.622 7 191 x2 = 0.28, df =1, p = 0.594 male 88 139 83 144 6 221 number of diagnosis one 55 131 x2 = 13.72, df = 1, p = 0.0002 52 134 x2 = 13.23, df = 1, p = 0.0002 3 183 x2 = 2.33, df = 1, p = 0.127> one 113 126 108 131 10 229 polypharmacy ≥ five drugs 104 95 x2 = 25.37, df = 1, p < 0.001 99 100 x2 = 23.34, df = 1, p < 0.001 8 191 x2 = 1.16, df = 1, p = 0.280< five drugs 64 162 61 165 5 221 fixeddose drugs combinations prescribed 116 93 x2 = 43.89, df = 1, p < 0.001 111 98 x2 = 41.88, df = 1, p < 0.001 9 200 x2 = 2.15, df = 1, p = 0.142not prescribed 52 164 49 167 4 212 j. lumbini. med. coll. vol 9, no 1, jan-june 2021 karki n, et al. assessment of prescription errors in the internal medicine department of a tertiary care hospital in nepal: a cross-sectional study jlmc.edu.np encounter calculated by using who prescribing indicators. the ideal who value is 2.[11] this finding was also nearly reflecting the practice of polypharmacy. polypharmacy is the concurrent use of multiple drugs; five or more than five.[12] this practice is likely while prescribing drugs among old aged persons because they have higher chances to be affected by multiple diseases. furthermore, polypharmacy may cause prescription errors by healthcare providers because when more numbers of medicines are prescribed, chances of creating errors are also higher. in this study, prescription errors were observed in about one-third of the patients. the findings of a few studies were dissimilar to our study, where more than two-third of the patients had prescription errors.[13,14]however, two studies had demonstrated results related to the frequency of prescription errors similar to our study.[15,16] prescription errors occur from circumstances like mistakes, lapses and slips.[1] they are avoidable and can be minimized if assessed by clinical pharmacologists because they have deep knowledge of medicines, their therapeutic responses, their adverse effects and drug interactions.[1,3] so the team of clinical pharmacologists, doctors, nurses, paramedics and administration personnel will become effective if they work collectively to achieve common goal of preventing or minimizing errors during drug prescriptions. among the prescription errors, our study displayed that errors of omission were higher. the similar types of results have been found in some studies.[4,7,8,14,15,17] the reason behind this may be that, in majority of those prescriptions, doses of drugs and prescriber’s name/signatures were missing because of pressure of increased numbers of patients visited to opd, increased workload and mismanagement of time. whereas, few studies contradicted with our findings that showed errors of commission were predominant.[13,18] among errors of omission, dose of the drugs was not mentioned in about one-fourth of prescriptions. the reason for this finding was that the doses of the drugs were missed in one of the drugs of fdc. for example, in our study, fixed dose combination of salmaterol and fluticasone was commonly prescribed. in prescription form, dose of salmaterol was mentioned, but dose of fluticasone was missed to mention. to avoid prescription errors, doses of both drugs of fdc should be written. prescription errors may occur unknowingly while working under unfavorable environment. awareness of the possibility of such prescription errors may be useful to minimize the same in the future. to the researcher’s best knowledge, only one potential event that may cause drug-drug interaction was observed in our study. in contrast to our study shrestha et al. and pote et al. found that there were higher numbers of drug-drug interactions (10.2% and 68.2% respectively).[4,16] however, drug interaction found in our study did not have potential to cause any harm to the patient. the potential drug interaction was between sucralfate and proton pump inhibitor. this drug interaction reduces therapeutic response of sucralfate because proton pump inhibitor raises ph of stomach to more than 5. hence, the effect of sucralfate is reduced because it acts at ph less than 5. drug-drug interactions should not be ignored because they have potential to diminish therapeutic response, produce adverse effects or even fatal problems.[9] they should be evaluated with special attention in order to prevent them. moreover, our study also demonstrated that more than one-third of all of the cases showed some levels of severity of medication error according to ncc merp index. the majority of errors belonged to category b (21.6%) followed by category a and category c but none to more severe categories. one study conducted by shrestha et al. supported finding of our study and demonstrated that about two-third of errors belonged to category b.[14] whereas, in contrast to our study, some studies showed that majority of errors belonged to category c.[7,15,18] in ncc merp index, category a defines “any circumstances that have the capacity to cause error”, while category b indicates that “an error occurred but it did not reach the patient”.[2] according to ncc merp index category a, b, c and d do not cause any harm to the patient, while category e, f, g, h and i cause temporary harms or permanent harms or even death of patients[2,9] single out-patient department-based study design, short duration of the study and convenience sampling method are the limitations of our study. besides this while analyzing the errors of commission, we assessed only the errors made in the act of writing the prescription regardless of the medical decision made. conclusion: j. lumbini. med. coll. vol 9, no 1, jan-june 2021 karki n, et al. assessment of prescription errors in the internal medicine department of a tertiary care hospital in nepal: a cross-sectional study jlmc.edu.np our study found that about one-third of patients had prescription errors. among them, errors of omission were the most common. errors of omission were more likely among patients who were prescribed five or more than five drugs, who were diagnosed with more than one disease and who were prescribed fixed-dose drugs combinations. we suggest that collaborative program be conducted among the physicians, clinical pharmacologists, nursing staff, paramedical staff and hospital administration as an effort to minimize prescription errors as this practice has been supported by previous studies. acknowledgement: • department of internal medicine, lmcth • associate professor dr. vinod kumar verma, department of pharmacology, lmcth • dr. kyushu shah, lecturer, department of pharmacology, lmcth • mr. keshav raj bhandari, statistician, lmcth • mr. bhakti neupane, head of health insurance section, lmcth conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. references: 1. world health organization. medication errors: technical series on safer primary care. who: geneva. report number: isbn 978-92-4-1511643, 2016. available from: https://apps.who.int/ iris/bitstream/handle/10665/252274/97892415 11643eng.pdf;jsessionid=fdb1be2683396d2da592f947714ebf5e?sequence=1 2. national coordinating council for medication error reporting and prevention (ncc merp). about medication errors [internet]. new york: ncc merp; 2015 [cited 2020 july 8]. available from: https://www.nccmerp.org/aboutmedication-errors 3. world health organization. who launches global effort to halve medication-related errors in 5 years [internet]. geneva: who;2017 [cited 2020 july 10]. available from:https://www. who.int/news-room/detail/29-03-2017-wholaunches-global-effort-to-halve-medicationrelated-errors-in-5-years 4. shrestha r, prajapati s. assessment of prescription pattern and prescription error in outpatient department at tertiary care district hospital, central nepal. journal of pharmaceutical policy and practice. 2019;12(0):16. doi: https://doi. org/10.1186/s40545-019-0177-y 5. velo gp, minuz p. medication errors: prescribing faults and prescription errors. br j clin pharmacol. 2009;67(6):624-8. pmid: 19594530 doi: https://doi.org/10.1111/j.13652125.2009.03425.x 6. ansari m, neupane d. study on determination of errors in prescription writing: a semi-electronic perspective. kathmandu university medical journal. 2009;7(27):238-41. pmid: 20071869 doi: https://doi.org/10.3126/kumj.v7i3.2730 7. sheikh d, mateti uv, kabekkodu s, sanal t. assessment of medication errors and adherence to who prescription writing guidelines in a tertiary care hospital. future journal of pharmaceutical sciences. 2017;3(0):60-64. doi: http://dx.doi.org/10.1016/j.fjps.2017.03.001 8. degu g, tessema f. biostatistics. university of gondar, ethiopia public health training initiative, the carter center. 2005. available from: https://www.cartercenter.org/resources/ pdfs/health/ephti/library/lecture_notes/env_ health_science_students/ln_biostat_hss_final. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 karki n, et al. assessment of prescription errors in the internal medicine department of a tertiary care hospital in nepal: a cross-sectional study jlmc.edu.np pdf 9. sapkota s, pudasaini n, singh c, gc s. drug prescribing pattern and prescription error in elderly: a retrospective study of inpatient record. asian journal of pharmaceutical and clinical research. 2011;4(3):129-32. available from: https://innovareacademics.in/journal/ajpcr/ vol4issue3/450.pdf 10. agency for healthcare research and quality (ahrq). medications at transitions and clinical handoffs (match) toolkit for medication reconciliation [internet]. ahrq: 5600 fishers lane, rockville; 2012 [cited 2019 july 20]. available from: https://www.ahrq.gov/patientsafety/resources/match/matchtab6.html 11. demeke b, molla f, assen a, melkam w, abrha s, masresha b, et al. evaluation of drugs utilization pattern using who prescribing indicators in ayder referral hospital, northern ethiopia. international journal of pharma sciences and research. 2015;6(2):343-7. available from: http://www.ijpsr.info/docs/ijpsr15-06-02-038. pdf 12. world health organization. medication safety in polypharmacy. who: geneva. report number: who/uhc/sds/2019.11, 2019. available from: https://apps.who.int/iris/handle/10665/325454 13. laatikainen o, snecks s, turpeinen m. the risks and outcomes resulting from medication errors reported in the finnish tertiary care units: a cross-sectional retrospective register study. front pharmacol. 2020;10(0):1571. pmid: 32009966 doi: https://doi.org/10.3389/fphar.2019.01571 14. shrestha s, ramanath kv. study and evaluation of medication errors in medicine and orthopedic wards of a tertiary care hospital. british journal of pharmaceutical research. 2015;7(3):183-95. doi: https://doi.org/10.9734/bjpr/2015/18736 15. patel s, patel a, patel v, solanki n. study of medication error in hospitalized patients in tertiary care hospital. indian journal of pharmacy practice. 2018;11(1):32-6. available from: https://pdfs.semanticscholar.org/ b457/93af15baf9a53391ba5d8241bcd50f15c2ff. pdf 16. pote s, tiwari p, d’cruz s. medication prescribing errors in a public teaching hospital in india: a prospective study. pharm pract (granada).2007;5(1):17-20. pmid: 25214913 doi:https://doi.org/10.4321/s188636552007000100003 17. paudel rs, piyani rm, shrestha s, prajapati a, adhikari b. prescription errors and pharmacist intervention at outpatient pharmacy of chitwan medical college. journal of chitwan medical college. 2015;5(12):20-24. doi: https://doi. org/10.3126/jcmc.v5i2.13150 18. boostani k, noshad h, farhood f, rezaee h, teimouri s, entezari-maleki t, et al. detection and management of common medication errors in internal medicine wards: impact on medication costs and patient care. advanced pharmaceutical bulletin. 2019;9(1):174-79. pmid: 31011571 doi: https://doi.org/10.15171/apb.2019.020 j. lumbini. med. coll. vol 7, no 2, july-dec 2019 baral s, et al. baral s, et al. axial torsion and meckel’s diverticulitis: a diagnostic conundrum 113 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 30 may, 2019 accepted: 7 december, 2019 published: 31 december, 2019 a lecturer, department of surgery b professor, department of surgery cassistant professor, department of surgery dlumbini medical college teaching hospital, palpa, nepal. corresponding author: suman baral e-mail: brylsuman.sur@gmail.com orcid: https://orcid.org/0000-0003-0906-138x_______________________________________________________ ———————————————————————————————————————— abstract introduction:meckel’s diverticulum is one the most common congenital anomalies of gastrointestinal tract that mimics acute appendicitis, gastroenteritis, peptic ulcer disease. complications related to it can be hemorrhage, intestinal obstruction, perforation while axial torsion is one of the rarest complications. case: an 11 year boy presented with the history of pain at peri-umbilical region for four days with 2-3 episodes of vomiting. abdominal examination revealed tenderness at suprapubic area with a mass around 5 x 3 cm along hypogastrium. ultrasonography of abdomen revealed an avascular structure in central area with clumping of bowel and omentum over the lesion while computed tomography scan of abdomen revealed blind ended gas filled structure at hypogastrium with thickened enhancing irregular wall associated with adjacent mesenteric fat plane stranding and prominent adjacent axial vessels supplying inflammatory lesion. exploratory laparotomy showed axial twisting of diverticulum about 10 x 5 cm arising from anti-mesenteric border around 50 cm proximal to ileo-caecal junction with a fibrous band attached to the fundus and ileum leading to gangrenous diverticulum with clumping of bowel loops along with omental covering. de-twisting and adhesiolysis along with excision of the diverticulum was done with two layered closure of the defect. conclusion: axial torsion is the rarest of the complication of meckel’s diverticulum and should be managed with utmost caution. excision of the twisted diverticulum with or without wedge resection of the involved ileum is the procedure of choice. keywords: exploratory laparotomy, intussusception, meckel's diverticulum case reporthttps://doi.org/10.22502/jlmc.v7i2.284 suman baral,a,d raj kumar chhetri,b,d neeraj thapac,d axial torsion and meckel’s diverticulitis: a diagnostic conundrum how to cite this article:how to cite this article: baral s, chhetri rk, thapa n.baral s, chhetri rk, thapa n. axial torsion and meckel’s axial torsion and meckel’s diverticulitis: a diagnostic conundrum. journal of lumbini diverticulitis: a diagnostic conundrum. journal of lumbini medical college. 2019;7(2):113-115. doi: https://medical college. 2019;7(2):113-115. doi: https://doi.doi. org/10.22502/jlmc.v7i2.284org/10.22502/jlmc.v7i2.284 epub: 2019 december 31. epub: 2019 december 31. introduction: meckel’s diverticulum is one the most common congenital anomalies of gastrointestinal tract that occurs in about 2 4% of the population. the clinical presentation mimics that of acute appendicitis, gastroenteritis, peptic ulcer or pelvic inflammatory disease. various complications related to meckel’s diverticulum can be hemorrhage, intestinal obstruction and perforation while axial torsion is one of the rarest complications. in most cases, preoperative diagnosis is often difficult. radiological investigations include abdominal ultrasonography and computed tomography scans which might reveal features of intussusception along with a cystic avascular tubular structure if there is torsion of the diverticulum. definitive management includes excision of the diverticulum from the base if the base is narrow whilst wedge resection is warranted for the wide base. case report: an 11 years boy presented with the history of pain at peri-umbilical region for four days which was colicky, non-radiating, gradually increasing in severity. it was associated with two to three episodes of vomiting on the first day of illness. also, there j. lumbini. med. coll. vol 7, no 2, july-dec 2019 baral s, et al. baral s, et al. axial torsion and meckel’s diverticulitis: a diagnostic conundrum 114 jlmc.edu.np was a history of constipated stool for the same duration. there was no history of fever, cough, burning micturition, yellowish discoloration of eye, abdominal distention or weight loss. he gave no history of tuberculosis or any surgery in the past. at presentation, he was ill looking but well oriented to time, place and person. vitals were stable. laboratory parameters were within normal limit. on per abdominal examination, mild tenderness could be elicited at suprapubic area. a mass about 5 x 3 cm was appreciated at suprapubic region. tenderness was present, however rebound tenderness was absent. ultrasonography (usg) revealed an avascular structure in central area with clumping of bowel and omentum over the lesion. contrast enhanced computed tomography (cect) revealed blind ended gas filled structure at hypogastrium with thickened enhancing irregular wall associated with adjacent mesenteric fat plane stranding and prominent adjacent axial vessels supplying inflammatory lesion (fig. 1). fig. 1. showing blind ended gas-filled structure at hypogastrium with thickened enhancing irregular wall associated with adjacent mesenteric fat plane stranding and prominent adjacent vessels suggesting inflammatory lesion. exploratory laparotomy revealed axial twisting of diverticulum about 10 x 5 cm arising from anti-mesenteric border around 50 cm proximal to ileo-caecal junction with a fibrous band attached to the fundus and ileum leading to gangrenous diverticulum with clumping of bowel loops along with omental covering (fig. 2). de-twisting and adhesiolysis along with excision of the meckel's diverticulum was done with two layered closure of the defect. fig. 2. axial twisting of diverticulum with a fibrous band attached to the fundus and ileum leading to gangrenous diverticulum. post-operative period went uneventful and the patient got discharged on the seventh postoperative day. histopathology report revealed meckel’s diverticulum with gangrenous changes (fig. 3). fig. 3. sections from the meckel’s diverticulum showing ileal type epithelium lined by tall columnar cells admixed with goblet cells along with presence of all three layers of bowel wall discussion: meckel’s diverticulum is one of the most common congenital anomalies of gastro intestinal tract which is seen in almost 2-4% of the population. due to presence of ectopic gastric mucosa, most of the patients especially in the younger age group present with features of gastrointestinal bleed, however adults might present with features of obstruction, intussusception, ulceration and hemorrhage.[1] risk factors for developing symptoms include age <50 years, male sex, size greater than two cm and j. lumbini. med. coll. vol 7, no 2, july-dec 2019 baral s, et al. baral s, et al. axial torsion and meckel’s diverticulitis: a diagnostic conundrum 115 jlmc.edu.np the presence of abnormal histology or ectopic tissue (pancreatic and gastric being the most common). [2,3] axial torsion of the diverticulum is a rare complication which can be seen as rotating of md along the axis at its base with no involvement of ileal loops and mesentery ultimately leading to compromised vascular supply and gangrene.[4] various factors have been described for the causes of twisting of diverticulum but the underlying mechanism is still unclear. however, retained fibrous band at umbilicus to the head of the diverticulum might cause rotation if it is followed by larger meckel’s diverticulum and narrow base.[5] preoperative diagnosis is often difficult as the clinical condition mimics acute appendicitis, gastroenteritis, peptic ulcer or pelvic inflammatory disease.[6] features of intussusception may be evident in usg as along with a cystic avascular tubular structure if there is torsion of the diverticulum.[7] obstructive features may be seen on x-ray abdomen examination if ileal loops are involved. definitive management includes excision of the diverticulum from the base if the base is narrow whilst wedge resection is warranted for the wide base. conclusion: meckel’s diverticulum is one of the most common congenital anomalies of gastrointestinal tract. common presentations can be features of intussusception, gastro intestinal bleed and features of small bowel obstruction might be evident. axial torsion is the rarest of the complication and should be managed with utmost caution. excision of the twisted diverticulum with or without wedge resection of the involved ileum is the procedure of choice. competing interests: the authors declare that no competing interest exists. source of funds: no funds were available. references: 1. sagar j, kumar v, shah dk. meckel’s diverticulum: a systematic review. journal of the royal society of medicine. 2006;99(10):501-5. doi: https:// doi.org/10.1177%2f014107680609901011 2. park jj, wolff bg, tollefson mk, walsh ee, larson dr. meckel diverticulum: the mayo clinic experience with 1476 patients (19502002). ann surg. 2005;241(3):529-33. pmid: 15729078. doi: https://doi.org/10.1097/01. sla.0000154270.14308.5f 3. soltero mj, bill ah. the natural history of meckel’s diverticulum and its relation to incidental removal. a study of 202 cases of diseased meckel’s diverticulum found in king county, washington, over a fifteen year period. am j surg. 1976;132(2):168-73. pmid: 952346. doi: https://doi.org/10.1016/00029610(76)90043-x 4. parab sv, salve pg, dahiphale a, thakare r, aiwale a. axial torsion of meckel’s diverticulum: a rare case report. j clin diagn res. 2017;11(9):pd05-pd06. pmid: 29207775. doi: https://doi.org/10.7860/jcdr/2017/28613.10580 5. moore gp, burkle fm jr. isolated axial volvulus of a meckel’s diverticulum. am j emerg med. 1988;6(2):137-42. pmid: 3281683. doi: https:// doi.org/10.1016/0735-6757(88)90052-6 6. botezatu r, marian r, gica n, lancu g, peltecu g, panaitescu am. axial torsion and infarction of meckel\’s diverticulum in the 3rd trimester of pregnancy. chirurgia (bucur). 2018;113(2):2669. doi: http://dx.doi.org/10.21614/ chirurgia.113.2.266 7. gallego-herrero c, pozo-garcia g, marínrodriguez c, andres ci. torsion of a meckel’s diverticulum: sonographic findings. pediatric radiology. 1998;28(8):599-01. doi: https://doi. org/10.1007/s002470050425 j. lumbini. med. coll. vol 7, no 2, july-dec 2019 adhikaree a, et al. apical hypertrophic cardiomyopathy: a case report and review of literatureadhikaree a, et al. apical hypertrophic cardiomyopathy: a case report and review of literature 116 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 18 august, 2019 accepted: 25 november, 2019 published: 2 january, 2020 adm cardiology resident bprofessor cnational academy of medical sciences, kathmandu, nepal ddepartment of cardiology, shahid gangalal national heart center, kathmandu, nepal corresponding author: ajay adhikaree e-mail: ajay.bijay@gmail.com orcid: https://orcid.org/0000-0001-5125-7365_______________________________________________________ ———————————————————————————————————————— abstract: introduction: apical hypertrophic cardiomyopathy (ahcm) is a unique variant with distinct clinical presentation, genetics, treatment, complications and outcome. case: a 52 year non-hypertensive asian male presented with exertional shortness of breath for two years without chest pain, palpitation or syncope. apex beat was heaving. electrocardiogram revealed non q wave deep symmetrical t wave inversion in anterolateral leads and echocardiography demonstrated hypertrophied apical septum. coronary angiogram showed normal coronaries with typical “ace of spade” configuration during ventriculography. conclusion: characterization of various forms of hypertrophic cardiomyopathy is essential for management purpose as apical hypertrophic cardiomyopathy usually have benign course. key words: apical hypertrophic cardiomyopathy, hypertrophic cardiomyopathy case reporthttps://doi.org/10.22502/jlmc.v7i2.296 ajay adhikaree,a,c man bahadur kc,b,d rabi mallab,d apical hypertrophic cardiomyopathy: a special entity. how to cite this article:how to cite this article: adhikaree a, kc mb, malla r. apical hypertrophic adhikaree a, kc mb, malla r. apical hypertrophic cardiomyopathy: a special entitycardiomyopathy: a special entity. journal of lumbini medical . journal of lumbini medical college. 2019;7(2):116-120. doi: https://college. 2019;7(2):116-120. doi: https://doi.org/10.22502/jlmc.doi.org/10.22502/jlmc. v7i2.296v7i2.296 epub: 2020 january 2. epub: 2020 january 2. introduction: first described by sakamoto et al, apical hypertrophic cardiomyopathy (ahcm) is an infrequent variant localized to apex of the heart. [1] yamaguchi et al. subsequently portrayed its typical end systolic left ventriculogram pattern resembling “ace of spade”. hence it is also known as yamaguchi disease.[2] in japanese population, it encompasses about 15% of all cases of hypertrophic cardiomyopathy,[1,2] however in non japanese population it is only 1-3%.[3,4] it has dissimilar genetics, age distribution, clinical course, and complications compared to other forms of hypertrophic cardiomyopathy.[3,5,6] these attributes make ahcm an unique entity of discussion. case report: a 52 years diabetic gentleman with a body mass index of 24.5kg/m2, non-smoker, non-hypertensive presented to cardiac opd with complaint of occasional shortness of breath on prolonged exertion for two years without orthopnoea or paroxysmal nocturnal dyspnoea. he denied any history of fever, cough, weight loss, chest tightness, noisy breathing, chest pain, palpitation, dizziness, excessive fatigability, pre-syncope, syncope or sleep related disorders. there was no past history of chest problem, cardiac disease, thyroid illness, neurological or hematological disorder. there was no family history of cardiac diseases. his diabetes had been on good control with anti-diabetes medications for last six years. blood pressure: 120/80 mm hg, heart rate: 82/min regular, saturation: 100% in ambient air. there was no pallor or edema. apex beat was localized at left 5th intercostal space 9cm from mid-sternal line and was heaving. other systemic examinations were unremarkable. hematology, glycated hemoglobin, renal function test with electrolytes, creatinine phosphokinase (cpk-mb), troponin i and thyroid profile were normal. chest x-ray was unremarkable. electrocardiography (ecg) showed non-q wave deep symmetrical t wave inversion in leads i, ii, avl, v2-v6 with giant t wave inversion (1.0 mv) in j. lumbini. med. coll. vol 7, no 2, july-dec 2019 adhikaree a, et al. apical hypertrophic cardiomyopathy: a special entityadhikaree a, et al. apical hypertrophic cardiomyopathy: a special entity 117 jlmc.edu.np leads v3 and v4 (fig. 1). fig.1. ecg showing giant t wave inversion in precordial leads. with such ecg findings, he underwent treadmill test multiple of times in past and all of them were negative and was advised for coronary angiography. echocardiography revealed hypertrophic apical one-third of interventricular septum (17mm), normal aortic gradient, absent left ventricular outflow gradient, absence of intraventricular/apical mass with no regional/global wall motion abnormality (fig. 2). coronary angiography showed normal epicardial coronary arteries with typical “ace of spades” configuration of left ventricle at end systole during ventriculography (fig. 3). he was put on beta-blocker, advised for family screening including regular follow up examination. discussion: ahcm has two morphological forms: a) pure apical form: hypertrophy (>15mm) confined to left ventricular apex below the papillary muscle, and b) distal dominant form: apical hypertrophy extends to the interventricular septum without basal septal hypertrophy. transition of ahcm to and from other forms of hypertrophic cardiomyopathy has not yet been documented.[7] though genetic association is rare, some ahcm have familial association with autosomal dominant inheritance involving sarcomere gene mutation (cardiac actin glu10lys).[3,6,8,9] patient may be asymptomatic or present with atypical chest pain, angina, palpitation, dyspnoea, pre/ syncope or cerebrovascular accident.[3,6,10] they may have hypertension, forceful apical beat with or without widely split second heart sound and or fourth heart sound.[6] essential for diagnosis is typical ecg showing non-q deep (giant) t wave inversion, high qrs voltage over the precordial leads, intra ventricular conduction abnormalities or arrhythmias in the form of atrial fibrillation, supra ventricular tachycardia, non sustained ventricular tachycardia and even ventricular fibrillation[1,2,3,6] and can occur in following entities: a) adamsfig. 2. echocardiography: showing normal interventricular septum at base and hypertrophy of apex. fig. 3. left ventriculography showing normal diastolic flow and end systolic ace of spade configuration. j. lumbini. med. coll. vol 7, no 2, july-dec 2019 adhikaree a, et al. apical hypertrophic cardiomyopathy: a special entityadhikaree a, et al. apical hypertrophic cardiomyopathy: a special entity 118 jlmc.edu.np stokes attacks associated with complete heart block, b) ischemic heart disease, c) bradycardia, d) right ventricular hypertrophy and right bundle branch block, e) metabolic disturbances, f) changes during coronary angiography and g) cerebral disturbance. [11] this giant t wave inversion is resultant of altered repolarisation changes of hypertrophied apical musculature.[1] echocardiography should also be performed with high degree of suspicion. echocardiographic diagnostic criteria includes: a) asymmetric lv hypertrophy (lvh) predominantly at the apex of the ventricle; b) lv wall thickness of 15mm or more during diastole; and c) apical to posterior wall thickness ratio of 1.5 or more determined by two dimensional echocardiography. [3] use of intravenous echocardiographic contrast agents can be of help if apical endocardium is not visualized properly.[12] echocardiography carries sensitivity of 91% for diagnosing ahcm. [3] angiography demonstrates no obstructive lesion. hemodynamic studies display absence of pressure gradient in left ventricular outflow tract and complete systolic obliteration of the apex with relative sparing of ventricular cavity at base during left ventriculography forming the typical “ace of spade” configuration.[2] cardiac magnetic resonance imaging (cmri) is decisive when there is suspicion of ahcm by ecg and echocardiographic feature is inconclusive or technically challenging. cmri has the advantage of being less operator dependant, multi-planar detection and excellent soft tissue contrast.[13] mimickers of ahcm and their diagnostic tools are listed below in the table.[14] disease diagnostic tool to establish diagnosis of ahcm coronary artery disease echocardiogram/coronary angiogram and lvg left ventricular apical tumors echocardiogram with contrast/cct/cmri left ventricular apical thrombus echocardiogram with contrast/cct/cmri isolated ventricular non-compaction cmri/cct endomyocardial fibrosis lvg/cmri ahcm: apical hypertrophic cardiomyopathy; cmri: cardiac magnetic resonance imaging; lvg: left ventriculography; cct: cardiac computed tomography. treatment of symptomatic patient constitutes beta blocker, verapamil and anti-arrhythmic agents. amiodarone and procainamide are used for atrial fibrillation and ventricular arryhthmias.[3,15,16,17] implantable cardioverter defibrillator (icd) is recommended in patient who have survived a cardiac arrest due to ventricular tachycardia, ventricular fibrillation or who have spontaneous sustained ventricular tachycardia causing syncope or hemodynamic compromise.[18] long term follow up studies depict ahcm as benign entity with 15 year survival of 95% and annual cardiovascular mortality of 0.1%0.8%. [3,19] predictors for cardiovascular comorbidity[3] includes a) age at presentation < 41 years, b) left atrial enlargement and c) new york heart association functional class ii or more at baseline and that for cardiovascular mortality18 includes a) lv outflow obstruction, b) atrial fibrillation and c) female gender. almost one third of patients (30%) can develop serious cardiovascular complication of atrial fibrillation and myocardial infarction.[3] hence periodic lifelong follow up should be initiated even for asymptomatic patient.[20] conclusion: coronary artery disease, aortic stenosis and hypertension should be ruled out in every case presenting with such symptoms and electrocardiographic and/or echocardiographic presentation before designating a diagnosis of hypertrophic cardiomyopathy. moreover, specifying the types of hypertrophic cardiomyopathy is important as apical hypertrophic cardiomyopathy carries benign prognosis compared to other variants. conflict of interest: the authors declare that no competing interest exits. source of funds: no funds were available. j. lumbini. med. coll. vol 7, no 2, july-dec 2019 adhikaree a, et al. apical hypertrophic cardiomyopathy: a special entityadhikaree a, et al. apical hypertrophic cardiomyopathy: a special entity 119 jlmc.edu.np references: 1. sakamoto t, tei c, murayama m, ichiyasu h, hada y. giant t wave inversion as a manifestation of asymmetrical apical hypertrophy (aah) of the left ventricle: echocardiographic and ultrasono-cardiotomographic study. jpn heart j. 1976;17(5):611-29. pmid: 136532. doi: https://doi.org/10.1536/ihj.17.611 2. yamaguchi h, ishimura t, nishiyama s, nagasaki f, nakanishi s, takatsu f, et al. hypertrophic nonobstructive cardiomyopathy with giant negative t waves (apical hypertrophy): ventriculographic and echocardiographic features in 30 patients. am j cardiol. 1979;44(3):40112. pmid: 573056. doi: https://doi. org/10.1016/0002-9149(79)90388-6 3. eriksson mj, sonnenberg b, woo a, rakowski p, parker tg, wigle ed, et al. longterm outcome in patients with apical hypertropic cardiomyopathy. j am cardiol. 2002;39(4):63845. pmid: 11849863. doi: https://doi. org/10.1016/s0735-1097(01)01778-8 4. kitaoka h, doi y, casey sa, hitomi m, furuno t, maron bj. comparision of prevalence of apical hypertrophic cardiomyopathy in japan and the united states. am j cardiol. 2003;92(10):1183-6. pmid: 14609593. doi: https://doi.org/10.1016/j.amjcard.2003.07.027 5. gruner c, care m, siminovitch k, moravsky g, wigle ed, woo a, et al. sarcomere protein gene mutations in patients with apical hypertrophic cardiomyopathy. circ cardiovasc genet. 2011;4(3):288-95. pmid: 21511876. doi: https:// doi.org/10.1161/circgenetics.110.958835 6. sakamoto t, amano k, hada y, tei c, takenaka k, hasegawa i, et al. asymmetric apical hypertrophy: ten year experience. postgrad med j. 1986;62(728):567-70. pmid: 3774694. doi: https://doi.org/10.1136/pgmj.62.728.567 7. kubo t, kitaoka h, okawa m, hirota t, hoshikawa e, hayato k, et al. clinical profiles of hypertrophic cardiomyopathy with apical phenotype-comparison of pure-apical form and distal-dominant form. circ j. 2009;73(12):2330-6. pmid: 19838003. doi: https://doi.org/10.1253/ circj.cj-09-0438 8. arad m, penas-lado m, monserrat l, maron bj, sherrid m, ho cy, et al. gene mutations in apical hypertrophic cardiomyopathy. circulation. 2005;112(18):2805-11. pmid: 16267253. doi: https://doi.org/10.1161/ circulationaha.105.547448 9. chen cc, lei mh, hsu yc, chung sl, sung yj. apical hypertrophic cardiomyopathy: correlations between echocardiographic parameters, angiographic left ventricular morphology, and clinical outcomes. clin cardiol. 2011;34(4):233-8. pmid: 21400548. doi: https://doi.org/10.1002/clc.20874 10. paudel n, alurkar vm, jha gs, kafle r, sapkota s, dhakal n. apical variant of hypertrophic cardiomyopathy presenting as recurrent syncope and wide complex tachycardia. journal of advances in internal medicine. 2017;6(2):32-4. doi: https://doi. org/10.3126/jaim.v6i2.18539 11. jacobson d, schrire v. giant t wave inversion. br heart j. 1966;28(6):768-75. pmid: 4224501. doi: https://doi.org/10.1136/ hrt.28.6.768 12. thanigaraj s, perez je. apical hypertrophic cardiomyopathy: echocardiographic diagnosis with the use of intravenous contrast image enhancement. j am soc echocardiogr. 2000;13(2):146-9. pmid: 10668018. doi: https://doi.org/10.1016/s0894-7317(00)90026-9 13. suzuki j, shimamoto r, nishikawa j, yamazaki t, tsuji t, nakamura f, et al. morphological onset and early diagnosis in apical hypertrophic cardiomyopathy: a long term analysis with nuclear magnetic resonance imaging. j am coll cardiol. 1999;33(1):146-51. pmid: 9935021. doi: https://doi.org/10.1016/ s0735-1097(98)00527-0 14. yusuf sw, bathina jd, banchs j, mouhayar en, daher in. apical hypertrophic j. lumbini. med. coll. vol 7, no 2, july-dec 2019 adhikaree a, et al. apical hypertrophic cardiomyopathy: a special entityadhikaree a, et al. apical hypertrophic cardiomyopathy: a special entity 120 jlmc.edu.np cardiomyopathy. world j cardiol. 2011;3(7):2569. pmid: 21860706. doi: https://doi.org/10.4330/ wjc.v3.i7.256 15. chen sc, wang kt, hou cjy, chou ys, tsai ch. apical hypertrophic cardiomyopathy with severe myocardial bridging in a syncopal patient. acta cardiologica sinica. 2003;19(3):179-84. available from: https:// insights.ovid.com/acta-cardiologica-sinica/ a c t a c s / 2 0 0 3 / 0 9 / 0 0 0 / a p i c a l h y p e r t r o p h i c cardiomyopathy-severe/11/00013108 16. ridjab d, koch m, zabel m, schultheiss hp, morguet aj. cardiac arrest and ventricular tachycardia in japanese-type apical hypertrophic cardiomyopathy. cardiology. 2007;107(2):816. pmid: 16804296. doi: https://doi. org/10.1159/000094147 17. okishige k, sasano t, yano k, azegami k, suzuki k, itoh k. serious arrhythmias in patients with apical hypertrophic cardiomyopathy. intern med. 2001;40(5):396-402. pmid: 11393409. doi: https://doi.org/10.2169/internalmedicine.40.396 18. authors/tasks force members, elliott pm, anastasakis a, borger ma, borggrefe m, cecchi f, et al. 2014 esc guidelines on diagnosis and management of hypertrophic cardiomyopathy: the task force for the diagnosis and management of hypertrophic cardiomyopathy of the european society of cardiology. eur heart j. 2014;35(39):2733-79. pmid: 25173338. doi: https://doi.org/10.1093/eurheartj/ehu284 19. lee ch, liu py, lin lj, chen jh, tsai lm. clinical characteristics and outcomes of hypertrophic cardiomyopathy in taiwan a tertiary center experience. clin cardiol. 2007;30(4):177-82. pmid: 17443650. doi: https://doi.org/10.1002/clc.20057 20. stainback rf. apical hypertrophic cardiomyopathy. tex heart inst j. 2012;39(5):747-9. pmid: 23109785. lmc journal vol. 2.indd 89 clinical profi le of pa ents with acute coronary syndrome in lumbini medical college and teaching hospital: a prospec ve study che ri bk, paudel ms, dhungana sp and shamsuddin lumbini medical college and teaching hospital (lmcth), palpa, nepal corresponding author: dr. bishal kc, department of internal medicine, lumbini medical college and teaching hospital, palpa, nepal; e-mail: bishalk@gmail.com abstracts background: the clinical profi le among pa ents with acute coronary syndromes (acs) is not well studied in this western part of nepal where lumbini medical college and teaching hospital (lmcth) is situated. cardiovascular disease is now the most common non communicable disease killing thousands of people worldwide. the trend of incidence is increasing in the developing countries including nepal. objec ve: to obtain the clinical profi le of pa ent presen ng with acs in lmcth. material and method: this is a prospec ve study carried out in lmcth in the department of internal medicine april 14, 2013 to october 14, 2013. pa ents were diagnosed to have acs based on their clinical fi ndings, electrocardiogram (ecg) and troponin test. those with non-cardiac chest pain were excluded. a detail history and all the data pertaining to the pa ent were noted analyzed in a systema c way. results: a total of 40 pa ents with acs presented during the study period in lmcth. the mean age of presenta on was 67±18 years. thirty out of those cons tute male (75%). six pa ents (15%) died during the study period. seventeen (42.5%) presented with central chest pain, 13(32.5%) presented with le sided chest pain, 4(10%) presented with acute shortness of breath. four (10%) pa ent presented in the state of cardiogenic shock and 2 (5%) presented with the ventricular tachycardia (vt) as their complica on. 6 (15%) had unstable angina (ua), 14 (35%) had non st eleva on myocardial infarc on (nstemi) and 20 (50%) had st eleva on myocardial infarc on (stemi). of the total 20 (50%) pa ent who had stemi, only four of them underwent thrombolysis. anterior wall mi was the most common wall involved. circadian varia on study showed peak incidence of acute coronary syndrome during the early morning hours. mean dura on of symptoms before presenta on to the hospital facility was 4 days. mean hospital stay was 5±2 days. conclusion: cardiovascular disease is common in this western part of nepal. stemi was the commonest presenta on and the incidence was more among the male and the elderly pa ents. keywords: acute coronary syndrome, s t eleva on myocardial infarc on, ventricular tachycardia introduction pa ents with ischemic heart disease (ihd) presents with two main spectrum, stable angina in which the pa ent has chronic coronary artery disease and those who with acute coronary syndrome consis ng of pa ents with st eleva on myocardial infarc on (stemi), unstable angina (ua) and non-st-segment eleva on mi (nstemi).1 due to the advances in medical sciences of various invasive and non-invasive therapeu c strategies the mortality related acs has signifi cantly reduced in the developed world over the past 2 decades.2-7 the prevalence of coronary artery disease is related to various modifi able and non-modifi able risk factors such as gender, age and ethnicity. the cardiovascular disease has become a major health burden in developing countries which is on the verge of epidemic.8 patients and methods the study was conducted prospec vely for six months in the department of internal medicine from april 14, 2013 to october 14, 2013. those cases with proven noncardiac chest pain were excluded from the study. the cases were grouped into those presented with stemi and those presented with nstemi and ua. cases of chest pain/ discomfort with eleva on of st segment in ecg leads/ presumed new onset le bundle branch block in ecg were categorized as stemi. cases of angina at rest without st segment eleva on were categorized as nstemi if their cardiac troponin t (trop i) was posi ve and as ua if their trop i was nega ve. the baseline clinical characteris cs analyzed were the age, gender, hypertension (blood pressure > 140/90 mm hg and/ or those already taking treatment for hypertension), diabetes mellitus (fas ng blood glucose >126 mg/dl and/or postprandial blood glucose >200 mg/dl and those who were on treatment for diabetes mellitus), dyslipidemia (cholesterol >190 mg/dl and/or triglycerides >200 mg/dl), smoking status, dura on of chest pain before hospitaliza on, me of occurrence of original article l m coll j 2013; 1(2): 89-92 90 journal of lumbini medical college the acs, clinical course in the hospital, the mean dura on of hospital stay and complica ons related to the acs and its treatment. in cases with stemi, the details of the area of myocardium infarcted, the associated mechanical complica ons and conduc on abnormali es, further, a record was made whether thromboly c therapy was received or not. the cause of death was also studied. results a total of 40 pa ents with acute coronary syndrome (acs) presented during the study period in lmcth. the mean age of presenta on was 67±18 years. thirty pa ents were males (75%). six (15%) pa ents died during the study period. a comparison of the clinical characteris cs of the pa ents with acs is shown in the table 1. pa ents presented with various symptoms in the hospital. seventeen (42.5%) presented with central chest pain, 13(32.5%) presented with le sided chest pain, 4(10%) presented with acute shortness of breath. four (10%) pa ent presented in the state of cardiogenic shock and 2 (5%) presented with the ventricular tachycardia (vt). the pa ent presented with cardiogenic shock and vt died. table 1: the baseline characteris cs among males and females with acs variables total n (%) 40 (100) male n (%) 30 (75) female n (%) 10 (25) p value mean age 67.85 65.13 76 <0.001 mean dura on before hospitaliza on 4days 4.44days 2.6 days <0.001 symptoms before hospitaliza on <6hrs 7-12 hrs >24hrs 14 (35) 2 (5) 24 (60) 10 (33.33) 2 (6.66) 18 (60) 4 (40) 0 6 (60) <0.001 --<0.001 smoking history 26 (65) 20 (66.66) 6 (60) <0.001 hypertension 22 (55) 14 (46.66) 8 (80) <0.001 diabetes 8 (20) 8 (26.66) 0 ---thrombolysis 4 (10) 4 (13.33) 0 ---of the total 20 (50%) pa ent who had stemi, only four of them underwent thrombolysis. rest was not thrombolysed because of the late presenta on and the complica on they had which contraindicated thrombolysis. acs was most common in anterior wall and inferior wall than any others wall (fi g 2). eighteen pa ents (45%) had anterior wall involvement, 14(35%) had inferior wall, 6(15%) had extensive wall involvement. all six mortali es were from involvement of anterior wall. the me of onset of chest pain among pa ents with stemi showing the circadian varia on of cardiac events is depicted in figure 3. mean dura on of symptoms before presenta on to the hospital facility was 4 days. mean hospital stay was 5±2 days. fig 1. categories of pa ents with acs fig 2. involved wall in pa ents with acs fig 3. circadian varia on of cardiac events no ced among pa ents with acs discussion lumbini medical college with its 700 bed teaching hospital has emerged as a ter ary referral center for the hospitals in western nepal and diff erent health facili es of peripheries. there are few data regarding the acute coronary syndrome from this part of nepal. so this study was done to know the spectrum of acute coronary syndrome as they present in hospital and their clinical profi le. 91 bk chettri et al cardiovascular disease is on the rise in the developing country which has become a burden.8 even in the developed countries, despite of eff orts of reducing the major risk factors like cigare e smoking and sedentary lifestyle, the cardiovascular disease remain the major cause of morbidity and mortality due to increase popula on of elderly popula on and absolute increases in obesity and diabetes.9 there has been rise in the incidence of coronary artery disease in the asian popula on.10-12 of the total 40 pa ents who were diagnosed with acs by the clinical, ecg and laboratory parameters, 50% had stemi, 35% had nstemi and, 15% had unstable angina. this study also showed a higher propor on of stemi cases among pa ents with acs as observed in the create registry.13 the mean age of presenta on was 67±18 years. the mean age of pa ent presen ng with stemi was 67±14 years, which is comparable to observa ons of create registry13 and study done by teoh m et al.14 though we observed an in-hospital mortality rate of 15% that was much higher than the mortality rate observed among acs cases in the create registry (5.6%), it was comparable to the mortality rates among pa ents, not undergoing coronary interven ons, observed by other.15 higher in-hospital mortality rate among our stemi cases compared to the mortality rate observed among cases from the create registry 13 (30% vs. 8.6%) may be related to the higher number of elderly pa ents in our study. there was a male preponderance was observed in this study was comparable to another series reported from north india,16 create registry 13 and study done by teoh m et al.15 seventeen (42.5%) presented with central chest pain, 13(32.5%) presented with le sided chest pain, 4(10%) presented with acute shortness of breath. study done by patel et al17 also showed similar fi ndings of higher rate classic chest pain among the pa ent with acs. of the total 20 (50%) pa ent who had stemi, only four of them underwent thrombolysis which was due to late presenta on in the hospital facility or due to the complica on. the mean dura on of symptoms before hospitaliza on was 4 days which is diff erent from the western18 and indian13, 19 studies which shows increasing trends towards the earlier presenta on. this is mainly due to the lack of educa on, lack of health awareness, remote loca ons and lack of transporta on system and inaccessible health facility. circadian variation of incidence of acute coronary syndrome, with an early morning peaking of events, were observed in our study which is similar to western studies and in a recent study 20 reported from singapore and from indian studies recently conducted by gopal et al.21 signifi cantly higher numbers of pa ent with acs in our study had risk factors like hypertension, diabetes and cigare e smoking as observed in other studies.18, 19 conclusion acute coronary syndrome is common in this western part of the country. the main limita on of this study was the short dura on and the small sample size. further larger prospec ve studies with large sample size are required to verify the fi ndings of this study. reference 1. christopher p.c, eugene b. unstable angina and non-stsegment eleva on myocardial infarc on. in: braunwald e, fauci as, kasper dl, hauser sl, longo dl, jameson jl (editors). harrison's principle of internal medicine 18th edi on. usa: mcgraw-hill companies inc; 2012.p.2015. 2. fox ka. management of acute coronary syndromes: an update. heart 2004; 90: 698-706. 3. white hd, barbash gi, califf rm et al. age and outcome with contemporary thromboly c therapy. results from the gusto-i trial. global u liza on of streptokinase and tpa for occluded coronary arteries trial. circula on 1996; 94: 1826-33. 4. fassa aa, urban p, radovanovic d et al. amis plus inves gators. trends in reperfusion therapy of st segment eleva on myocardial infarc on in switzerland: six year results from a na onwide registry. heart 2005; 91: 882-88. 5. patel mr, chen ay, roe mt et al. a comparison of acute coronary syndrome care at academic and nonacademic hospitals. am j med 2007; 120: 40-6. 6. watkins s, thiemann d, coresh j, powe n, folsom ar, rosamond w. fourteen-year (1987 to 2000) trends in the a ack rates of, therapy for, and mortality from non-steleva on acute coronary syndromes in four united states communi es. am j cardiol 2005; 96: 1349-55. 7. de winter rj, windhausen f, cornel jh et al. invasive versus conservative treatment in unstable coronary syndromes (ictus) inves gators. early invasive versus selectively invasive management for acute coronary syndromes. n engl j med 2005; 353: 1095-104. 8. reddy ks, yusuf s. emerging epidemic of cardiovascular disease in developing countries. circula on 1998; 97; 596-601. 9. iqbal j, keith a.a. fox: epidemiological trends in acute coronary syndromes: understanding the past to predict and improve the future. arch med sci 2010; 6, 1a: s 3-s 14. 10. mc keigue p m, miller g j, marmot m g. coronary heart disease in south asians overseas: a review. j clin epidemiol 1989; 42(7): 597-609. 11. cappuccio fp, barbato a, kerry sm. hypertension, diabetes and cardiovascular risk in ethnic minori es in the uk. br j diabetes vasc dis 2003; 3286-93. 12. patel kcr, bhopal rs. the epidemic of coronary heart disease in south asian populations: causes and consequences. warley, uk: south asian health founda on, 2004. 92 journal of lumbini medical college 13. xavier d, pais p, devereaux pj et al. treatment and outcomes of acute coronary syndromes in india (create): a prospective analysis of registry data. lancet 2008; 371(9622): 1435-42. 14. molly t, susan l, michael r, richard gm, simon d. acute coronary syndromes and their presenta on in asian and caucasian pa ents in britain. heart 2007; 93(2): 183-8. 15. monteiro p. portuguese registry on acute coronary syndromes. impact of early coronary artery bypass gra in an unselected acute coronary syndrome pa ent popula on. circula on 2006; 114(1 suppl): i467-72. 16. holay mp, janbandhu a, javahirani a, pandharipande ms, suryawanshi sd. clinical profi le of acute myocardial infarc on in elderly (prospec ve study). j assoc physicians india 2007; 55: 188-92. 17. p a t e l h , r o s e n g r e n a , e k m a n i . s y m p t o m s in acute coronary syndromes: does sex make a diff erence? am heart j. 2004; 148(1): 27-33. 18. steg ag, goldberg rj, gore jm et al. grace inves gators. baseline characteris cs, management prac ces and inhospital outcomes of pa ents hospitalized with acute coronary syndromes in the global registry of acute coronary events (grace). am j cardiol 2002; 90: 35863. 19. jose vj, gupta sn. mortality and morbidity of acute st segment eleva on myocardial infarc on in the current era. indian heart j 2004; 56: 210-14. 20. bhalla a, sachdev a, lehl ss, singh r, d’cruz s. ageing and circadian varia on in cardiovascular events. singapore med j 2006; 47(4): 305-8. 21. gopal m, boopathy n, venkatesan r, jagannathan v. circadian varia on in acute coronary syndromes. web med central cardiology 2010;1(9):wmc00533 j. lumbini. med. coll. vol 9, no 1, jan-june 2021 sharma r, et al. morphological variation of circle of willis in nepalese population: a 3d time-of-flight magnetic resonance angiography based study jlmc.edu.np ___________________________________________________________________________________ submitted: 20 may, 2021 accepted: 21 june, 2021 published: 30 june, 2021 aassistant professor, department of radiology blecturer, department of radiology cresident, department of radiology dlumbini medical college and teaching hospital, palpa, nepal. corresponding author: rupesh sharma e-mail: roopskarma@gmail.com orcid: https://orcid.org/0000-0002-3422-6150_______________________________________________________ abstract: introduction: the circle of willis (cow) is an anatomic ring of vessels located at the base of brain connecting the anterior and posterior circulation by uniting the internal carotid and vertebrobasilar systems to maintain an adequate cerebral perfusion. the importance of a detailed information of the cow morphology and integrity in any patient cannot be overemphasized, especially for neuro-physicians, neurosurgeons and interventional neuroradiologists who are considering intervention to the intracranial arteries. this study was conducted to study the variation of cow among nepalese population and compare the results with those of other nationalities. methods: it was a prospective cross-sectional study performed using a 1.5 tesla mri machine. complete anatomical assessment of the cow was done. the anterior and posterior components of cow were defined as per the standard literature and evaluated in detail. results: a total of 118 patients were studied during the period out of which 75 (63.6%) were males and 43 (36.4%) were females. a morphologically normal cow configuration was found only in 55 (46.6%) cases whereas a variant configuration was present in 63 (53.4%) cases. the most common variation was noted in the pcom which was present in 42 (67%) cases. the most common single variation in abnormal cow configuration was absent right pcom. conclusion: the morphologic variation of the cow is more common than the normal textbook configuration in nepalese population, pcom being the most commonly involved vessel. keywords: circle of willis, magnetic resonance angiography, time of flight, nepalese original research articlehttps://doi.org/10.22502/jlmc.v9i1.448 rupesh sharma,a,d sona pokharel,b,d phanindra neupane,b,d ritu raj subedi,c,d morphological variation of circle of willis in nepalese population: a 3d time-of-flight magnetic resonance angiography based study how to cite this article:how to cite this article: sharma r, pokharel s, neupane p, subedi rr. morphological variation of circle of willis in nepalese population: a 3d timeof-flight magnetic resonance angiography based study. journal of lumbini medical college. 2021;9(1):5 pages. doi: https://doi. org/10.22502/jlmc.v9i1.448. epub: june 30, 2021. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. introduction: the circle of willis (cow) is an anatomic ring of vessels located at the base of brain connecting the anterior and posterior circulation by uniting the internal carotid and vertebrobasilar systems to maintain an adequate cerebral perfusion. [1,2] it has two distinct components namely the anterior and posterior components. it provides collateral flow to the brain especially in situations of arterial incompetency such as cerebrovascular disease. moreover, its ability to redistribute blood flow depends upon its morphology. various studies have found considerable variation in the morphology of cow in healthy individuals and individuals of different ethnicity. the importance of a detailed information of the cow morphology and integrity in any patient cannot be overemphasized, especially for neurophysicians, neurosurgeons and interventional neuroradiologists who are considering intervention to the intracranial arteries. most of the previous studies were based on cadaver studies. in fact it was sir thomas willis, an english physician who provided a complete description and illustration of cerebral vascular anatomy and its physiological significance as early as 1664.[3] j. lumbini. med. coll. vol 9, no 1, jan-june 2021 sharma r, et al. morphological variation of circle of willis in nepalese population: a 3d time-of-flight magnetic resonance angiography based study jlmc.edu.np with the advent of modern imaging technologies like computed tomographic angiography (cta) and magnetic resonance angiography (mra), significant progress has been made in the imaging of cow with unparalleled details. though digital subtraction angiography (dsa) is the gold standard of angiographic evaluation, studies have found that time of flight (tof) mra gives comparable results to dsa for evaluation of cow.[4] although cta is an excellent imaging modality, mra has certain advantages over cta in that besides being a noninvasive method, there is no radiological hazard and no intravenous contrast agent is required when using the tof sequence. unfortunately very few studies, if at all any, have been done on the morphologic variation of cow based on nepalese population. so this study was conducted to study the variation of cow among nepalese population and compare the results with those of other nationalities. methods: study population: it was a prospective cross-sectional study based on convenience sampling, comprising of the patients coming to the magnetic resonance imaging (mri) unit of department of radiodiagnosis and imaging, lumbini medical college and teaching hospital (lmc-th) for mri brain and mra. the study after being approved by review committee of lmc (irc-lmc 012-c/019), was done over a period of 12 months from may 2019 to april 2020. patients with history of brain surgery or trauma, previously known or newly diagnosed brain tumors, cerebrovascular disease, vascular malformation or any other significant cerebral pathology were excluded from the study. imaging and evaluation: the mri examinations were performed using a 1.5 tesla mri magnetom sempra with tim+dot system (siemens company, germany) by a qualified technician. data acquisition using tof was done with the following parameters: tr 27 milliseconds (ms), te 7 ms, slice thickness 0.6 mm, flip angle 25 degrees, matrix size 256x228. the post processing of the images was done by maximum intensity projection (mip). complete anatomical assessment of the cow was done on osirix® workstation. the anterior and posterior components of cow were defined as per the standard literature and evaluated in detail. vessel with a minimum transverse diameter of 0.8 mm and seen as a continuous segment was classified as normal whereas any vessel less than 0.8 mm was considered to be hypoplastic.[5,6] non-visualization or discontinuous vessel was considered absent. the anterior component of cow includes bilateral internal carotid artery (ica), a1 segment of bilateral anterior cerebral artery (aca) and anterior communicating artery (acom). similarly the posterior component includes posterior communicating artery (pcom), p1 segment of bilateral posterior cerebral artery (pca) and the single basilar artery tip. when both the anterior and posterior components formed a complete ring, it was considered a complete circle. however, when either the anterior or the posterior component formed a complete circle, it was referred to as a partially incomplete circle. it includes both the hypoplastic and absent vessels. when none of the components formed a complete circle it was termed as an incomplete cow. the data were entered and analyzed using statistical package for social sciences (spsstm) version 20. the descriptive results were presented in terms of mean, standard deviation, frequency and percentage. results: a total of 118 patients were studied during the period out of which 75 (63.6%) were males and 43 (36.4%) were females. the age of the patients ranged from 7 to 75 years with a mean age of 41.9 (+/17.5) years. a morphologically normal cow configuration (figure 1) was found only in 55 (46.6%) cases whereas a variant configuration was present in 63 (53.4%) cases (figures 2-5). a total of 43 (57%) males and 12 (27%) females had normal configuration. complete cow was noted in 60 (50.8%) patients, partially incomplete cow in 55 (46.6%) and incomplete cow in three (2.5%) patients. the most common variation was noted in the pcom including unilateral or bilateral hypoplastic and absent vessel, which was present in staggering 42 (67%) cases out of total 63 cases with abnormal cow configuration. the most common single variation in abnormal cow configuration was absent right pcom which was present in 16 (13.6%) cases as shown in the table below. the study also showed that females were more likely to have a variant configuration of cow as compared to males {x2(df=1, n=118)=9.510, p=0.002}. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 sharma r, et al. morphological variation of circle of willis in nepalese population: a 3d time-of-flight magnetic resonance angiography based study jlmc.edu.np figure 1. normal cow. figure 2. absent acom (arrow) and b/l pcom (arrowheads). figure 3: duplicated left a1 (arrow). figure 4. absent left a1 (arrow) and hypoplastic left p1 (arrow head). figure 5. absent b/l pcom (arrows). table 1. frequency of cow configuration. cow variation frequency (n=118*) normal cow configuration 55 (46.6%) absent acom 7 (5.9%) hypoplastic right a1 9 (7.6%) hypoplastic left a1 2 (1.7%) duplicated right a1 1 (0.8%) duplicated left a1 2 (1.7%) hypoplastic right pcom 6 (5.1%) hypoplastic left pcom 5 (4.2%) hypoplastic b/l pcom 3 (2.5%) absent right pcom 16 (13.6%) absent left pcom 3 (2.5%) absent b/l pcom 9 (7.6%) hypoplastic right p1 1 (0.8%) hypoplastic left p1 1 (0.8%) median artery of corpus callosum originating from acom 3 (2.5%) *in 14 (11.9%) cases, more than one variation was noted. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 sharma r, et al. morphological variation of circle of willis in nepalese population: a 3d time-of-flight magnetic resonance angiography based study jlmc.edu.np discussion: the circle of willis (cow) is an important arterial anastomotic structure for adequate cerebral perfusion, especially in times of arterial incompetency as evidenced by the fact that adequate collaterals have been found to be associated with a lower risk of hemispheric stroke and transient ischemic attack (tia) in severe carotid artery stenosis.[7] moreover a wide range of variations have been found in the morphology and integrity of this collateral system in different studies done in different parts of the world. these variations are known to be associated with occurrence, course, prognosis and outcome of certain cerebrovascular diseases such as stroke and aneurysms. this study was conducted to see the anatomic variations in cow in nepalese population based on tof mra. we noticed that a morphologically normal textbook cow configuration was present in less than half of the total cases, 46.6%. of all the components of cow, pcom was noted to be the most commonly involved vessel with absent right pcom being the single most common variation. quite similar to our findings, naveen et al. in a tof mra study in india found that 50% cases had normal cow configuration with hypoplastic or absent pcom being the most common variation. [8] karatas et al. in a cta based study in turkey found that only 28% had normal cow morphology with pcom hypoplasia and aplasia being the most common variations.[9] though the rate of abnormal cow was significantly more than that in our study, the finding that pcom variation was the most common was same as in our study. gunnal et al. found normal cow anatomy in 60 % cases with pcom variation being the most common.[10] this observation was comparable to what we found in our study. zaninovich et al. found that a complete cow configuration was present in only 37.1% cases and pcom was the most common artery to show variations.[11] they also observed that there was a statistically significant decrease in the completeness of cow with increasing age in both the sexes. in our study females were significantly more likely to have a variant configuration of cow as compared to males while no significant association of the variant morphology with age was noted. a study based on egyptian population showed that a complete cow was present in only 28% cases and again pcom variation was noted to be the most common.[12] they also found that posterior circulation variation was more common (62%) as compared to anterior circulation which was similar to our findings of 65% posterior circulation variation. many other studies have found that pcom is the most common component of cow to show variations albeit to a varying degree.[13,14,15,16,17] incomplete cow configuration has been found to be associated with future anterior circulation stroke in patients with no prior cerebrovascular disease.[6] our study found three (2.5%) patients with incomplete cow configuration. timely advice regarding precautionary measures can be helpful in such cases. there are few innate limitations associated with mra. when the flow within the vessel is turbulent as in stenosis or when it is slow, there can be signal loss because of spin dephasing. some high signal structures such as subacute thrombus may be incorporated into mip images which may alter the cow morphology. conclusion: the morphologic variation of the cow is more common than the normal textbook configuration in nepalese population, pcom being the most commonly involved vessel. this finding is roughly similar to many studies done in other parts of the world. a larger population based and a multicentric study is necessary to better establish the normal pattern of cow morphology. acknowledgement: mr. jitendra k. shah, mr. rakesh yadav, mr. pradeep karki, mr. rupak raj, department of radiology, lmc-th. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. j. lumbini. med. coll. vol 9, no 1, jan-june 2021 sharma r, et al. morphological variation of circle of willis in nepalese population: a 3d time-of-flight magnetic resonance angiography based study jlmc.edu.np references: 1. cui y, xu t, chen j, tian h, cao h. anatomic variations in the anterior circulation of the circle of willis in cadaveric human brains. int j clin exp med. 2015;8(9):15005-10. pmid:26628984 pmcid: http://www.ncbi.nlm.nih.gov/pmc/ articles/pmc4658873/ 2. wijesinghe p, steinbusch hwm, shankar sk, yasha tc, de silva krd. circle of willis abnormalities and their clinical importance in ageing brains: a cadaveric anatomical and pathological study. journal of chemical neuroanatomy. 2020;106(0):101772. doi: https://doi.org/10.1016/j.jchemneu.2020.101772 3. ustun c. neurowords dr. thomas willis’ famous eponym: the circle of willis. j hist neurosci. 2005;14(1):16-21. pmid: 15804755 doi: https://doi.org/10.1080/096470490512553 4. li j, wang j, wei x, zhao yw, wang f, li y. examination of structural variations of the circle of willis by 3d time-of-flight magnetic resonance angiography. front neurosci. 2020;14(0):71. pmid: 32116517 doi: https:// doi.org/10.3389/fnins.2020.00071 5. krabbe-hartkamp mj, van der grond j, de leeuw fe, de groot jc, algra a, hillen b, et al. circle of willis: morphologic variation on three-dimensional time-of-flight mr angiograms. radiology. 1998;207(1):103-11. pmid: 9530305 doi: https://doi.org/10.1148/ radiology.207.1.9530305 6. van seeters t, hendrikse j, biessels gj, velthuis bk, mali wp, kappelle lj, et al. completeness of the circle of willis and risk of ischemic stroke in patients without cerebrovascular disease. neuroradiology. 2015;57(12):1247-51. pmid: 26358126 doi: https://doi.org/10.1007/s00234015-1589-2 7. henderson rd, eliasziw m, fox aj, rothwell pm, barnett hj. angiographically defined collateral circulation and risk of stroke in patients with severe carotid artery stenosis. north american symptomatic carotid endarterectomy trial (nascet) group. stroke. 2000;31(1):128-32. pmid: 10625727 doi: https://doi.org/10.1161/01.str.31.1.128 8. naveen sr, bhat v, karthik ga. magnetic resonance angiographic evaluation of circle of willis: a morphologic study in a tertiary hospital set up. ann indian acad neurol. 2015;18(4):391-7. pmid: 26713008 doi: https://doi.org/10.4103/0972-2327.165453 9. karatas a, coban g, cinar c, oran i, uz a. assessment of the circle of willis with cranial tomography angiography. med sci monit. 2015;21:2647-52. pmid: 26343887 doi: https://doi.org/10.12659/msm.894322 10. gunnal sa, farooqui ms, wabale rn. anatomical variations of the circulus arteriosus in cadaveric human brains. neurol res int. 2014;2014(0):687281. pmid: 24891951 doi: https://doi.org/10.1155/2014/687281 11. zaninovich oa, ramey wl, walter cm, dumont tm. completion of the circle of willis varies by gender, age, and indication for computed tomography angiography. world neurosurg. 2017;106(0):953-63. pmid: 28736349 doi: https://doi.org/10.1016/j.wneu.2017.07.084 12. zaki sm, shaaban mh, abd al galeel wa, el husseiny aaw. configuration of the circle of willis and its two parts among egyptian: a magnetic resonance angiographic study. folia morphol (warsz). 2019;78(4):703-9. pmid: 30761512 doi: https://doi.org/10.5603/ fm.a2019.0015 13. jalali kondori b, azemati f, dadseresht s. magnetic resonance angiographic study of anatomic variations of the circle of willis in a population in tehran. arch iran med. 2017;20(4):235-9. pmid: 28412828 14. shaikh r, sohail s. mra-based evaluation of anatomical variation of circle of willis in adult pakistanis. j pak med assoc. 2018;68(2):18791. pmid: 29479090 15. ravikanth r, philip b. magnetic resonance angiography determined variations in the circle of willis: analysis of a large series from a single center. tzu chi med j. 2019;31(1):52–9. pmid: 30692833 doi: https://doi.org/10.4103/tcmj. tcmj_167_17 16. varga a, di leo g, banga pv, csobay-novák c, kolossváry m, maurovich-horvat p, et al. multidetector ct angiography of the circle of willis: association of its variants with carotid artery disease and brain ischemia. eur radiol. 2019;29(1):46-56. pmid: 29922933 doi: https://doi.org/10.1007/s00330-018-5577-x 17. yeniçeri iö, çullu n, deveer m, yeniçeri en. circle of willis variations and artery diameter measurements in the turkish population. folia morphol (warsz). 2017;76(3):420-5. pmid: 28150270 doi: https://doi.org/10.5603/ fm.a2017.0004 j. lumbini. med. coll. vol 7, no 2, july-dec 2019 nepal s, et al. clinico-epidemiology of hymenoptera stings in and around kaski district, nepal 50 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 24 december, 2018. accepted: 21 november, 2019. published: 29 december, 2019. a lecturer, department of community medicine b assistant professor, department of forensic medicine c additional professor, department of forensic medicine & toxicology d lumbini medical college and teaching hospital, palpa, nepal. e all india institute of medical sciences, jodhpur, india. corresponding author: alok atreya e-mail: alokraj67@hotmail.com orcid: https://orcid.org/0000-0001-6657-7871 _______________________________________________________ —–————————————————————————————————————————————— abstract: introduction: in nepal, morbidity and mortality from hymenoptera stings is mainly from three commonly encountered insects: hornets (local: aringal), wasps (local: barulo) and honey bees (local: mahuri). the present study documents the incidence of hymenoptera sting in western region of nepal and explores the cause behind such unprovoked attack upon human subjects. methods: this hospital-based study included all the patients with history of insect sting attending the emergency department of manipal teaching hospital, pokhara from may 2015 till november 2015. results: of total 16 cases during the study period three were brought dead cases. the alleged insect happened to be bee in two cases, hornet in two cases, and wasp in eight cases with a case of unidentified insect sting. severe burning pain with swelling, redness and itching were the common presenting symptom in all the admitted patients (n=13). conclusion: agricultural activity during the day was the cause of most unprovoked stings followed by deliberate destruction of the insect hive. immediate medical attention in the nearby health care facility to the victims might decrease mortality. the health care facility also needs to have surplus lifesaving medication to counteract the life-threatening anaphylaxis reactions from such stings. keywords: bees, envenomation, hornets, hymenoptera, nepal original research articlehttps://doi.org/10.22502/jlmc.v7i2.276 samata nepal,a,d alok atreya,b,d tanuj kanchanc,e clinico-epidemiology of hymenoptera stings in and around kaski district, nepal. how to cite this article:how to cite this article: nepal s, nepal s, atreya a, kanchan t. clinico-epidemiology of atreya a, kanchan t. clinico-epidemiology of hymenoptera stings in and around kaski district, nepal. hymenoptera stings in and around kaski district, nepal. journal of lumbini medical college. 2019;7(2):50-55. doi: journal of lumbini medical college. 2019;7(2):50-55. doi: doi.org/10.22502/jlmc.v7i2.276doi.org/10.22502/jlmc.v7i2.276 epub: 2019 december 29. epub: 2019 december 29. introduction: stings from insects of hymenoptera group are common in developing countries. the venom the insects possess in their stings is capable of life threatening anaphylactic reaction associated with unanticipated mortality.[1-5] the immunoglobulin ige present in the venom which is capable of late-phase inflammatory reaction is the reason for morbidity from the stings.[6] in nepal, the emergency hospital visits due to stings are mainly from three commonly encountered insect groups; hornets (local: aringal), wasps (local: barulo) and honey bees (local: mahuri). it is well recognized fact that these fierce insects sting only when provoked. [1] if these insects feel a threat from intruder bashing their hives, colonies or being attacked; they counter attack by the use of their powerful stings. though isolated cases of insect stings are reported from different regions, detailed analysis of insect stings and their outcomes are lacking in literature. the objective of the present study was to observe the incidence of insect sting and present its detailed clinico-epidemiological profile in the region, and measures for prevention and raise public awareness. j. lumbini. med. coll. vol 7, no 2, july-dec 2019 nepal s, et al. clinico-epidemiology of hymenoptera stings in and around kaski district, nepal 51 jlmc.edu.np methods: this descriptive cross sectional study was carried out in the emergency department (ed) of manipal teaching hospital, pokhara, nepal. an approval was obtained from the institutional research committee (irc) before the commencement of the study. all the patients attending the ed with a history of bee or wasp sting between may 2015 and november 2015 were included in the study. three patients who were brought dead to the ed with an alleged history of wasp sting during the study period were also included. the study duration was chosen between may and november because venom specific ige has seasonal variation and maximum number of casualties are reported in this period of the year.[2,3] all the patients in the present study were initially registered either a case of bee sting or wasp sting based on the history given by the patients and/ or the attendants. although, wasp and hornets are two different insect species, there was likelihood that hornet stings too were designated as wasp stings. to be more specific in this regard, a coloured photograph each of hornet and wasp was shown to all the patients registered as a case of wasp sting for confirmation. when the patient or their caregivers, after looking at the photograph claimed it was neither wasp nor hornet, the case was categorized under unidentified insect sting. detailed history was obtained from the patient and/or patient’s caregivers after obtaining informed consent. the specific variables were noted which included age and gender of the patient, insect involved, site stung, activity prior to sting, and the presenting symptoms. the patients were followed up in the wards and data on complications, outcome of treatment and duration of hospital stay were noted. the collected data was analysed using statistical package for social sciences (spsstm) software 16.0 and results expressed in proportions. results: a total of 16 cases of bee and wasp stings brought to the emergency department (ed) of manipal teaching hospital, pokhara were analysed in the present investigation. of all the cases of insect stings (n=16), one patient was referred from primary health centre and three patients were brought dead to the ed with a history of wasp sting, others had directly reported to the ed. two cases were registered as those from bee sting and other fourteen as wasp sting. the study group comprised of ten males (62.5%) and six females (37.5%) with a mean age of 25.25±18.36 and 37.0±10.07 years respectively. on showing the picture of the alleged insect, two cases were assigned as bee stings, two cases as hornet and eight cases as wasp stings. the three brought dead cases with alleged history of wasp sting, could not be confirmed yet placed under wasp sting category. demographic characteristics of the patients are presented in table 1. severe burning pain with swelling, redness and itching were the presenting symptom in all the patients who got admitted (n=13) to the hospital. table 1. demographic characteristics of the patients. (n=16) variable frequency n (%) sex male 10 (62.5%) female 06 (37.5%) age distribution ≤ 10 years 03 (18.75%) 11-30 years 06 (37.5%) ≥31 years 07 (43.75%) mean age (years) male 25.25±18.36 female 37.00±10.07 insect involved bee 02(12.50%) wasp 11* (68.75%) hornet 02 (12.50%) unidentified 01(6.25%) activity during sting cutting paddy 01 (6.25%) rearing goat in jungle 01 (6.25%) playing 01 (6.25%) honey hunting 01 (6.25%) walking 01 (6.25%) cutting grass 03 (18.75%) destroying the hide 04 (25.00%) wasp hunting 04 (25.00%) time of sting morning (6am to noon) 03 (18.75%) day (noon to 6pm) 11 (68.75%) evening (6pm onwards) 02 (12.5%) * wasps were involved in all three brought dead cases j. lumbini. med. coll. vol 7, no 2, july-dec 2019 nepal s, et al. clinico-epidemiology of hymenoptera stings in and around kaski district, nepal 52 jlmc.edu.np rash over areas other than the sting site was seen in five cases (38.56%). besides, four patients (30.77%) complained of shortness of breath. the sting was confined to head and neck region in four cases (30.77%) and one case each (7.69%) in the trunk and upper limb. in the remaining seven cases (53.85%) the sting was not confined to a particular region rather was generalised over a wide area. history obtained from the patient and/ or their caregivers revealed that day time was the most vulnerable period as 68.75% of the total casualties occurred during this period. unprovoked sting occurred mostly during agricultural activities like cutting paddy, cutting grass, rearing goat etc. one child suffered bee sting while playing. it was observed that deliberate destruction of the insect hive was the main reason of hymenoptera sting in our study. in four cases (25%), the patients were stung while destroying the hive in their neighbourhood. there were four patients stung during wasp hunting and a case from lamgunj district where a patient was stung by a swarm of bees while he was honey hunting. no mortality was reported for the patients admitted to the hospital (n=13). duration of stay in the hospital varied between two days and four days with a mean hospital stay of 2.92±0.86 days. antihistaminic medication was the treatment given to all admitted cases whereas injection hydrocortisone (steroid) and adrenaline were used only in six admitted cases. two patients in the study had abnormal renal function and one patient had deranged liver function test reports. one patient with haematological complication had an abnormal prothrombin time (pt) where blood did not clot within two minutes. this was the only patient who was transfused four units of fresh frozen plasma and was also administered vitamin k. clinical presentation, complications and outcome of hymenoptera stings in the study are shown in table 2. discussion: reactions to insect stings are varied ranging from local irritation to systemic manifestations including anaphylaxis, organ failure and death. small peptides, vaso-active amines and proteins are responsible for initiation of painful stimuli following the sting.[2] the triad of inflammatory responses; redness (rubor), pain (dolor) and swelling (tumor) are invariably present in hymenopteroid stings as observed in our cases. the venom consisting of phospholipase, hyluronidase and enzyme protein is the culprit for tissue damage and fatal anaphylaxis. the pathophysiology of ige mediated allergic reaction provoked by the venom and its systemic manifestation is exhaustively studied previously and is not within the scope of this article.[4-9] studies have shown that fatality from hymenoptera venom occurs mostly within one to two hours of sting.[2,4,10] if a patient is injected with epinephrine within this time then the mortality would certainly decline. intradermal skin testing for venom specific ige is usually table 2. clinical presentation and outcome. (n=13) variable frequency n (%) signs and symptoms swelling 13 (100%) severe pain (burning) 13 (100%) redness 13 (100%) itching 13 (100%) rash (other than sting site) 05 (38.46%) shortness of breath 04 (30.77%) sting site head and neck 04 (30.77%) trunk 01 (7.69%) limbs 01 (7.69%) multiple sites 07 (53.85%) duration of hospital stay (days) 2 05 (38.46%) 3 04 (30.77%) 4 04 (30.77%) mean duration (days) 2.92±0.86 complications abnormal liver function test 01 (7.69%) abnormal renal function test 02 (15.38%) haemolysis 01 (7.69%) outcome recovered and discharged 10 (76.93%) left against medical advice 03 (23.07%) mortality 00 (--)* * three cases of wasp stings were brought dead to the hospital j. lumbini. med. coll. vol 7, no 2, july-dec 2019 nepal s, et al. clinico-epidemiology of hymenoptera stings in and around kaski district, nepal 53 jlmc.edu.np done to determine the severity of anaphylaxis and also to determine the patients needing treatment with venom immunotherapy (vit). the tertiary centre where this study was conducted had no provision of skin testing for venom specific ige and neither was treatment with vit. it is believed that once a person stung by the insect of this group and develops anaphylaxis reaction, there is less than 5% chance that such reaction would occur in subsequent stings. [6,11-13] the demographic and clinical findings from the previous studies on insect stings are consistent with our findings yet the previous studies did not explore much on the cause of such stings in humans. beekeeping, formally a secondary activity for some farmers in nepal, presently has become a business replacing sustenance crop farming.[14] the interesting and unique observation as to cause of bee sting in our study was wild honey hunting. the toxic effect of wild honey on humans especially in the areas of surplus wild nectar flower rhododendron (national flower of nepal) has already been reported,[15] yet bee sting due to wild honey hunting has not been previously reported. honey hunting, formerly done as a small and subsidiary activity, nowadays,has become a business, as the collected honey when exported earns a handsome amount of money. even the intoxicating mad honey is sold in the markets in japan and korea where it is used for its medicinal properties. recently, honey hunting has emerged as a recreational and adventurous sport for the tourist intending to experience this event, which is also a source of income for the indigenous communities. [16] hornets hunt on honey bees and hornet stings too cannot be denied during this activity. hymenopterans do not attack human unless provoked. humans fear hymenopterans because of the painful stingers they possess. the hive or colony near the residential area is usually destroyed fearing such an attack. in the present study, four cases of wasp sting resulted while trying to destroy the colony in their neighbourhood. the commonest way of destruction of hive is by making a thick smoke below the hive so that the insects are repelled and the hive is destroyed by a long bamboo stick. the authors during interview of the patients in the study found out that three cases were stung by the insect when they were trying to hunt the wasp larvae. it is a popular belief among the local people that the larva of the wasp/hornet is an energy food and also an aphrodisiac. the number of cases and the number of mortality in the present study may seem low but the findings reveal bitter reality. out of 16 cases in the present study only three cases were from kaski district where the study centre is located. there were only two cases who sought treatment at rural health-post before reaching the study centre. the authors want to highlight the fact that fourteen cases didn’t seek treatment at the rural health posts in their locality and travelled two to four hours to reach the tertiary care centre. the two cases who visited the health post were also referred to tertiary centre without epinephrine injections. this point to the fact that the rural health workers in nepal are not familiar with epinephrine injections/ auto-injectors or it is unavailable. as a consequence people do not trust the care given at the primary health care centres by incompetent care givers. the authors want to highlight a case where a lady stung by hymenoptera was successfully treated and recovered in a primary health care centre when the nervous health assistant consulted and sought help from a doctor at tertiary centre by telephone.[17] telemedicine in the form of telephone consultation is not only cost effective but also a life-saving in the remote areas of nepal. sometimes unavailability of vehicle, difficult geographical terrain, bumpy roads delay the transport of the patient to the tertiary centre and the patient may collapse and die even before reaching the hospital. government of nepal states there are 208 primary health care centres (phccs), 1559 health-posts (hps) and 2247 sub health-posts (shps).[18] the authors recommend the government should conduct awareness programs for the public and also should provide emergency life saving drugs (e.g.epinephrine injections) invariably to all the rural health posts of the country. all the phccs, hps and shps should necessarily have a telephone line so that in case of emergency telephone consultation could be made. there should be training and workshops for the care givers from time to time to refresh their knowledge and skills. the locals who live near wild and those who indulge in hymenoptera hunting activity should be made aware that in case of stings they should visit the nearby health post so that life threatening allergic reactions is prevented and human lives are saved in time. j. lumbini. med. coll. vol 7, no 2, july-dec 2019 nepal s, et al. clinico-epidemiology of hymenoptera stings in and around kaski district, nepal 54 jlmc.edu.np conclusion: usually insect stings cause minor and selflimited reactions, but the insects of hymenoptera group are infamous for causing severe systemic reactions and fatality in some cases. therefore, patients who are stung by hymenopteriod insects require timely and aggressive therapy. the early use of epinephrine, immediately after sting or at the onset of systemic symptoms are proved life-saving. there should be surplus supply of life saving drugs at the primary health care centre in the rural areas and there should be awareness amongst the public to seek treatment at nearest accessible health care provider that would save time and dime. acknowledgement: the findings of this study were presented at12th annual national conference of indian society of toxicology (toxocon-12), held on 6th and 7th april 2018 at sikkim manipal institute of medical sciences, gangtok, sikkim, india. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. j. lumbini. med. coll. vol 7, no 2, july-dec 2019 nepal s, et al. clinico-epidemiology of hymenoptera stings in and around kaski district, nepal 55 jlmc.edu.np references: 1. reisman re. insect stings. n eng j med. 1994;331:523-7. pmid: 8041420 doi: https:// doi.org/10.1056/nejm199408253310808 2. warpinski jr, bush rk. stinging insect allergy. wilderness environ med. 1990;1:249-7. doi: https://doi.org/10.1580/0953-9859-1.4.249 3. paudel b, paudel k. a study of wasp bites in a tertiary hospital of western nepal. nepal med coll j. 2009;11:52-6. pmid: 19769240 4. golden db. anaphylaxis to insect stings. immunol allergy clin north am. 2015;35:287– 302. pmid: 25841552 doi: https://doi. org/10.1016/j.iac.2015.01.007 5. turner pj, gowland mh, sharma v, ierodiakonou d, harper n, gracez t et al. increase in anaphylaxis-related hospitalizations but no increase in fatalities: an analysis of united kingdom national anaphylaxis data, 1992-2012. j allergy clin immunol. 2015;135:956-63. pmid: 25468198 doi: https://doi.org/10.1016/j. jaci.2014.10.021 6. umemoto l, poothullil j, dolovich j, hargreave fe. factors which influence late cutaneous allergic responses. j allergy clinimmunol. 1976;58:60-8. pmid: 947978 doi: https://doi. org/10.1016/0091-6749(76)90107-x 7. golden db. large local reactions to insect stings. j allergy clin immunol pract. 2015;3:331-4. pmid: 25819508 doi: https:// doi.org/10.1016/j.jaip.2015.01.020 8. castells mc, hornick jl, akin c. anaphylaxix after hymeoptera sting: is it venom allergy, a clonal disorder, or both? j allergy clinimmunol pract. 2015;3:350-5. pmid: 25858055 doi: https://doi.org/10.1016/j.jaip.2015.03.015 9. ewan pw. venom allergy. bmj. 1998;316:13658. pmid: 9563993 doi: https://doi.org/10.1136/ bmj.316.7141.1365 10. barnard jh. studies of 400 hymenoptera sting deaths in the united states. j allergy clinimmunol. 1973;52:259-64. pmid: 4746790 doi: https://doi.org/10.1016/00916749(73)90044-4 11. sigdel mr, raut kb. wasp bite in a referral hospital in nepal. j nepal health res counc. 2013;11:244-50. pmid: 24908524 12. kumar mk, thakur sn. acute renal failure and seizure following multiple wasp stings: a case report. journal of nepal paediatric society. 2012;32:65-8. doi: http://dx.doi.org/10.3126/ jnps.v32i1.5238 13. wijerathne bt, rathnayake gk, agampodi sb. hornet stings presenting to a primary care hospital in anuradhapura district, sri lanka. wilderness environ med. 2014;25:122-6. pmid: 24411975 doi: https://doi.org/10.1016/j. wem.2013.09.012 14. pokhrel s. comparative benefits of beekeeping enterprise in chitwan, nepal. journal of agriculture & environment. 2009;10:39-50. doi: http://dx.doi.org/10.3126/aej.v10i0.2129 15. kurdziel m, sutherland t. wild honey intoxication in the remote himalaya. wilderness environ med. 2013;24:473-4. pmid: 23958230 doi: https://doi.org/10.1016/j.wem.2013.05.008 16. indigenous honeybees and honey hunters of himalayas: a case of apislaboriosa in kaski district of nepal. available from: http://www. icimod.org/?q=1511 (accessed 24 august 2015) 17. lama t, karmacharya b, chandler c, patterson v. telephone management of severe wasp stings in rural nepal: a case report. j telemedicine telecare. 2011;17:105-8. pmid: 21139015 doi: https://doi.org/10.1258/jtt.2010.100606 18. annual report 2070/71(2013/2014). department of health services. ministry of health and population. government of nepal. available from: https://dohs.gov.np/wp-content/ uploads/2014/04/annual_report_2070_71.pdf (accessed 28 february 2016) j. lumbini. med. coll. vol 7, no 2, july-dec 2019 karki d et al. prevalence and associated risk factors of hypertension among adults in palpa district, nepalkarki d et al. prevalence and associated risk factors of hypertension among adults in palpa district, nepal 107 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 5 september, 2019 accepted: 7 december, 2019 published: 19 january, 2020 a lecturer, department of community medicine b lumbini medical college teaching hospital, palpa, nepal. corresponding author: deelip kumar karki e-mail: deelipkarki2039@gmail.com orcid: https://orcid.org/0000-0002-3838-9993_______________________________________________________ abstract: introduction: hypertension mostly remains asymptomatic when controlled, however there is always an increased risk of heart disease, stroke and renal failure. the higher the blood pressure, the higher the likelihood of harmful consequences to the heart, blood vessels, eyes, brain and kidneys. methods: a community-based cross-sectional study was conducted in adult population. the blood pressure was measured on left arm, the respondents in sitting posture and arm support at the heart level. results: the prevalence of hypertension was 22% and higher in people above 60 years of age. prevalence of hypertension was more in people who had elevated waist to hip ratio (65%) and positive family history (40.8%). the prevalence of hypertension was observed high among diabetics (63.2%) and smokers (33.3%). conclusion: the prevalence of hypertension was seen positively associated with increasing age, smoking, alcohol sedentary lifestyle, diabetes, stress, central obesity and >25 bmi. keywords: hypertension, prevalence, risk factors original research articlehttps://doi.org/10.22502/jlmc.v7i2.300 deelip kumar karki,a,b samata nepal,a,b keshav raj bhandaria,b prevalence and associated risk factors of hypertension among adults in palpa district, nepal how to cite this article:how to cite this article: karki dk, nepal s, bhandari kr. prevalence and associated risk factors of hypertension among adults in palpa district, nepal. jour-journal of lumbini medical college. 2019;7(2):107-112. doi: nal of lumbini medical college. 2019;7(2):107-112. doi: https://doi. org/10.22502/jlmc.v7i2.300. epub: 2019 january 19.. epub: 2019 january 19. introduction: globally cardiovascular diseases account for approximately 17 million deaths per year, nearly one-third of the total deaths.[1] worldwide, nearly one billion people have hypertension; of these, twothirds are in the middleand low-income countries. hypertension is one of the most important causes of premature deaths and the problem is growing. approximately one-third of the adult population in south east asia has high blood pressure.[2] nepal demographic and health survey (2016) showed that 17% of women and 23% of men aged 15 years and above had hypertension.[3] there are a number of behavioral risk factors responsible for hypertension including consumption of food with excessive salt and fat, eating not enough fruits and vegetables, alcohol and tobacco use, physical inactivity, obesity, poor stress management, family history of hypertension, high cholesterol and dyslipidemia. addressing behavioral risk factors, e.g. unhealthy diet, harmful use of alcohol, smoking and physical inactivity can prevent hypertension. this study aimed to evaluate the prevalence and associated risk factors of hypertension in palpa district, nepal. methods: this was an observational cross-sectional study conducted in ribdikot rural municipality and tansen municipality of palpa district over a period of two months from may to july, 2019. ethical approval was taken from institutional review committee of the institute (irc-lmc 01-c/019) prior to commencement of data collection. the sample size was calculated using the formula: n>zpq/e2; where, z= 1.96; prevalence of hypertension (p)=41%[4]; q=1-p and margin of error (e)=5%. the minimum sample size thus calculated was 371.71. a total of 372 participants were taken for the study. interview schedule was developed and j. lumbini. med. coll. vol 7, no 2, july-dec 2019 karki dk et al. prevalence and associated risk factors of hypertension among adults in palpa district, nepalkarki dk et al. prevalence and associated risk factors of hypertension among adults in palpa district, nepal 108 jlmc.edu.np informed consent was taken from the participants. multi stage sampling method was adopted for the study. the blood pressure was measured on the left arm in sitting quietly on a chair with feet on the floor, legs uncrossed and the arm supported at the heart level. the first reading was taken at least after 15 minutes of rest. the second measurement was obtained after the participant had rest for at least three minutes of the first measurement. if the two readings were different, their mean wasnoted. the systolic blood pressure was recorded at phase i korotkoff sounds, while the diastolic blood pressure was recorded at phase v korotkoff sounds. similarly, systolic blood pressure < 140 mm of hg and diastolic blood pressure < 90 mm of hg was considered normal blood pressure. systolic blood pressure as of 140 mm of hg or above and/or diastolic pressure 90 mm of hg or above was considered hypertension. [5,6] participants currently on antihypertensive medication were also considered hypertensive. weight of the participants was measured by weighing machine. to measure height, the participant was made to stand vertically against the wall and just over the head, height was marked on the wall and measured with a measuring tape.body mass index (bmi) was calculated as weight in kilograms divided by square of height in meters (kg/ m2) and classified into four groups as underweight (bmi< 18.5 kg/m2), normal weight (bmi 18.524.9 kg/m2), overweight (bmi 25-29.9 kg/m2) and obese (bmi≥30 kg/m2).[7] waist circumference was measured over light clothing while breathing out, relaxing and not contracting any abdominal muscles at a level midway between the lower rib margin and the iliac crest in centimeters rounded up to nearest 0.5 cm. central obesity was defined as increased waist circumference > 88 cm in women and more than >102 cm in men. a waist-to-hip ratio >1.0 for men and >0.8 for women was also considered central obesity.[8] current smoker was defined as someone who has smoked greater than 100 cigarettes in his life time and smoking every day or some days over the past 6 months. non-smoker was defined as someone who has not smoked greater than 100 cigarettes in his life time and does not currently smoke.[9] physical activity was classified as: [10] high: a. vigorous-intensity activity on at least three days achieving a minimum total physical activity of at least 1500 min/week, or b. seven or more days of any combination of walking, moderate-intensity or vigorous intensity activities achieving a minimum total physical activity of at least 3000 met-min/week moderate: a. three or more days of vigorous-intensity activity of at least 20 min per day, or b. five or more days of moderate-intensity activity and/or walking of at least 30 min per day, or c. five or more days of any combination of walking, moderate-intensity or vigorous intensity activities achieving a minimum total physical activity of at least 600 met-min/week. low: a. low is the lowest level of physical activity. those individuals who did not meet the criteria for moderate and high were considered low. total amount of alcohol intake was calculated in number of standard drinks (10 grams of pure ethanol). any participant who drank alcohol within the last 30 days of data collection was defined as current alcohol user. all the data were collected in a preformed proforma. they were entered to and analyzed using statistical package for social sciences (spsstm) software version 16. qualitative data were expressed in frequencies and percentages. chi square test and odds ratio were used to analyze the data. a p-value <0.05 was considered statistically significant. results: there was a total of 372 participants in the study. most of the participants were 40-59 years of age group and more than half (52.7%) were female. most of them (61.6%) were brahmin or chhetri. more than one quarter (26.3%) were farmers and 15.3% were illiterate. table 1 shows the age and gender distribution of normotensive and hypertensive participants. table 2 shows that 9.5% of the participants in the age group 20-39 years had hypertension whereas 34.8% of those of age 60 years and above had the condition. there was no statistically significant difference in the prevalence of hypertension in terms of sex (p=0.422) and ethnicity (p=0.145). prevalence of hypertension was found more among illiterate than literate. prevalence of hypertension was high in those with elevated waist/hip ratio as compared to normal waist/hip ratio (p<0.001, or= 9). similarly, 65.3% of those with bmi >25 kg/m2 had hypertension and higher prevalence (40.8%) was found in those with positive family history j. lumbini. med. coll. vol 7, no 2, july-dec 2019 karki dk et al. prevalence and associated risk factors of hypertension among adults in palpa district, nepalkarki dk et al. prevalence and associated risk factors of hypertension among adults in palpa district, nepal 109 jlmc.edu.np table 1. demographic characteristics of the study population (n=372). variables normal bp stage 1 htn stage 2 htn under medication age (years) 20-39 134 (36.0) 4 (1.1) 4 (1.1) 6 (1.6) 40-59 111 (29.8) 18 (4.8) 14 (3.7) 12 (3.2) >60 45 (12.2) 10 (2.8) 4 (1.1) 10 (2.6) gender male 134 (36.0) 17 (4.6) 10 (2.6) 15 (4.0) female 156 (41.9) 15 (4.1) 12 (3.2) 13 (3.6) table 2. relation between blood pressure, demographic profile and other variables variables categories number of respondents normotension hypertension statistics age (years) 20-39 148 (39.8) 134 (90.5) 14 (9.5) χ2 = 23.7, p<0.00140-59 155 (41.7) 111 (71.6) 44 (28.4) >60 69 (18.5) 45 (65.2) 24 (34.8) gender male 176 (47.3) 134 (76.1) 42 (23.9) χ2 = 0.6, p=0.422 female 196 (52.7) 156 (79.6) 40 (20.4) ethnicity dalit 63 (16.9) 55 (87.3) 8 (12.7) χ2 = 3.8, p=0.145 janajati 80 (21.5) 61 (76.2) 19 (23.8) brahmin/ chhetri 229 (61.6) 174 (76.0) 55 (24.0) education illiterate 57(15.3) 40 (70.2) 17 (29.8) χ2 = 42.2, p<0.001 primary 107(28.8) 63 (58.9) 44 (41.1) secondary 103(27.7) 92 (89.3) 11 (10.7) intermediate 73 (19.6) 65 (89.0) 8 (11.0) bachelor and above 32 (8.6) 30 (93.8) 2 (6.2) waist/ hip ratio normal 332 (89.2) 276(83.1) 56 (16.9) χ2 = 48.1, p<0.001 or= 9elevated 40 (10.8) 14 (35.0) 26 (65.0) bmi <25 323 (86.8) 273 (84.5) 50 (15.5) χ2 = 61.4, p<0.001 or= 10> 25 49 (13.2) 17 (34.7) 32 (65.3) family history yes 98 (26.3) 58 (59.2) 40 (40.8) χ2 = 27.2, p<0.001 no 274 (73.7) 232 (84.7) 42 (15.3) smoking yes 69 (18.6) 46 (66.7) 23 (33.3) χ2 = 6.2, p=0.012 no 303 (81.4) 244 (80.5) 59 (19.5) alcohol consumption yes 64 (17.2) 35 (54.7) 29 (45.3) χ2 = 24.3, p<0.001no 308 (82.8) 255 (82.8) 53 (17.2) diabetes yes 19 (5.1) 7 (36.8) 12 (63.2) χ2 = 19.6, p<0.001no 353 (94.9) 283 (80.2) 70 (19.8) physical activity low 180 (48.4) 130 (72.2) 50 (27.8) χ2 = 6.7, p=0.035 moderate 170 (45.7) 142 (83.5) 28 (16.5) heavy 22 (5.9) 18 (81.8) 4 (18.2) stress yes 40 (10.8) 8 (20.0) 32 (80.0) χ2 = 87.6, p<0.001no 332 (89.2) 282 (84.9) 50 (15.1) j. lumbini. med. coll. vol 7, no 2, july-dec 2019 karki dk et al. prevalence and associated risk factors of hypertension among adults in palpa district, nepalkarki dk et al. prevalence and associated risk factors of hypertension among adults in palpa district, nepal 110 jlmc.edu.np of hypertension. other factors such as smoking (p=0.012), alcohol consumption (p<0.001), diabetes (p<0.001) and sedentary lifestyle (p=0.035) were found statistically significant with hypertension. discussion: the prevalence of hypertension in this study was 22% which is similar to that of other studies. [11,12,13] this study further showed that the prevalence of hypertension was low (9.5%) in 20-39 years of age group but high (34.8%) among 60 years and above. this signifies the risk of hypertension increases with age. similar result was obtained in another study.[14] similarly, ndhs (2016) shows that the prevalence of hypertension increases with age. the lowest prevalence was observed among 30–39 years of age (21.7%) and the highest prevalence was 59.3% among participants above 60 years of age.[3] arterial and arteriolar stiffness and increased sodium retention are related to rise of blood pressure with age.[15] with increasing age, the aorta and arterial walls are stiffened and this contributes to the higher prevalence of hypertension in older age groups.[16] the prevalence was slightly higher in males (23.9%) than females (20.4%) but the difference observed between them was not statistically significant (p=0.422). there was a statistically significant association between obesity (p<0.001), central obesity (p<0.001) and hypertension. the result was consistent with the findings from other studies conducted in nepal.[17,18] similar findings showed that having bmi ≥ 25 (adjusted or 2.0) was significantly associated with hypertension.[12] another study found that obesity is a principal risk factor for development of hypertension.[19] the abdominal adipose tissue results in release of free fatty acids directly in the portal veins and altered lipid levels in the blood.[20] the free fatty acid release also results in endothelial dysfunction that develops hypertension. obesity and central obesity mean greater fat stores, insulin resistance, increased salt retention, and decreased physical activity all these contribute to rise in blood pressure level.[21] this study found that 40.8% of participants with positive family history had hypertension. there was a significant relation between hypertension and positive family history (or=3). similar finding showed that those who had family history of hypertension were nearly six times more likely to be hypertensive when compared to those who did not have (or 5.7).[12] there is statistically significant relationship between smoking and hypertension (p=0.012). many studies have proved that cigarette smoking increases the risk of hypertension.[22,23] alcohol consumption was also associated with hypertension (p<0.001). different studies in nepal have observed an association of alcohol consumption to hypertension.[17,18] another study demonstrated that alcohol intake was positively and significantly associated with risk of hypertension.[24] this study showed association between alcohol, tobacco use and hypertension because it is more prevalent in tobacco users and alcohol users as compared to non-users. our study depicted that around two-third diabetic patients had hypertension. another study revealed that the participants who were diabetic were 16 times more likely to be hypertensive than those who were not (aor=16.322, ci: 2.321-114.771).[25] conclusion: this study evaluated the prevalence and associated risk factors of hypertension. hypertension was found to be statistically significant with increasing age, smoking, alcohol consumption, sedentary lifestyle, diabetes, central obesity and bmi >25. screening programs for early detection of hypertension and health education program for prevention and control of hypertension are glaring necessities in the studied region. conflict of interest: the authors declare that no competing interests exist. source of funds: no funds were available. j. lumbini. med. coll. vol 7, no 2, july-dec 2019 karki dk et al. prevalence and associated risk factors of hypertension among adults in palpa district, nepalkarki dk et al. prevalence and associated risk factors of hypertension among adults in palpa district, nepal 111 jlmc.edu.np references 1. world health organization. a global brief on hypertension. world health organization. who/dco/whd/2013.2, 2013. 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associated risk factors of hypertension among people aged 50 years and more in banepa municipality nepal. kathmandu university medical journal. 2012;10(39):35-8. pmid: 23434959. doi: https://doi.org/10.3126/ kumj.v10i3.8015 25. dhakal s, singh r, yadav un, gurung lb. prevalence and factors associated with hypertension among elderly population in dhapasi vdc of kathmandu district. journal of hypertension: open access. 2017;6(3):242. doi: https://doi.org/10.4172/2167-1095.1000242 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 13 january, 2020 accepted: 06 may, 2020 published: 22 may, 2020 a lecturer, department of physiology b lumbini medical college teaching hospital, palpa, nepal. corresponding author: shaligram chaudhary e-mail: shaligram20@gmail.com orcid: https://orcid.org/0000-0002-7242-1846 _______________________________________________________ —–———————————————————————————————————————————— abstract introduction: the six-minute walk test is a simple test used to assess the exercise capacity. variability is noted in the six-minute walk distance in different population. obesity also affects the six-minute walk test results. the aims of the study were to examine the relationship between body mass index and post exercise oxygen saturation and to establish reference equation for the six-minute walk distance in young adults. methods: a cross-sectional study was conducted with 106 subjects of age 18-25 years. the participant walked as fast as possible on a flat surface for six minutes. after six-minute walk test, oxygen saturation and the distance walked were recorded. results: body mass index was negatively correlated with oxygen saturation (r=-0.587,p<0.001). mean six-minute walk distance for males was 584.43±23.71 m and for females 469.85±30.38 m (p<0.001). multiple linear regression analysis revealed sex and height as independent predictors of six-minute walk distance. the contributions of sex and height were statistically significant and explained 87.3% variance in the six-minute walk distance. conclusion: although the correlation between body mass index and oxygen saturation was statistically significant, the oxygen saturation values were still within normal range. sex and height were the most significant predictors of the six-minute walk distance. keywords: body mass index, obesity, oxygen saturation, six minute walk distance, six minute walk test original research articlehttps://doi.org/10.22502/jlmc.v8i1.310 shaligram chaudhary,a,b bibek koju,a,b lok raj joshia,b six-minute walk test in healthy nepalese young adults aged 18 to 25 years: a crosssectional study how to cite this article:how to cite this article: chaudhary s, koju b, joshi lr. six-minute walk test in healthy nepalese young adults aged 18 to 25 years: a crosssectional study. journal of lumbini medical college. 2020;8(1):6 pages doi: journal of lumbini medical college. 2020;8(1):6 pages doi: https://doi.org/10.22502/jlmc.v8i1.310. epub: 2020 may 22.https://doi.org/10.22502/jlmc.v8i1.310. epub: 2020 may 22. introduction: the six-minute walk test (6mwt) is a safe, easy to administer, and well tolerated submaximal test to evaluate exercise capacity that reflects activities of daily living better than other walk test. [1,2] the participant walks as fast as possible on a flat surface for six minutes, the distance walked is recorded as six-minute walk distance (6mwd).[2] various factors including age, sex, height, weight, physical activity and body mass index (bmi) have been reported to affect 6mwd in healthy people. [3,4,5,6] abnormally high bmi is now one of the major health problems worldwide.[7,8] it causes accumulation of fat in the chest and abdomen causing restriction of lung expansion.[9] it has been found to be associated with lower oxygen saturation (spo2) after exercise and lower 6mwd.[10,11] besides these factors, 6mwd is variable in healthy population due to population related differences.[12] american thoracic society (ats) encourages the investigators to publish reference values of the 6mwd for several healthy ethnicities using 6mwt.[2] the 6mwd reference value obtained from healthy participants helps the clinicians to interpret the 6mwd in patients and their expected 6mwd in the absence of disease of that age group. recent studies have established j. lumbini. med. coll. vol 8, no 1, jan-june 2020 chaudhary s, et al. chaudhary s, et al. six-minute walk test in healthy nepalese young adults aged 18 to 25 years: a crosssectional studysix-minute walk test in healthy nepalese young adults aged 18 to 25 years: a crosssectional study jlmc.edu.np regression equations to predict the 6mwd in healthy nigerians,[3] chinese population,[5] western indian population,[4] korean adults,[12] brazilians,[13] and arab populations.[14] however, regression equation has not been established in the nepalese context. this study attempted to assess the relationship between bmi and oxygen saturation of hemoglobin after 6mwt. it also aimed to establish the regression equation for 6mwd in 18-25 years old healthy students of a medical college in nepal. methods: this was a cross-sectional study conducted in the department of physiology, lumbini medical college (lmc), pravas, palpa. the study was carried out over a period of four months from august 2019 to november 2019. it included apparently healthy male and female students between age group of 18-25 years willing to participate voluntarily. participants having physical disability affecting test procedure, basal heart rate < 50bpm or >100 bpm, basal systolic blood pressure >150 mmhg or diastolic blood pressure >100 mmhg, basal spo2< 85% and respiratory symptoms for a month before the study were not included in the study. ethical clearance was obtained from institutional review committee of the institute (irc-lmc 08-j/018) prior to data collection. the sample size was calculated using the formula n= [(zα + zβ) /c] 2 + 3 where, n=total number of subjects required zα and zβ = the standard normal deviate for α and β c = 0.5* ln {(1 + r) / (1 r)} r = expected correlation coefficient.[15] for this study, the expected correlation coefficient was r = 0.27 based on study by kapur vk et al.[10] with α = 0.05 and the power of study 80%. according to the calculations, a total of 106 health science students were selected by convenient sampling method. test procedure: one hundred six students who fulfilled inclusion criteria were recruited for the study after obtaining their verbal consent. initial explanation about the aim and purpose of study, test procedure, method of testing, and instructions on how to perform the test was given. they were requested to complete the physical activity readiness questionnaire before test procedure.[16] the 6mwt was performed according to the standardized protocol of american thoracic society between 09:00 and 13:00 hours in order to reduce intra-day variability.[2] the participants were asked to come with comfortable cloth and light meals. at the starting point, basic medical history and clinical examination were taken for check on contraindications. bmi, resting heart rate, bp, borg scores for dyspnea[17] and fatigue, and spo2 (dr. morepen pulse oximeter p004) were recorded after rest for 10 minutes. for the 6mwt, the participants were asked to walk while attempting to cover as much distance as possible in six minutes. the test was performed on a flat surface corridor of 15meter length marked with small cones at the starting and end points and at every three meter distance the corridor was marked, the time and laps were recorded on a worksheet. participants were encouraged in every minute with standard statements “you are doing well”, “keep up the good work”. they were allowed to stop and rest during the test when tired, developed symptoms of dyspnea, dizziness, leg cramps or chest pain, but were instructed to resume walking as soon as they could. after completion of the test again heart rate, bp, spo2 and borg dyspnea score were recorded. also, the distance covered over the six minutes was recorded as the 6mwd.[3] data analysis: data were reported as mean and standard deviation (sd). independent t-test was used to compare means of continuous variables. the relationship between spo2 after 6mwt and bmi was examined using pearson’s correlation coefficient. pearson’s correlation coefficients were also used to analyze relationships between 6mwd and participant’s characteristics. stepwise regression analysis was performed on the following characteristics: age, height, weight, sex and bmi to determine their contribution to 6mwd. all data were analyzed using statistical package for social sciences (spsstm) software 16.0. p value less than 0.05 was considered as significant. results: out of 106 participants, 53 were males and 53 were females. a summary of the physical characteristics of the participants is shown in table 1. the mean height was higher in males (171.06±5.25 cm) than in females (157.26±5.89 cm). the mean values of spo2 before and after 6mwt were 98.03 ± 0.47% and 95.82 ± 0.88% respectively [t(105) = 28.361, p<0.001].there was no statistically significant correlation between spo2 before 6mwt and bmi (r=-0.108, p=0.27). spo2 after 6mwt was j. lumbini. med. coll. vol 8, no 1, jan-june 2020 chaudhary s, et al. chaudhary s, et al. six-minute walk test in healthy nepalese young adults aged 18 to 25 years: a crosssectional studysix-minute walk test in healthy nepalese young adults aged 18 to 25 years: a crosssectional study jlmc.edu.np negatively correlated with bmi (r=-0.587, p<0.001) i.e. decrease in spo2 is associated with increasing bmi. however, the spo2 values were within normal range for all the participants. the mean 6mwd was 584.43±23.71 m for male participants and 469.85±30.38 m for female participants. the females walked significantly shorter distance than the males [t(104) =12.730,p<0.001]. (table 1) pearson’s correlation matrix showed that 6mwd was positively correlated with age (r=0.248, p=0.010), height (r=0.852, p<0.001), weight (r=0.629, p<0.001), and bmi (r=0.265,p=0.006) in the overall analysis of the participants (table2). 1 shows the relationship between the 6mwd and height in the combined group. weight and bmi did not have significant contribution to 6mwd. the regression equation for 6mwd (cm) when sex (male=1, female=2) and height (cm) are known is: 6mwd = 204.043 -77.652 x sex + 2.678 x height (standard error of estimate = 22.903) variables males (mean ± sd) females (mean ± sd) statistics age (years) 22 ± 1.37 21.32 ± 0.73 t (104) = 3.18, p = 0.002 height (cm) 171.06 ± 5.25 157.26 ± 5.89 t (104) = 12.73, p<0.001 weight (kg) 69.40 ± 11.64 54.36 ± 9.12 t (104) = 7.39, p<0.001 bmi (kg/m2) 23.61 ± 2.90 21.95 ± 3.54 t (104) = 2.64, p = 0.010 spo2 before exercise (%) 97.98 ± 0.31 98.08 ± 0.58 t (104) = 1.04, p = 0.301 spo2 after exercise (%) 95.68 ± 0.87 95.96 ± 0.85 t (104) = 1.69, p = 0.094 pulse rate before 6mwt (bpm) 83.15 ± 9.52 83.81 ± 7.82 t (104) = 1.04, p = 0.301 pulse rate after 6mwt (bpm) 121.74 ± 17.14 121.87 ± 8.66 t (104) = 1.688, p = 0.094 modified borg score 0.72 ± 0.30 0.62 ± 0.32 t (104) = 1.55, p = 0.124 6mwd (m) 584.43 ± 23.71 469.85 ± 30.38 t (104) = 21.64, p<0.001 table 1: characteristics of the study participants (n=106) table 2: correlation of 6mwd with different parameters in combined participants. parameters pearson’s correlation with 6mwd p value age 0.248 0.010 height 0.852 <0.001 weight 0.629 <0.001 bmi 0.265 0.006 to analyze if the predictor variables were independently related to 6mwd, variables showing overall significant correlation were considered for stepwise regression analysis (table 3). stepwise regression analysis gave the model with sex and height that predicted 6mwd statistically significantly [f(2,103)= 353.774, p<0.001] with an r2(coefficient of determination) of 0.873. figure fig 1: relationship of 6mwd after 6mwt and height discussion the aims of this study were to determine the correlation of spo2 with bmi, and also to determine 6mwd, to establish prediction equation for 6mwd in apparently healthy young adults aged 18-25 years. the present study showed a significant j. lumbini. med. coll. vol 8, no 1, jan-june 2020 chaudhary s, et al. chaudhary s, et al. six-minute walk test in healthy nepalese young adults aged 18 to 25 years: a crosssectional studysix-minute walk test in healthy nepalese young adults aged 18 to 25 years: a crosssectional study jlmc.edu.np decrease in spo2 after 6mwt with increasing bmi. lower spo2 observed in the obese participants may be related to an imbalance in the ventilation/perfusion (v/q) ratio during the exercise test. during exercise, cardiac output increases and increased cardiac output is not accompanied by increased ventilation, leads to decrease in (v/q) ratio in obese participants. the result is decrease in oxygen saturation.[18] pulmonary function decreases in obesity which may be due to the added mechanical load of adipose tissue that reduces chest wall compliance and impedes diaphragm descent.[10] in our study the magnitude of correlation with spo2 after 6mwt and bmi was r = -0.587.the correlation was statistically significant (p<0.001) though, the spo2 values were still within normal range. this result is consistent with the previously published studies (r = -0.27, r = -0.81, p<0.001). [10,19]similarly faria ag et al.[18] and anupama n et al.[20] had found lower oxygen saturation with increased bmi. another study done by zou h et al.[21] found a significant difference between oxygen saturation before and after the test both in males and females. whereas in one study by ahmed yb et al.[22] there was no significant correlation between spo2 and bmi. this difference may be explained by difference in the measurement of resting oxygen saturation. the author did not take the oxygen saturation after exercise. there was a significant difference in the distance walked between male and female groups in our study. the male group walked a greater distance than the female group possibly because the males were taller and had higher levels of physical activity and a greater muscle mass. these results are consistent with the previous studies.[3,4,21] the result of this study showed negative correlation between the 6mwd and sex and positive correlation with height, weight and bmi. in the previous studies the results showed negative correlation of the 6mwd with weight and bmi which may be due to the fact that severe obesity rises the workload for a given exercise intensity, reducing the 6mwd.[11] these studies also showed positive correlation between 6mwd and height.[3,4,21] the contrast correlation of 6mwd with weight and bmi may be due to the fact that in our study the participants did not have severe obesity and those with higher bmi or weight also had greater height (evaluated with scatter plot). the significant effect of height on the 6mwd was attributed to a longer stride in the taller individuals. the stride length is one of the foremost determinants of gait velocity.[23] moreover, physical activity level was a predictor factor for 6mwd.[6] the major determinants of 6mwd in the overall analysis were sex followed by height. the forward stepwise multiple linear regression showed only sex and height were independent predictors explaining 87.3% of the variance in distance for combined group (coefficient of determination r2=0.873) as shown in table 3. these finding are comparable with previously published results (r2=0.587, r2=0.62, r2= 20-78%).[6,13,14] there are some limitations to our study. we did not recruit individuals who were older than 25 years of age. our reference equation may not be applicable to the population beyond this age. in this study the subjects were medical students and many of them did not have severe obesity. we used convenience sample rather than a random sample which may not be representative of a wider nepalese population. conclusion: although there was moderate negative statistically significant correlation between bmi and spo2 after 6mwt in young adults in the study, spo2 values were still within normal range. sex and height were the most significant predictors of the 6mwd and the regression equation explained 87.3% of the variance in the distance for both sexes of same age. conflict of interest: the authors declares that no competing interests exist source of fund: no funds were available. table 3: stepwise regression analysis of predictors of 6mwd in combined participants. model unstandardized coefficient(b) standard error (se) r r2 standard error of estimate (see) p value constant 204.043 74.763 0.934 0.873 22.903 0.007 sex -77.652 7.116 <0.001 height 2.678 0.403 <0.001 r2 = coefficient of determination j. lumbini. med. coll. vol 8, no 1, jan-june 2020 chaudhary s, et al. chaudhary s, et al. six-minute walk test in healthy nepalese young adults aged 18 to 25 years: a crosssectional studysix-minute walk test in healthy nepalese young adults aged 18 to 25 years: a crosssectional study jlmc.edu.np references: 1. singh sj, puhan ma, andrianopoulos v, hernandes na, mitchell ke, hill cj, et al. an official systematic review of the european respiratory society/american thoracic society: measurement properties of field walking tests in chronic respiratory disease. european respiratory journal. 2014;44:1447-78. available from: https:// erj.ersjournals.com/content/erj/44/6/1447.full. pdf 2. holland ae, spruit ma, troosters t, puhan ma, pepin v, saey d, et al. an official european respiratory society/american thoracic society technical standard: field walking tests in chronic respiratory disease. eur respir j. 2014;44(6):1428-1446. pmid: 25359355. doi: https://doi.org/10.1183/09031936.00150314 3. ajiboye oa, anigbogu cn, ajuluchukwu jn, jaja si. prediction equations for 6-minute walk distance in apparently healthy nigerians. hong kong physiotherapy journal. 2014;32(2):65–72. doi: https://doi.org/10.1016/j.hkpj.2014.04.003 4. fernandes l, mesquita am, vadala r, dias a. reference equation for six minute walk test in healthy western india population. j clin diagn res. 2016;10(5):cc014. pmid: 27437206. doi: https://dx.doi. org/10.7860/2fjcdr/2f2016/2f17643.7714 5. zou h, zhang j, chen x, wang y, lin w, lin j, et al. reference equations for the six-minute walk distance in the 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https://doi.org/10.4046/trd.2014.76.6.269 13. britto rr, probst vs, de andrade af, samora gar, hernandes na, marinho pem, et al. reference equations for the six-minute walk distance based on a brazilian multicenter study. braz j phys ther. 2013;17(6):556–63. pmid: 24271092. doi: https://doi.org/10.1590/s141335552012005000122 14. joobeur s, rouatbi s, latiri i, sfaxi r, ben saad h. influencing factors of the 6-min walk distance in adult arab populations: a literature review. tunis med. 2016;94(5):339–348. pmid: 27801484. 15. hulley sb, cummings sr, browner ws, grady dg, newman tb. estimating sample size and j. lumbini. med. coll. vol 8, no 1, jan-june 2020 chaudhary s, et al. chaudhary s, et al. six-minute walk test in healthy nepalese young adults aged 18 to 25 years: a crosssectional studysix-minute walk test in healthy nepalese young adults aged 18 to 25 years: a crosssectional study jlmc.edu.np power: applications and examples. in designing clinical research, 4rth ed. philadelphia, 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age and gait: a populationbased study of older adults. j gerontol a biol sci med sci. 2008;63(2):165–70. pmid: 18314452. doi: https://doi.org/10.1093/gerona/63.2.165 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 11 november, 2019 accepted: 13 may, 2020 published: 25 may, 2020 a lecturer, department of nursing b lumbini medical college teaching hospital, palpa, nepal. corresponding author: srishti bajracharya e-mail: srishti.bajracharya@gmail.com orcid: https://orcid.org/0000-0002-7070-8851 _______________________________________________________ —–————————————————————————————————————————————— abstract introduction: adolescent girls face different physical conversions, sexual changes and psychological pressures associated with growth and maturity, menstruation being one of them. menstruation is still clouded by taboos and socio-cultural restrictions resulting in ignorance of scientific facts and hygienic health practices. since response to menstruation depends upon awareness and knowledge about issues, menstrual hygiene education has shown to be effective in improving health by developing good knowledge, attitude and practice among adolescent girls. methods: an analytical study with one group pretest – posttest design was carried out to assess the effectiveness of structured teaching program on menstrual hygiene among 100 adolescent school girls studying in a public school in palpa. pretested semi structured questionnaire was used to assess knowledge and practice whereas valid maq (menstrual attitude questionnaire) was used for attitude. this was followed by structured teaching program consisting of information on menstruation, myths and hygiene. then a posttest was conducted after a week to the same respondents. results: the study resulted in statistically significant improvements (p<0.001) in total knowledge (63% to 66%), attitude (47% to 63%) and practice (43% to 49%) after implementation of the structured teaching program. there was positive correlation between knowledge and attitude scores (r=0.023), attitude and practice scores (r=0.026) and knowledge and practice scores (r=0.183). conclusion: the structured teaching program is effective in improving knowledge, attitude and practice on menstrual hygiene among adolescent school girls. thus, adding menstrual hygiene as part of curriculum may break the culture of silence. keywords: attitude, health education, knowledge, menstrual hygiene, practice original researcharticlehttps://doi.org/10.22502/jlmc.v8i1.305 srishti bajracharya,a,b pratibha bam,a,b priyanka bajracharyaa,b effectiveness of structured teaching program on menstrual hygiene among adolescent school girls how to cite this article:how to cite this article: bajracharya s, bam p, bajracharya p. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. journal of lumbini medical college. 2020;8(1):7 pages doi: . journal of lumbini medical college. 2020;8(1):7 pages doi: https://doi.org/10.22502/jlmc.v8i1.305. epub: 2020 may 25.https://doi.org/10.22502/jlmc.v8i1.305. epub: 2020 may 25. introduction: menstruation is a natural and physiological process occurring in girls at first between the ages of 13 and 15 years during adolescent period.[1] it is a monthly bleeding for two to seven days every 28 to 35 days from puberty till menopause.[2] a woman spends approximately six years of her life menstruating which can potentially decide how healthy her life will be.[1] adolescence is a period of transition from childhood to adulthood where changes in the pattern of thinking, attitude, moral standards and abilities take place and proper development could have a positive impact on health and quality of life.[3] this can be greatly influenced by peers, educators and parents.[4] however, most of the school going adolescent girls are unaware of the fundamental facts about menstruation and very little attention is paid to the proper management of hygiene by international health and development practitioners in most countries of the world.[2] j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . jlmc.edu.np adolescents account for nearly a quarter of nepal's population (approximately 6.4 million). every day, an estimated 290,000 women and adolescent girls in nepal menstruate.[1,2] menstruation is stigmatized and constraints during menstruation are common with lack of access to affordable materials and sanitation facilities at home and school.[5] the consequence is that many girls grow up with low self-esteem and disempowerment from poor educational attainments leading to lots of inconvenience.[6] few studies on menstrual hygiene in nepal show inadequate knowledge, attitude and practice in more than half of adolescent girls.[7,8,9] a variety of methods like lectures, discussions, demonstrations with multiple audio-visual aids and resources like menstrual cups, sanitary pads and washing soaps haves reported a positive impact on the awareness and menstrual practices of girls and less initiation of high risk and unhygienic behavior [10] thus, this study was done with the objective to find out the knowledge, attitude and practice regarding menstrual hygiene among adolescent school girls assuming significant improvement through structured teaching program. methods: this analytical study with one group pretest – posttest design was conducted among the students of classes eight and nine in a public school in palpa, nepal for a period of three weeks from 25th july to 15th august, 2019. ethical clearance was obtained from institutional review committee of lumbini medical college teaching hospital (irc-lmc 03g/019) and the official permission for the study was taken from the principal of the school. out of total 122 students from classes eight and nine, 111 students fulfilling the inclusion criteria were enrolled in the study. adolescent girls who had attained menarche, were willing to participate and present at the time of data collection were included in the study. whereas, absenteeism and denial for consent and those included in the pretesting of questionnaires were excluded. the data was collected by self-administered pretested questionnaire before and after the intervention of structured teaching program. content validity of the tool was done by the subject experts. forward and backward translation was done by language expert. eligible respondents were listed and given a serial number. pretesting was done in nepali language on 10 % of total samples, i.e. 11 to assess any constraints and to identify approximate time taken for completing the self-administered questionnaire. reliability of the tool was found 0.961 through cronbach's alpha using statistical package for the social sciences spsstm version 16. without any modification on the pretested tool, the data was collected from 100 respondents using non-probability convenient sampling technique. pretest was conducted followed by intervention of structured teaching program for an hour in each class consisting of information on menstruation, myths and menstrual hygiene. audio visual aids such as black board, slides, chart papers, metacards, and methods such as lecture, discussion and demonstration were used. teaching program was conducted by the same person in both the classes. the researcher herself with the help of coauthors collected the data from class eight and nine respectively in a given time. proper introduction of self and purpose of study was explained to the respondents. informed consent was taken from the parents of the girls before commencement of the study. pretest data was collected using the pretested questionnaire. each respondent was given about half an hour for completing the questionnaire followed by a structured teaching program on menstrual hygiene for around an hour. posttest was conducted after a week to the same respondents. tool: the tool consisted of four parts: part 1: bio-demographic information including symptoms of premenstrual syndrome (pms) defined by the respondent’s experiences of any discomfort or symptoms few days before menstruation. part 2: knowledge related questions (20 questions) part 3: attitude related questions: a valid tool menstrual attitude questionnaire (maq) consisting 33, 7-point likert scale statements was used to assess the attitude on menstrual hygiene. [11,12] part 4: practice related questions (30 questions) statistical analysis: j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . jlmc.edu.np the collected data was kept for coding and editing for analysis. data was processed using spss version 16. data analysis was done using descriptive and inferential statistics and expressed as frequency, percentage, mean, minimum, maximum, standard deviation (s.d) and standard error. inferential statistics like paired ‘t’ test was included to test the hypothesis for effectiveness of structured teaching program and correlation was used to assess the strength and direction of relationship between variables. scoring system: for knowledge and practice questions, each right answer was given 1 mark and the wrong answer was given 0. for attitude related 7 point likert scale questions, out of 33 statements, 11 negative statements were reverse scored. equal and above mean score was considered as adequate knowledge and practice with good attitude whereas low mean score was considered as inadequate knowledge and practice with poor attitude. results: a total of 100 girls from classes eight and nine were enrolled into the study. the mean age ±sd was 14.45±1.23 years with a range of 12-17 years. the mean age ±sd of menarche was 12.59±1.17 years with a range of 11-19 years. the mean length of cycle ±sd was 1.06±0.239 days. table 1 shows the menstrual parameters of the respondents. the pretest and posttest scores of knowledge, attitude and practice regarding menstrual hygiene are shown in table 2. this shows the minimum and maximum scores were increased in posttest as compared to the pretest. the effectiveness of structured teaching program of pretest and posttest knowledge, attitude & practice scores regarding menstrual hygiene was analyzed with paired t test (table 2). the difference in means for knowledge, attitude and practice were statistically significant (t=12.684, df=99, p-value <0.001), (t=9.913, df=99, p-value <0.001) and (t=11.547, df=99, p-value <0.001) respectively. therefore, we rejected the null hypothesis and concluded that giving teaching program on menstrual hygiene was effective. table 1. findings related to menstrual pattern (n=100) variables frequency (%) heard about menstruation if yes: source of information* yes 100 (100) mother 85 (88.50) sister 25 (26.00) friends 28 (29.20) relatives 5 (5.20) teachers 28 (29.20) books 22 (22.90) presence of pms yes 75 (75) no 25 (25) reaction to first menstruation indifferent 17 (17) scared 36 36) discomfort 47 (47) problems associated with menstruation yes 82 (82) no 18 (18) if yes, what is the problem?* pain abdomen 50 (72.50) backache 20 (29) headache 13 (18.80) chest pain 6 (8.70) nausea 7 (10.10) *multiple response table 2: knowledge, attitude and practice regarding menstrual hygiene (n=100) variables min score max score mean ±sd 95% ci of the difference statistics knowledge pretest 10 26 19.84 ±3.29 4.18-5.74 t=12.684, df=99, p=<0.001post test 16 30 24.80 ±2.37 attitude pretest 59 176 118.47 ±25.67 23.30-34.96 t=9.913, df=99, p=<0.001post test 100 192 147.60 ±18.12 practice pretest 2 19 14.13 ±2.28 2.63-3.72 t=11.547, df=99, p=<0.001post test 12 20 17.30 ±1.63 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . jlmc.edu.np table 3 depicts the level of pretest and posttest score of knowledge, attitude and practice. this shows more subjects had increased knowledge with good attitude and practice in posttest. table 3. comparison of level of pretest and posttest (n=100) variables level pretest posttest knowledge adequate 63 66 inadequate 37 34 attitude good 47 66 poor 53 34 practice adequate 43 49 inadequate 57 51 on analysis by pearson correlation, there was negligible positive correlation between the knowledge and attitude scores (r=0.023, p=0.822), attitude and practice scores (r=0.026, p=0.797) and knowledge and practice scores (r=0.183, p=0.068) though it was not proved significantly. figure 1: correlation between knowledge and practice (n=100) figure 1 shows the scatter plot for the correlation between knowledge and practice. thus, we can conclude that increment in knowledge could slightly improve attitude and practice. similarly, increment in attitude slightly improved practice. discussion: in this study, 30% of the students were 14 years with mean age of 14.15±1.23 years which is in accordance to another study.[6] this study showed more than half (64%) studied in class nine. the same result was displayed in another study.[13] almost all (96%) followed hindu religion, supported by the study which showed similar results.[14] this study revealed majority of the respondent’s parents were farmers in contrast to the study which revealed they were self-employed.[15] twenty six percent of the respondents had female siblings where more than half of the respondents (62%) were the first child of their parents. this finding was consistent with the study of vandana et al. where almost half (48%) were first in their birth order.[16] this study showed that all girls had heard about menstruation similar to the study conducted by fehintola et al. (96%).[17] half of the respondents gained information from their mother supported by the studies which showed their mother as a main informant source.[6,14] majority (43%) of the respondents attained menarche at the age of 12 years with mean ±sd of 12.59±1.17years. similar result was shown in another study.[18] most of the respondents had regular pattern of menstruation similar to a study where 90% of the respondents had their menstrual cycle length of 21 to 35 years of age. [6] majority of the respondents (94%) had normal duration of menstrual flow of 2-7 days congruent to the study which revealed more than fifty percent of the girls had normal duration of menstrual flow.[19]our study showed three quarters of the respondents experienced pms resembled by the study of fehintola et al.[17] it was observed that almost half of the respondents (47%) felt discomfort during their first menses contrary to the study where girls were scared and depressed.[17]this study demonstrated that 82% of the respondents faced problems during menstruation and stomachache (54%) was the commonest problem among all. the findings are similar to the study which revealed 82% of the respondents had crampy lower abdominal pain.[6] this study showed statistically significant difference between the pre-test and post test scores of knowledge, attitude and practice regarding menstrual hygiene. similar result was shown in another study.[20] the level of knowledge, attitude and practice regarding menstrual hygiene of respondents who participated in educational program was significantly better in our study alike j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . jlmc.edu.np study conducted by other authors.[7] it was found that most of the subjects had inadequate knowledge (37%) and average attitude (53%) and practice (57%) during pre-test. but, after structured teaching program session, most of the respondents had better knowledge (66%), attitude (66%) and practice (49%) in post-test with high significance (p=<0.001) this implies that in our study, structured teaching program was effective to improve the knowledge, attitude and practice of adolescent girls regarding menstrual hygiene which is coherent to the studies that showed the similar results.[3,10,21] a review of literature shows an increase in knowledge does not always cause behavior to change. but this study has shown that it is extremely necessary in changing some health behaviors and shape attitude with the practice which can be obtained through correct form of teaching programs. the present study showed there was weak positive correlation between knowledge and attitude scores (r=0.023), attitude and practice scores (r=0.026) and knowledge and practice scores (r=0.183) which was consistent with the study findings of another study.[22] the study has a few limitations to be considered. although data were prospectively collected, they may not be generalized. a comparative study could be conducted between private and public schools with more respondents. conclusion: the findings of the study illustrated that roughly half of the adolescent girls have good knowledge, attitude and practice on menstrual hygiene among adolescent girls, which indicates that there is still a lack. thus, designing and implementing health educational programs about menstrual hygiene and correction of misconceptions among adolescent girls are necessities. conflict of interest: the authors declares that no competing interests exist source of fund: no funds were available. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . jlmc.edu.np references: 1. ameade ep, garti ha. relationship between female university students’ knowledge on menstruation and their menstrual hygiene practices: a study in tamale, ghana. adv prev med. 2016;2016(article id:1056235):110. pmid:27525125. doi: https://doi. org/10.1155/2016/1056235 2. pokhrel s, mahantashetti n, angolkar m, devkota n. impact of health education on knowledge, attitude and practice regarding menstrual hygiene among pre university female students of a college located in urban area of belgaum. iosr journal of nursing and health science. 2014;3(4):38–44. available from: https://www.iosrjournals.org/iosr-jnhs/ papers/vol3-issue4/version-1/i03413844.pdf 3. alam m-u, luby sp, halder ak, islam k, opel a, shoab ak, et al. menstrual hygiene management among bangladeshi adolescent schoolgirls and risk factors affecting school absence: results from a cross-sectional survey. bmj open. 2017;7(7):e015508. doi: http:// dx.doi.org/10.1136/bmjopen-2016-015508 4. el-mowafy ri, moussa mmm, el-ezaby hh. effect of health education program on knowledge and practices about menstrual hygiene among adolescents girls at orphanage home. iosr journal of nursing and health science. 2014;3(6):48–55. available from: http://iosrjournals.org/iosr-jnhs/papers/vol3issue6/version1/j03614855.pdf 5. kuhlmann as, henry k, wall ll. menstrual hygiene management in resource-poor countries. obstet gynecol surv. 2017;72(6):35676. pmid: 28661550. doi: https://doi. org/10.1097/ogx.0000000000000443 6. kapoor a, khari s. knowledge, attitude and socio-cultural beliefs of adolescent girls towards 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https://doi.org/10.1111/j.1440172x.2012.02032.x 14. parajuli p, paudel n, shrestha s. knowledge and practices regarding menstrual hygiene among adolescent girls of rural nepal. journal j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . jlmc.edu.np of kathmandu medical college. 2017;5(1):23-7. doi: https://doi.org/10.3126/jkmc.v5i1.18262. 15. anusree pc, ardra r, aswathy bs, faseela vcm, gincy pb, anupama t. knowledge regarding menstrual hygiene among adolescent girls in selected schools, mangalore with a view to develop an information booklet. iosr journal of nursing and health science. 2014;3(1):55–60. available from: http://www. iosrjournals.org/iosr-jnhs/papers/vol3-issue1/ version-4/j03145560.pdf 16. vandana v, simarjeet k, amandeep k. assessment of knowledge of adolescent school going girls regarding menstruation and menstrual hygiene. 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of shimla, himachal pradesh. chrismed journal of health and research. 2017;4(2):99-103. available from: http://www. cjhr.org/text.asp?2017/4/2/99/201983 88 lamichhane a et al. correlation between c reactive protein and blood culture in neonatal sepsis at a tertiary care centre in western nepal j. lumbini. med. coll. vol 7, no 2, july-dec 2019 original research articlehttps://doi.org/10.22502/jlmc.v7i2.286 —–——————————————————————————————————————————— abstract: introduction: neonatal sepsis is a serious problem which needs to be addressed for a better outcome of the neonates. this study was conducted to determine the sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of c-reactive protein (crp) in neonates with sepsis in comparison with blood culture. methods: this cross-sectional study was carried out in clinically suspected neonates with sepsis in a tertiary hospital. association between c-reactive protein and blood culture positivity in neonatal sepsis was studied. results: out of 245 patients admitted with clinical suspicion of sepsis, 104 (42.45%, 95% ci: 36.18-48.90%) were blood culture proven sepsis. crp was reactive in 92 cases (88.5%, 95% ci: 80.71 % 93.89%) of blood culture proven sepsis. gram negative organisms were predominant, 58 (57.55%) seen from the isolates of blood culture while gram positive organisms were found to be 46 (43.23%). early onset sepsis was seen in 194 (79.18%) cases, while late onset sepsis accounted for 51(20.82%).the sensitivity and specificity of crp in the diagnosis of neonatal sepsis was 88.5% and 46.1% respectively with positive predictive value of 54.8% and negative predictive value of 84.1% and diagnostic accuracy of 64.1%. conclusion: neonatal sepsis is still an important cause of hospital admission in the neonatal intensive care unit of our hospital. this study highlights the high sensitivity and negative predictive value but lower specificity and positive predictive value of crp in relation to blood culture. the present study depicts a significant correlation between culture positivity and crp. keywords: blood culture, c reactive protein, neonatal intensive care unit, neonatal sepsis correlation between c reactive protein and blood culture in neonatal sepsis at a tertiary care centre in western nepal anita lamichhanea,b aparna mishraa,b introduction after prematurity and intra-partum complications, neonatal sepsis is the third leading cause of neonatal mortality, accounting for 42% of early and 13% of overall neonatal mortality.[1] a nepalese study has reported the prevalence of neonatal sepsis to be 20.3%.[2] diagnosing neonatal sepsis can become challenging as it resembles other conditions like congenital pneumonia, meconium aspiration syndrome, congestive heart failure and respiratory distress syndrome. despite being gold standard method to diagnose neonatal sepsis, blood culture is time consuming, requires well equipped laboratory and above all large amount of blood needs to be drawn from neonates.[3] the yield of blood culture is between 30-70%, hence some neonates go undetected. c-reactive protein (crp) is a helpful marker for the diagnosis of sepsis used in addition to blood culture.[4] various studies have shown that raised crp has high sensitivity, specificity, positive and negative predictive values for neonatal sepsis. [5,6] this study was conducted to determine the sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of crp in neonates with sepsis in comparison with blood culture. it also aimed to study the association of crp with blood culture results in the evaluation of neonatal sepsis. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. _____________________________________________________________________________ submitted: 03 june, 2019. accepted: 02 september, 2019. published: 17 november, 2019. a lecturer, department of pediatrics b lumbini medical college and teaching hospital, palpa, nepal. corresponding author: anita lamichhane e-mail: anitalamee@gmail.com orcid:https://orcid.org/0000-0002-5279-9956___________________________________________________ how to cite this article: lamichhane a, mishra a. correlation between c reactive protein and blood culture in neonatal sepsis at a tertiary care centre in western nepal. journal of lumbini medical college. 2019;7(2):8892. doi: https://doi.org/10.22502/jlmc.v7i2.286 epub: 2019 november 17. lamichhane a et al. correlation between c reactive protein and blood culture in neonatal sepsis at a tertiary care centre in western nepal jlmc.edu.npj. lumbini. med. coll. vol 7, no 2, july-dec 2019 89 methods: this observational, cross-sectional study was conducted in the neonatal intensive care unit (nicu) and special care baby unit (scbu) of lumbini medical college and teaching hospital (lmcth), nepal. data collection was done for a period of one month from 15 april 2019 to 15 may 2019. during this period, the files of all the neonates admitted to nicu and scbu from march 2017 to february 2019 with the diagnosis of neonatal sepsis were revisited from the record section. ethical approval was taken from the institutional review committee (irc-lmc014-a/019). all the outborn and inborn neonates, admitted to the nicu and scbu during the study period with suspected neonatal sepsis and weighing > 1500 grams were included in the study. neonates who had undergone recent surgical interventions (< two weeks) and those with congenital anomalies rendering them easily susceptible to infections such as cystic fibrosis, down’s syndrome, tracheoesophageal fistula etc. were excluded. data on all the relevant investigation reports like complete blood count, crp, peripheral blood smear, chest x-ray and blood cultures were noted. obstetric risk factors and/or clinical features of sepsis such as apnoea, respiratory distress, feeding intolerance and shock were noted. all the information including birth weight, gestational age at the time of delivery, sex, mode and place of delivery, clinical signs and symptoms, nicu stay, blood culture isolates, and outcome of the patients were retrieved from the manual search of case files from medical record department (mrd). sepsis was diagnosed based on clinical suspicion and laboratory values such as leucocytosis (>11,000 cells/mm3), leucopenia (<5000 cells/mm3), band cells and toxic granules in peripheral blood smear and positive crp (>10mg/dl) and positive blood culture.[7] neonates were classified as having early onset sepsis or late-onset sepsis according to age cut-off of 72 hours of life. taking the prevalence of 62%and sensitivity of 90.32% [8], the sample size was calculated using the formula n ≥ (z1α/2) 2 x sens (1-sens) d2 x prevalence where, z=1.96 at 95% confidence interval. p=prevalence, 62% d= margin of sampling error tolerated, 0.05 sens=sensitivity α = alpha (0.05) the minimum calculated sample size was 223.06. data were entered in an excel spreadsheet and analysed using statistical package for social sciences (spsstm) version 16. all the qualitative variables and level of crp were described by using mean ± standard deviation. the sensitivity, specificity, ppv and npv were calculated for crp in comparison to blood culture. the association between different variables and clinical outcome was examined using the pearson chi-square (x2) test. a p value < 0.05 was considered to be statistically significant. results: during the study period, a total of 547 neonates were admitted to the nicu and scbu. out of these, 245 neonates fulfilling the inclusion criteria were enrolled into the study. blood culture was positive in 104 neonates (42.45%, 95% ci: 36.1848.90%) and culture was negative in 141 (57.55%, 95% ci: 49.9-62.6%). most of the newborns presented with early onset sepsis (n=194, 79.18%), of which 69 (35.57%) cases were culture positive. there were no cases of polymicrobial sepsis, i.e. more than one organism isolated per episode. crp was reactive in 92 cases (88.5%, 95% ci: 80.71 % 93.89%) of blood culture proven sepsis. table 1. demographic parameters of the neonates enrolled in the study (n=245) variables frequency (%) sex male female 150 (61.22%) 95 (38.78%) place of delivery inborn outborn 171 (69.80%) 74 (30.20%) onset of sepsis early onset late onset 194 (79.18%) 51 (20.82%) mode of delivery normal delivery caesarean section instrumental delivery 164 (66.94%) 72 (29.39%) 9 (3.67%) risk factors for sepsis perinatal asphyxia meconium maternal fever prom* chorioamnionitis undetermined 36 (14.70%) 37 (15.10%) 27 (11.02%) 39 (15.92%) 06 (2.45%) 100 (40.81%) *prom: pre-labour rupture of membrane lamichhane a et al. correlation between c reactive protein and blood culture in neonatal sepsis at a tertiary care centre in western nepal jlmc.edu.npj. lumbini. med. coll. vol 7, no 2, july-dec 2019 90 table 1 presents the demographic details of the neonates. the mean weight of the neonates was 2.9±0.68 kg. the mean age at time of presentation was 3.79±6.04 days. gram negative organisms accounted for 58 (55.77%) cases of the culture proven sepsis, of which most were due to enterococcus and klebsiella. gram positive organisms isolated constituted 46 (44.23%) cases as shown in table 2. table 2. association of organisms with the onset of sepsis. organisms early onset sepsis (69 blood culture positive) late onset sepsis (35 blood culture positive) coagulase negative staphylococcus 12 (17.39 %) 7 (20%) staphylococcus aureus 9 (13.04 %) 10 (28.57%) alpha hemolytic streptococcus 5 (7.25%) 0 (0%) enterococcus 9 (13.04 %) 5 (14.29%) klebsiella 10 (14.49%) 4 (11.43%) pseudomonas 8 (11.60%) 3 (8.58%) acinobacter 8 (11.60%) 2 (5.71%) e. coli 5 (7.25%) 2 (5.71%) salmonella typhi 2 (2.89%) 0 (00%) staphylococcus epidermidis 1 (1.45%) 2 (5.71%) table 3 shows the association of crp with the blood culture results of the study population. there is a statistically significant association between crp reactivity and growth in blood culture, with a p value of <0.001(x2 =33.173, df=1) (table 3). table 3. association between crp and blood culture status (n=245) crp blood culture (n, %) p value growth no growth reactive 92 (54.76%) 76 (45.27%) p<0.001 nonreactive 12 (15.6%) 65 (84.4%) in this study, crp showed 88.5% sensitivity, 46.1% specificity, 54.8% ppv, 84.4% npv and diagnostic accuracy of 64.1% for diagnosis of culture positive neonatal sepsis. discussion: neonatal sepsis constitutes one of the important causes of nicu admissions. the gold standard for diagnosis, blood culture is costly and preliminary results are delayed. this study was done to compare and evaluate crp with blood culture results. the proportion of blood culture proven sepsis in our study (42.45%) was comparable to the study done by thakur et al. (42%) and rawat a et al.[8,9] other studies have reported similar prevalence. [10,11] in contrast, a study done by galhotra et al. [12] showed a prevalence of only 7.7%. this might be due to highly sensitive bacteria which responded to the antibiotics. other studies from nepal showed a prevalence of 32% and 48%.[13] this high prevalence which is similar to our results may be due to the increasing trend of antibiotic resistance. early onset sepsis accounted for 79.18% of the neonatal sepsis in this study. this is in agreement to a study by thapa b et al. which showed a prevalence of 91.4%.[14] the male preponderance (61.2%) in our study may be linked to the x-linked immunoregulatory gene factor which contributes to the host’s susceptibility to infections in male.[15] this can be compared to another study conducted at kanti children hospital in nepal in which males (69%) were more affected than females (31%).[15] chorioamnionitis was present in 5(4.85%) of culture proven sepsis in this study which is higher than that reported by radis et al. (0.7%).[16] this high incidence in our study may be due to the high rate of maternal fever (11.02%). our study revealed predominant bacterial isolates to be gram negative organisms (57.77%), which is similar to a study done by mendozapalomar n et al.[17] some other studies, on the other hand, showed a predominance of gram positive organisms from the bacterial isolates.[18] this may be due to the fact that the bacteria causing neonatal sepsis continue to change with place and time.[19] in this study, perinatal asphyxia, meconium stained amniotic fluid, maternal fever and prelabour rupture of membranes were the common risk factors associated with neonatal sepsis. this is in concordance to other studies which may be attributed to the immature immune system.[20] we found 88.5% sensitivity and 46.1% specificity of crp in relation to blood culture positivity. these results are comparable to a study done by bhatia et al. which showed 81.25% sensitivity and 42.86% specificity.[10] el-sonbaty et al. showed a sensitivity of 91%.[21] several studies have reported that the sensitivity of crp for lamichhane a et al. correlation between c reactive protein and blood culture in neonatal sepsis at a tertiary care centre in western nepal jlmc.edu.npj. lumbini. med. coll. vol 7, no 2, july-dec 2019 91 identifying neonatal infection ranges from 63% to 95%, and specificity from 40% to 97%.[5,22] our study showed that there is association between crp reactivity and culture positivity. crp was elevated in 88.5% of cases which is similar to a study done by lim et al.[23] which showed reactive crp in 84.2% of blood culture positive cases. hisamuddin et al. found only 76.92% sensitivity and 53.49% specificity of crp in ruling out sepsis. [5] saeed et al. also found similar results about crp sensitivity and specificity.[24] in our study, ppv and npv for crp were 54.8% and 84.4% respectively which is similar to a study by saboohi et al. which showed 91.3% npv. [25] there were certain limitations of our study. in case of outborn neonates, there was paucity of information regarding the mode of delivery, rupture of membranes, maternal infection or illness in the peripartum period available. lack of standardization also contributed to as one of the limiting factors. conclusion: neonatal sepsis is an important indication of admission to the neonatal intensive care unit of our hospital. a high index of suspicion is required for its diagnosis especially in the presence of risk factors and non-specific clinical features.there was predominance of gram negative organisms from the bacterial isolates in our study. this study highlighted the high sensitivity and negative predictive value but lower specificity and positive predictive value of crp in relation to blood culture. crp can therefore be employed as a good test for screening of neonatal sepsis. conflict of interest: the authors declare that no competing interest exits. source of funds: no funds were available. acknowledgement: mr. umesh dhakal, medical records department. mr. ram kishore yadav, department of microbiology. references: 1. zea-vera a, ochoa tj. challenges in the diagnosis and management of neonatal sepsis. journal of tropical pediatrics. 2015;61(1):1-13. doi:https://doi.org/10.1093/tropej/fmu079 2. khanal r, manandhar s, acharya gp. bacteriological profile of neonatal sepsis in a tertiary level hospital of nepal. journal of nepal paediatric society. 2014;34(3):175-180. doi: https://doi.org/10.3126/jnps.v34i3.9183 3. kumar b. evaluation of serum c-reactive protein in diagnosis and prognosis of neonatal septicemia. webmed central pediatrics.2013;4(7):wmc001643. available from: http://www.webmedcentral.com/article_ view/1643 4. sugimoto k, adomi s, koike h, esa a. procalcitonin as an indicator of urosepsis. research and reports in urology. 2013;26(5):7780. doi: https://doi.org/10.2147/rru.s42711 pmid: 24400237. 5. hisamuddin e, hisam a, wahid s, raza g. validity of c-reactive protein (crp) for diagnosis of neonatal sepsis. pakistan journal of medical sciences. 2015;31(3):527–31. doi: https://doi.org/10.12669/pjms.313.6668 pmid: 26150837 6. trivedi r, amer a, patel r, trivedi p. comparison of a rapid semi-quantitative latex agglutination slide method against quantitative particle enhanced turbidimetric immunoassay for measurement of c-reactiveprotein. international journal of medical and biomedical sciences. 2019;3(5):190-95. doi: https://doi. org/10.32553/ijmbs.v3i5.265 7. kleigman r, stanton b, st.geme j, schor n, behrman r, nelson w. nelson textbook of pediatrics. philadelphia: elsevier; 2016.p.517 8. thakur s, thakur k, sood a, chaudhary s. bacteriological profile and antibiotic sensitivity pattern of neonatal septicemia in a rural tertiary care hospital in north india. indian journal of medical microbiology. 2016;34(1):67-71. doi: https://doi.org/10.4103/0255-0857.174108 pmid: 26776121 9. rawat a, shukla os. haemato-bacteriological profile and antibiogram of suspected cases of early onset sepsis in very low birth weight neonates. sri lanka journal of child health. 2019;48(1):59-64. doi: http://dx.doi. org/10.4038/sljch.v48i1.8654 10. bhatia, s, verma cr, tomar bs, natani bs, goyal p, agarwal a. correlation of crp and lamichhane a et al. correlation between c reactive protein and blood culture in neonatal sepsis at a tertiary care centre in western nepal jlmc.edu.npj. lumbini. med. coll. vol 7, no 2, july-dec 2019 92 blood culture in evaluation of neonatal sepsis. indian journal of basic and applied medical research. 2016;6(1):663-70. available from: https://bit.ly/37dauux 11. kumar r, deka a, choudhury sn, roy m. c-reactive protein—as an early diagnostic marker of early onset sepsis and its correlation with blood culture. the new indian journal of obgyn. 2016;2(2):78-82. available from: http://journal.barpetaogs.co.in/pdf/0278.pdf 12. galhotra s, gupta v, chhina d, bains hs, chhabra a. comparative utility of c reactive protein and blood culture for diagnosis of neonatal septicaemia. international journal of research and development in pharmacy and life science. 2017;6(2):2586-2589. doi: http://dx.doi.org/10.21276/ijrdpl 2278.0238 13. lakhey a, shakya h. role of sepsis screening in early diagnosis of neonatal sepsis. journal of pathology of nepal. 2017;7(1):1103-10. doi: https://doi.org/10.3126/jpn.v7i1.16944 14. mishra d, chapagain rh, bhattarai s, jha nk, mishra r. clinico-pathological profile of late onset neonatal sepsis in a tertiary centre of nepal. medical journal of shree birendra hospital. 2019;18(2):2-6. doi: https://doi. org/10.3126/mjsbh.v18i2.23517 15. chapagain rh, acharya r, shrestha n, giri br, bagale bb, kayastha m. bacteriological profile of neonatal sepsis in neonatal intermediate care unit of central paediatric referral hospital in nepal. journal of nepal health research council. 2015;13(3):205-8. doi: https://doi. org/10.33314/jnhrc.v0i0.673 16. randis tm, rice mm, myatt l, tita atn, leveno kj, reddy um et al. incidence of earlyonset sepsis in infants born to women with clinical chorioamnionitis. journal of perinatal medicine. 2018;46(8):926-33. doi: https://doi. org/10.1515/jpm-2017-0192 17. mendoza-palomar n, balasch-carulla m, gonzález-di lauro s, céspedes mc, andreu a, frick ma et al. escherichia coli early-onset sepsis: trends over two decades. european journal of pediatrics. 2017;176(9):1227-34. doi: https://doi.org/10.1007/s00431-0172975-z 18. shivanna v, sunkappa sr, venkatesha d. the rising trend of coagulase-negative staphylococci in neonatal septicemia. indian journal of pathology and microbiology. 2016;59(4):51012. available from: http://www.ijpmonline.org/ text.asp?2016/59/4/510/191806 19. roy i, jain a, kumar m, agarwal sk. bacteriology of neonatal septicaemia in a tertiary care hospital of northern india. indian j med microbiol. 2002;20(3):156-9. pmid: 17657057 20. afsharpaiman s, torkaman m, saburi a, farzaampur a, amirsalari s, kavehmanesh z. trends in incidence of neonatal sepsis and antibiotic susceptibility of causative agents in two neonatal intensive care units in tehran, i.r iran. journal of clinical neonatology. 2012;1(3):124-30. available from http://www. jcnonweb.com/text.asp?2012/1/3/124/101692 21. el-sonbaty m, al sharany w, youness er, mohamed na, abdel-hamid ta, abdel-razek ara. diagnostic utility of biomarkers in diagnosis of early stages of neonatal sepsis in neonatal intensive care unit in egypt. egyptian pediatric association gazette. 2016;64(2):91– 6. doi: https://doi.org/10.1016/j. epag.2016.01.002 22. brown jve, meader n, cleminson j, mc guire w. creactive protein for diagnosing late – onset infection in newborn infants. cochrane database of systematic reviews 2019;1:cd012126. doi: https://doi.org/10.1002/14651858.cd012126. pub2 23. lim wh, lien r, huang y-c, chiang mc, fu r-h, chu s-m, et al. prevalence and pathogen distribution of neonatal sepsis among verylow-birth-weight infants. pediatrics and neonatology. 2012;53(4):228–34. doi: https:// doi.org/10.1016/j.pedneo.2012.06.003 24. saeed t, zahoor-ul-haq m, subhani f, zulfiqar r, raja tm. c-reactive protein (crp) levels in early diagnosis of neonatal sepsis. journal of rawalpindi medical college. 2014;18(1):5860. available from: http://www.journalrmc. com/volumes/1405749935.pdf 25. saboohi e, saeed f, khan rn, khan ma. immature to total neutrophil ratio as an early indicator of early neonatal sepsis. pakistan journal of medical sciences. 2019;35(1):24146. doi: https://doi.org/10.12669/pjms.35.1.99 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 12 february, 2020 accepted: 24 may, 2020 published: 10 june, 2020 a lecturer, department of anatomy b lumbini medical college teaching hospital, palpa, nepal. corresponding author: chandan sintakala e-mail: csintakalachandan@gmail.com orcid: https://orcid.org/0000-0002-7440-760x _______________________________________________________ —–————————————————————————————————————————————— abstract introduction: dermatoglyphics is the science that deals with the study of dermal ridge patterns on the digits, palms and soles as a whole. the present study is based on fingerprints related with the dermatoglyphic patterns of digits of hands. apart from individual identification in institutions, it is also useful in forensic investigations to identify the criminals or dead bodies in accidental cases. this study aimed to find out the fingerprint patterns in right and left hands of undergraduate medical students. methods: the study was performed in 200 students (97 males and 103 females) from first and second years of mbbs and b.sc. nursing streams. the fingerprints were collected individually by pressing each of the finger tips on the stamp pad and then pressing it on a4 sized plain paper until the best finger print was observed. results: out of 2000 fingerprints, 1218(60.9%) were loops, 581 (29.05%) were whorls, 134(6.7%) were arches, and 67(3.35%) were composites. in males, there were 620 loops, 226 whorls, 98 arches and 26 composites whereas 602 loops, 351 whorls, 36 arches and 41 composites were found in females. conclusion:the loop patterns were more common than other fingerprint patterns. comparatively arches and loops were more common in males and whorls and composites in female. key words: arch, dermatoglyphics, fingerprint, loop, whorl original research articlehttps://doi.org/10.22502/jlmc.v8i1.315 chandan sintakala,a,b prabina manandhar,a,b niraj pandey a,b dermatoglyphic patterns among undergraduate students of a medical college: a descriptive cross-sectional study how to cite this article:how to cite this article: sintakala c, manandhar p, pandey n. dermatoglyphic patterns . dermatoglyphic patterns among undergraduate students of a medical college: a descriptive among undergraduate students of a medical college: a descriptive cross-sectional study. journal of lumbini medical college. cross-sectional study. journal of lumbini medical college. 2020;8(1):6 pages doi: 2020;8(1):6 pages doi: https://doi.org/10.22502/jlmc.v8i1.315 epub: 2020 june 10 .epub: 2020 june 10 . introduction: fingerprint is an important tool for identification of an individual which is not matched even between identical twins. it is an impression on the epidermis of the tips of each of the finger. its study is known as dactylography which is derived from greek words, “daktylos” meaning ‘finger’ and “graphein” meaning ‘to write’. it is also known as dactyloscopy or dermatoglyphics. [1] dermatoglyphics is defined as the science which deals with the study of dermal ridge configuration on the digits, palms and soles as a whole.the dermatoglyphic pattern appears as early as 1016 weeks of intra-uterine life.[2] dermatoglyphic pattern remains same throughout life. it is disturbed if the skin is damaged to a depth at least about 1mm. in addition to identification of individuals in institutions, it is also used in forensic investigations of crimes, gender identification of buried dead bodies and correlation of blood grouping.[3,4,5,6] various conditions as hypertension, obesity and diabetes have also been found to be associated with dermatoglyphic findings.[7,8,9] dermatoglyphics is also helpful in diagnosis of chromosomal disorders and genetic diseases.[10,11] the fingerprints have been classified into following patterns:[12] j. lumbini. med. coll. vol 8, no 1, jan-june 2020 sintakala c, et al. dermatoglyphic patterns among undergraduate students of a medical college: a descriptive cross-sectional study.. dermatoglyphic patterns among undergraduate students of a medical college: a descriptive cross-sectional study. jlmc.edu.np 1. arch 2. loop 3. whorl fingerprints can also be classified as follows:[10] 1. visible prints: visible to the naked eye. 2. latent prints: not seen by naked eye and visible by dusting, fuming or chemical reagents. 3. impressed prints or plastic prints: visible to the naked eye forming impression on clay, wax, paint etc. surfaces which take impression. even monozygotic twins developing from the same fertilized egg have distinctive fingerprints. the fingerprints are an indispensable tool for the identification and gender differentiation in the context of ever-increasing frequency of crimes.[13] this study aimed to evaluate the fingerprint patterns of right and left handsin a population of medical students. methods: this was an observational cross sectional study carried out in the department of anatomy, lumbini medical college and teaching hospital (lmcth) from 20 december, 2019 to 10 january, 2020. ethical clearance was obtained from the institutional review committee (irc-lmc: 01-j/019 ). a total of 200 undergraduate students from the first and second years of mbbs and b.sc. nursing were enrolled into the study. informed consents were taken from the participants. the fingerprints were collected following the procedure mentioned here. first step: each of the students was asked to rub his/her hands by towel and wash the hands if necessary. then he/she was asked to press a finger tip on a stamp pad and rub it firmly with all fingers; first on right hand then on left hand fingers. second step: they were asked to press the finger tip on a clear a4 size paper firmly so that their fingerprints were printed in the paper. third step: no name and address of the participants were taken so that the records remained anonymous. they were assured that their prints would not be misused and all the samples after study would be destroyed. fourth step: they were asked to give finger prints till a clear print was obtained in the given paper and this print was recorded. bad prints with faint print and bold print in which fingerprints were difficult to observe were discarded. fifth step: after the fingerprint was obtained, pattern of the fingerprint was noted in a paper either as arch, whorl, loop or composite of each of the right and left fingers with the help of a lens or by naked eye. the samples were thus collected one by one from all the participants. fingerprints from burned, inflamed or scarred hands were excluded. the prints were taken with the fingers applied with regular and firm pressure on a bold paper. entire prints of ten fingers of the participants were prepared. only plain prints were included and roll prints were not taken. the data thus collected were entered into statistical package for social sciences (spsstm) software version 20. the parameters analyzed were the pattern frequency in males and females on their right and left hands. results: the present study of dermatoglyphic patterns obtained 2000 fingerprints from each of the ten fingers of 97 males and 103 females. out of them, 1218 (60.9%) were loops (607 in right hand and 611 in left hand), 581 (29.05%) were whorls (306 in right and 275 in left),134 (6.7%) were arches (59 in right and 75 in left), and 67 (3.35%) were composites (28 in right and 39 in left). the frequency and the percentage of all fingerprint patterns are shown in table 1. the frequency and percentage of loops, whorls, arches, and composites of males and females in right and left hands are also shown. the study also showed that the frequencies of loops and arches were relatively higher in males as compared with females whereas the whorl and composite patterns were more common in females as compared with males. the composite pattern was not observed in the middle, ring, and little fingers of male right hands and the middle finger of female left hands. similarly, arch was not observed in the thumbs and middle fingers of female right hands. table 2 shows the comparison of the present study’s findings with that of other published works. discussion: j. lumbini. med. coll. vol 8, no 1, jan-june 2020 sintakala c, et al. dermatoglyphic patterns among undergraduate students of a medical college: a descriptive cross-sectional study.. dermatoglyphic patterns among undergraduate students of a medical college: a descriptive cross-sectional study. jlmc.edu.np fingerprint is the worldwide important tool for the individual identification and gender differentiation proven by many studies. sam nm et al.[1] recorded relatively high frequency (6.35%) of composites which is higher than present study (3.3%). the study of mehta aa et al.[2]showed the percentage of whorls in male index finger as 45% and ring finger as 63.57% which were higher than those of loops and arches. this finding was in contrast to other studies and the present study as well. in overall distribution, fingerprint patterns in both hands among males and females were not significantly different. shrestha i et al.[14] had shown maximum number of arches i.e. 15.28% compared to other studies and it exceeded by 9.1% as compared with our study which showed only 6.7% arches. loop pattern was shown as the most common pattern (60.9%) in the present study which is similar to the study by kumar a et al.[12] maximum whorls (42.2%) were shown in the study by das nk et al.[15] and this finding was very different from the present study (29.1%). in the study of kanchan t et al.,[16] loops were most often found on little finger (77.7%) table 1: distribution of fingerprint patterns in males and females. patterns loop whorl arch composite male female male female male female male female right hand thumb 60 (61.9%) 47 (45.6%) 29 (29.1%) 45 (43.7%) 4 (4.1%) 4 (4.1%) 11 (10.7%) index 44 (45.4%) 61 (59.2%) 28 (28.9%) 32 (31.1%) 20 (20.6%) 8 (7.8%) 5 (5.1%) 2 (1.9%) middle 73 (75.5%) 82 (79.6%) 15 (15.5%) 19 (31.1%) 9 (9.3%) 2 (1.9%) ring 56 (57.1%) 37 (35.9%) 34 (35.1%) 62 (60.2%) 7 (7.2%) 2 (1.9%) 2 (1.9%) little 78 (80.4%) 71 (68.9%) 12 (12.4%) 28 (27.2%) 7 (7.2%) 2 (1.9%) 2 (1.9%) left hand thumb 65 (67.0%) 57 (55.3%) 20 (20.6%) 39 (37.9%) 6 (6.2%) 6 (6.2%) 7 (6.8%) index 46 (47.4%) 45 (43.7%) 30 (30.9%) 42 (40.8%) 19 (19.6%) 12 (11.7%) 2 (2.1%) 4 (3.9%) middle 62 (63.9%) 76 (73.8%) 20 (20.6%) 17 (16.5%) 13 (13.4%) 10 (9.7%) 2 (2.1%) ring 51 (52.6%) 42 (40.8%) 33 (34.0%) 54 (52.4%) 9 (9.3%) 4 (4.1%) 7 (6.8%) little 85 (87.6%) 84 (81.6%) 5 (5.2%) 13 (12.6%) 4 (4.1%) 2(1.9%) 3 (3.1%) 4 (3.9%) total 620 (31%) 602 (30.1%) 226 (11.3%) 351 (17.55%) 98 (4.9%) 36 (1.8%) 26 (1.3%) 41 (2.05%) table 2. comparison of dermatoglyphics pattern among different studies. author year sample size arch % loop % whorl % composite % kanchan t. et al.[16] 2006 110 4.5 57.5 38 sam nm. et al.[1] 2015 200 6.2 57.1 30.35 6.35 ray ak. et al.[3] 2015 200 20.5 47.05 28.75 3.25 kumar a. et al.[12] 2018 400 4.5 57.2 38.3 das nk. et al.[15] 2018 200 5.5 52.3 42.2 shrestha r. et al.[17] 2019 200 7.5 51.8 40.15 0.7 hirachan n. et al.[18] 2019 250 7.3 52.6 39.4 0.6 shrestha i. et al.[14] 2019 196 15.28 52.71 27.38 4.6 present study 2020 200 6.7 60.9 29.1 3.3 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 sintakala c, et al. dermatoglyphic patterns among undergraduate students of a medical college: a descriptive cross-sectional study.. dermatoglyphic patterns among undergraduate students of a medical college: a descriptive cross-sectional study. jlmc.edu.np followed by middle finger (73.7%) and index finger (49.1 %). frequency of whorls was maximum on the ring finger (55%) followed by thumb (53.6%) and index finger (38.2%). fifty six percent of the total arches were present on the index finger. this preference for arches on the index finger was marked in males (68%) when compared to females (44%). there was insignificant difference in overall distribution of fingerprint pattern in both hands among males and females which was almost similar to present study. the study by shrestha r et al.[17] and hirachan n et al.[18] showed minimum number of composites which were 0.7% and 0.6% respectively. some of the studies including those by kanchan t et al.[16], kumar a et al.[12] and das nk et al.[15] did not find the composite pattern. the present study also did not observe composite and arch patterns in some fingers of males and females. loops were seen on all of the digits, whorls were predominant on thumb,index and ring fingers. percentages of patterns of finger prints seen in the study of hamid s et al.[11] were loops (57.6%),whorls (30.3%) and arches (7.4%) which were almost similar to the present study where loops (60.9%) were followed by whorls (29.1%), and arches (6.7%) respectively. furthermore, loops were predominantly found on middle finger (25.52%) followed by little finger (23.6%), thumb (18.05%), ring finger (17.01%) and frequency of whorls was maximum on the index finger (27.72%) followed by thumb (25.08%) and ring finger (24.75%). out of all arches, 48.64% were present on the thumb and middle fingers. there was insignificant difference in overall distribution of fingerprint patterns in both hands among males and females when compared with present study.[11] the distribution of various patterns of the finger prints in our study were almost similar with previous studies with only few differences. this type of study is very important for the individual identification as well as for comparison of fingerprints of students in any other fields like engineering, management, commerce, and so on with the fingerprints of health science students. there are a few limitations of our study. ink method was used to record finger prints as digital method was not feasible. besides this, our sample included students from a single medical college and therefore our findings may not be generalized to all health science students. conclusion: fingerprint is a guideline parameter for the individual identification in present days. the maximum number of fingerprints were recorded as loops followed by whorls,arches, and composites. loops and arches were the dominant fingerprint patterns in males while whorls and composites were dominant in females. loops were most common in little finger while whorls were recorded most from ring finger. arches were most common in index fingers and composites were most common in thumb finger. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 sintakala c, et al. dermatoglyphic patterns among undergraduate students of a medical college: a descriptive cross-sectional study.. dermatoglyphic patterns among undergraduate students of a medical college: a descriptive cross-sectional study. jlmc.edu.np references: 1. sam nm, rema p, nair vb. study of fingerprint patterns in 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indian journal of forensic medicine and toxicology. 2010;4(1):41-3. available from: https:// www.indianjournals.com/ijor.aspx?target=ijor:ijfmt&volume=4&issue=1&article=016 9. van der sande mab, walraven gel, milligan pjm, banya was, ceesay sm, nyan oa, et al. family history: an opportunity for early interventions and improved control of hypertension, obesity and diabetes. bull world health organ. 2001;79(4):321-8. pmid: 321-28. 11357211. 10. bhat gm, mukhdoomi ma, shah ba, ittoo ms. dermatoglyphics: in health and disease a review. international journal of research in medical sciences. 2014;2(1):31-7. available from: https://www.msjonline.org/index.php/ijrms/article/view/2050/1944 11. hamid s, hussain a, rashid m, kaur m, yasin s, kaloo r. distribution of fingerprint patterns among first year medical students in skims medical college. global journal for research analysis. 2016;5(4):8-9. available from: https://www.worldwidejournals.com/global-journal-for-research-analysis-gjra/fileview/ april_2016_1464954528__06.pdf 12. kumar a, prasad m, kumar s, kumari p, goel n. study of fingerprint patterns among medical students in igims, patna, bihar. journal of medical science and clinical research. 2018;6(12):7726. doi: https://dx.doi.org/10.18535/jmscr/ v6i12.125 13. chauhan a, shukla sk. feasibility of ridge density: a comparative study of fingerprint ridge densities among different indian population. journal of forensic science criminal investigation. 2017;5(1):001-004. doi: https://juniperpublishers.com/jfsci/jfsci.ms.id.555654.php 14. shrestha i, malla bk. study of fingerprint patterns in population of a community. j nepal med j. lumbini. med. coll. vol 8, no 1, jan-june 2020 sintakala c, et al. dermatoglyphic patterns among undergraduate students of a medical college: a descriptive cross-sectional study.. dermatoglyphic patterns among undergraduate students of a medical college: a descriptive cross-sectional study. jlmc.edu.np assoc. 2019;57(219):293-6. pmid: 32329450. doi: https://doi.org/10.31729/jnma.4621 15. das nk, tamuli rp, saikia b. sarmah s. fingerprint patterns of mbbs students: a study from assam. international journal of medical and health research. 2018;4(4):18-21. avaialble from: http://www.medicalsciencejournal.com/ archives/2018/vol4/issue4/4-3-38 16. kanchan t, chattopadhyay s. distribution of fingerprint patterns among medical students. journal of indian academy of forensic medicine. 2006;28(2):65-8. http://medind.nic.in/jal/ t06/i2/jalt06i2p65.pdf 17. shrestha r, hirachan n, koju s. shrestha n, lamichhane a. association of fingerprints with the abo blood grouping among students in gandaki medical college. journal of gandaki medical college-nepal. 2019;12(2):63-6. doi: https:// doi.org/10.3126/jgmcn.v12i2.27212 18. hirachan n, shrestha r, koju s, limbu d. an overview of fingerprint patterns among students of gandaki medical college, pokhara, nepal. journal of gandaki medical college-nepal. 2019;12(1):31-3.doi: https://doi.org/10.3126/ jgmcn.v12i1.22609 j. lumbini. med. coll. vol 7, no 2, july-dec 2019 tamrakar sr, tamrakar sr, et al. paradigm shift in gynecological surgeries over eight years in dhulikhel hospital.et al. paradigm shift in gynecological surgeries over eight years in dhulikhel hospital. 70 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 14 march, 2019 accepted: 21 november, 2019 published: 31 december, 2019 a associate professor, department of obstetrics & gynaecology b lecturer, department of obstetrics & gynaecology cdhulikhel hospital, kathamandu university of school medical sciences, dhulikhel corresponding author: suman raj tamrakar e-mail: drsuman3947@gmail.com orcid: https://orcid.org/0000-0002-4735-6851_______________________________________________________ —–————————————————————————————————————————————— abstract introduction: one of the greatest achievements in the surgical fields is the paradigm shift from open surgery to minimal invasive surgery. hysteroscopy, laparoscopy, laparoscopy assisted vaginal hysterectomy and total laparoscopic hysterectomy are frequently performed minimal invasive gynecological surgeries. theses surgeries are being regularly performed in dhulikhel hospital. this study aims to review the changes in surgical approaches in the field of gynecological surgeries in this institute. methods: this was a retrospective study of changes in surgical approaches from conventional to minimal invasive surgery in the field of gynecological surgeries from 2010 to 2018. demographic characteristics of patients and indication for various minimal invasive surgeries were compared over this time period. results: there were significant changes in surgical approaches from conventional open surgeries to minimally invasive approach through the years. there was no obvious difference in demographic characteristics of the cases and the indications for hysterectomy and endometrial sampling were comparable. conclusion: there was definitely paradigm shift in conventional method to minimal invasive methods for major gynecological surgeries like hysterectomy, ovarian cystectomy, salpingectomy for ectopic pregnancy and endometrial samplings. keywords: ectopic, endometrial sampling, hysterectomy, ovarian cystectomy, paradigm shift original research articlehttps://doi.org/10.22502/jlmc.v7i2.282 suman raj tamrakar,a,c bhagirathi kayasthab,c paradigm shift in gynecological surgeries over eight years in dhulikhel hospital how to cite this article:how to cite this article: tamrakar sr, kayastha b. paradigm shift in gynecological surgeries tamrakar sr, kayastha b. paradigm shift in gynecological surgeries over eight years in dhulikhel hospital. journal of lumbini medical over eight years in dhulikhel hospital. journal of lumbini medical college. 2019;7(2):70-75. doi: https://doi.org/10.22502/jlmc.college. 2019;7(2):70-75. doi: https://doi.org/10.22502/jlmc. v7i2.282 epub: 2019 december 31.v7i2.282 epub: 2019 december 31. introduction: one of the greatest achievements in the surgical fields is the paradigm shift from open surgery to minimal invasive surgery (mis). mis has become increasingly popular among both surgeons and patients since early 1970s.hysteroscopy, laparoscopy, laparoscopy assisted vaginal hysterectomy (lavh) and total laparoscopic hysterectomy (tlh) are frequently performed minimal invasive gynecological surgeries. varieties of mis in gynecology are being done for diagnostic and therapeutic purposes.[1] there are ample of publications in mis globally but very limited nepalese publications related to different gynecological minimal invasive surgeries are found. [2,3,4,5,6] minimal invasive gynecological surgeries are being regularly performed in dhulikhel hospital (dh) since early years of its establishment. over the period we have noticed the shifting of surgical approaches from conventional to minimal invasive mostly in benign gynecological cases. mis services in gynecology in the form of diagnostic hysteroscopies were started in dh since january 2004. operative hysteroscopy was started for polypectomy in august 2004.operative laparoscopy such as ovarian cystectomy and tubal sterilization were performed since may 2004. diagnostic laparoscopy with or without chromotubation were started for infertility j. lumbini. med. coll. vol 7, no 2, july-dec 2019 tamrakar sr, tamrakar sr, et al. paradigm shift in gynecological surgeries over eight years in dhulikhel hospital.et al. paradigm shift in gynecological surgeries over eight years in dhulikhel hospital. 71 since may 2005 and laparoscopic salpingectomies for ectopic pregnancy since january 2010. laparoscopy assisted vaginal hysterectomy started since february 2011, total laparoscopic hysterectomy since june 2015 and laparoscopic myomectomy since 2017. this study aims to review the changes in surgical approaches in the field of gynecological surgeries in this institute. methods: this is a retrospective study of changes in surgical approaches from conventional to minimal invasive surgery in the field of gynecological surgeries from 2010 to 2018. this study was undertaken in department of obstetrics and gynecology after reviewing all the patient record files and electronic record from outpatient and inpatient departments and operation theatre. ethical clearance was taken from the hospital research committee. for analysis purpose initial 100 cases each of hysterectomy, ovarian cystectomy, endometrial sampling and 50 ectopic pregnancies managed surgically from 2010 to 2015 were compared respectively with the same number of cases performed in 2018. demographic variables like age, caste, parity and indications for various mis were compared through the years. analysis was done using spss™ version 16. descriptive data were presented as frequency, percentage and mean. non parametric chi square test was used to analyze relationship between categorical data. p value less than 0.05 was considered statistically significant. results: the mean age of patients undergoing different operative procedures in the previous years and in 2018 were comparable with no statistically significant differences. the mean ages of hysterectomy cases were 45.14±7.41 and 45.46±6.6 years (p=0.7474) and of ovarian cystectomy cases were 30.58±11.70 and 29.52±8.90 years (p=0.4717) in the two time periods. likewise the mean ages of surgically managed ectopic cases were 26.74±5.57 and 28.36±5.88 years (p=0.1604); and endometrial sampling cases were 39.02±9.96 and 41.12±9.07 years (p=0.1206). there was no difference in caste distribution of the cases except for the group janajati other than newar. this group underwent hysterectomy less but underwent more of endometrial sampling over the period (table 1). likewise there was no difference in address of cases coming for different gynaecological surgeries from different parts of nepal. patients coming for hysterectomy and endometrial sampling from other districts were increased while those undergoing ectopic surgery from kavre district were decreased (table 2). indications for hysterectomy and endometrial sampling were also comparable though there were few significant differences (table 3). parity and gestation age of the ectopic cases were also comparable (table 4). dermoid cysts were the commonest benign ovarian lesions with 29 and 30 in initial and latest cases respectively. forty seven table 1: caste of operated cases. hysterectomy ovarian cystectomy ectopic endometrial sampling initial (n=100) latest (n=100) initial (n=100) latest (n=100) initial (n=50) latest (n=50) initial (n=100) latest (n=100) brahmin/ chhetri 37 50 36 35 24 18 52 38 madheshi 3 5 1 1 1 2 4 lower caste 1 6 2 6 2 3 6 2 newar 35 30 34 30 8 13 26 29 other janajati 24 9 28 28 15 15 14 27 j. lumbini. med. coll. vol 7, no 2, july-dec 2019 tamrakar sr, tamrakar sr, et al. paradigm shift in gynecological surgeries over eight years in dhulikhel hospital.et al. paradigm shift in gynecological surgeries over eight years in dhulikhel hospital. 72 initial and 53 latest ovarian lesions were other than dermoid cysts. likewise, 10 initial and seven latest ovarian lesions were of endometriotic cysts. we have found 14 initial and 10 latest ovarian lesions were twisted per operatively. there were significant changes in surgical approaches from conventional open surgeries to minimally invasive approach. abdominal hysterectomies performed in the early years were 84 vs 24 in the recent years. this was significantly different in the recent years where laparoscopy assisted hysterectomy performed in the early years were 16 vs 76 in the recent years. (x2=72.464, df=1, p<0.0001). similarly cystectomies performed via open route were 69 vs 25 in the previous and latest years whereas laparoscopic cystectomies were 31 vs 75. table 2: address of operated cases hysterectomy ovarian cystectomy ectopic endometrial sampling initial (n=100) latest (n=100) initial (n=100) latest (n=100) initial (n=50) latest (n=50) initial (n=100) latest (n=100) kavre 50 45 59 55 35 23 67 55 sindhupalchowk/ dolakha/ ramechhap/ sindhuli 17 10 12 11 7 15 15 13 kathmandu valley 27 30 26 24 6 11 14 20 other districts 6 15 3 10 2 1 4 12 table 3: indication of open and laparoscopic hysterectomies and endometrial sampling indications hysterectomy indications endometrial sampling initial latest p value initial latest p value aub 33 34 aub 64 47 0.0156 chronic pelvic pain/ endometriosis 6 4 0.515 abortion/molar pregnancy 10 2 0.0172 ovarian lesions 12 2 0.005 polyp* 15 19 0.4515 fibroids/ adenomyosis 35 51 0.022 fibroids/adenomyosis 4 29 <0.0001 cervical lesions 9 4 0.151 cervical lesions 3 2 polyp* 5 5 infertility 2 chronic pelvic pain/ endometriosis 2 1 * cervical / endometrial table 4: parity and gestational age of ectopic pregnancy parity initial latest 1. primigravida 10 14 2. multigravida 32 34 3. unknown 8 2 period of gestation 1. up to 5 weeks 12 14 2. 6 weeks 9 11 3. 7 weeks 12 11 4. 8 weeks 7 8 5. 9 weeks 1 3 6. ≥ 10 weeks 1 1 7. unknown 8 2 j. lumbini. med. coll. vol 7, no 2, july-dec 2019 tamrakar sr, tamrakar sr, et al. paradigm shift in gynecological surgeries over eight years in dhulikhel hospital.et al. paradigm shift in gynecological surgeries over eight years in dhulikhel hospital. 73 (x2=38.860, df=1, p<0.0001). conventional method of endometrial sampling was used in 63 vs 8 cases in initial and later years whereas hysteroscopy was used in 37 vs 92 cases in initial and latest years. (x2=66.055, df=1, p<0.0001). discussion: one of the most remarkable innovations in surgery has been the changeover from laparotomy to laparoscopy. the first reported laparoscopic hysterectomy was in 1989 by harry reich, for endometriosis.[7] since then, laparoscopic hysterectomy has been considered as an alternative to abdominal hysterectomy.the aspiration for minimal invasive surgery and the capacity of surgeons to update surgical skills has contributed to the significant recent developments in laparoscopic surgery.[7] beside mean age, caste and address of the patients, indications of initial and latest gynecological surgery in dh were almost comparable except that for fibroids/adenomyosis. patients have benefitted from innovative developments in gynecological mis. today uterine lesions (myomas, polyps, septae) are routinely treated by hysteroscopy. symptomatic myomas and most of the benign adnexal (including ovarian) pathology can be managed by laparoscopic procedure.[8] this might be the reason for increment of mis for fibroid/adenomyosis in dh. the indications of mis in gynecology were similar to that of other hospitals of nepal. in a study, shakya b compared the accuracy of hysterosalpingography (hsg) with hysteroscopy (hsc) while evaluating uterine pathology in patients with infertility. [2] hysteroscopy correctly diagnosed atrophic endometrium, polyp and endometrial cancer which was also confirmed by histopathology finding. sharma j et al concluded hysteroscopy was reliable method for evaluating cases of abnormal uterine bleeding (aub), first line diagnosing method for benign lesions. [3] hysteroscopy guided biopsy was most accurate in diagnosing pathology. though all hysteroscopy cases were done for different forms of aub, ultrasound diagnosis were myoma, endometrial polyp and carcinoma in 14, 6 and 2% respectively.[3] and 47% (n=47, n=100) latest cases underwent endometrial sampling (mostly hysteroscopy guided) for aub while 29% (n=29, n=100) for fibroids/adenomyosis and 19% (n=19, n=100 for polyp in this study. in a study by saha r et al, altogether 300 patients successfully underwent laparoscopy. of which 115 cases were diagnostic laparoscopy and 185 cases were operative laparoscopy. subfertility was the most common indication for diagnostic laparoscopy (65) followed by that for chronic pelvic pain (42). of the 115 operative laparoscopy, 88 cases were done for ovarian lesions with laparoscopic cystectomy were being the most common indication (65 cases) followed by that for lavh (60 cases). [4] and indications of hysterectomies and operative procedures for initial and latest operative cases of this study were shown in table 3 and 5 respectively. subedi s et al., studied 100 patients who underwent laparoscopic (25 cases of diagnostic and 75 cases of therapeutic) procedures. fifty-three patients with an ovarian mass underwent laparoscopic cystectomy. laparoscopic salpingectomy was done in 11 patients with ectopic pregnancy.[5] bajracharya n et al, shared an experience of 217 laparoscopic procedures over seven and half years. lap cystectomy 97(46%), lap salpingectomy 27(13%), tlh 33(16%), diagnostic laparoscopy 32 (15%), lap oophorectomy 10(5%), lavh 7(3%) and bilateral tubal ligation 3(2%) cases were done in that period.[6] the variation of each method should be explored more clearly to make the proper choice of surgical method for each individual case. in daejeon st. mary’s hospital of korea, the hysterectomy method has changed based on the recent shift from laparotomy to multi port access (mpa)-tlh. [7] similar to this study, hysterectomy approach in dh has also changed over the period. with the widespread use of laparoscopic surgery, the rate of laparoscopically-assisted surgery increased from 0.3% in 1990 to 14% in 2005 [9]laparoscopic assisted or mis in gynecological lesions are significantly increased in dh over eight years. laparoscopic procedure has various important advantages over laparotomy; hence it has become preferred surgical method. in parallel with the advancements in laparoscopic surgery and increased experiences with lavh, tlh has become a common alternative to abdominal hysterectomy. the benefits of laparoscopic surgery, i.e. decreased pain, better cosmetic results, faster recovery, shorter hospital stay, and earlier return to normal activities increased the popularity of this route.[10] we have j. lumbini. med. coll. vol 7, no 2, july-dec 2019 tamrakar sr, tamrakar sr, et al. paradigm shift in gynecological surgeries over eight years in dhulikhel hospital.et al. paradigm shift in gynecological surgeries over eight years in dhulikhel hospital. 74 also experienced same in dh. while we prefer mis to conventional gynecological surgeries, we are anxious about its complications. of the 261 laparoscopic hysterectomies, eight cases (3.07%) turned into open in our study. fibroid (five cases), dermoid cyst (two cases) and grade iv endometriosis (one case) were the reasons for turning into laparotomy. as a major complication, one case required re-laparotomy for pelvic hematoma following lavh and another case required ureteric injury repair following tlh. other minor complications were requirement of blood transfusion (at most three pints), minimal bleeding per vaginum, port site infection and hematoma but the numbers were very few.[11] as such there is less incidence of surgical site infection in not only in mis but also in conventional surgeries in dh. shrestha s et al conducted study at dh from february to april, 2014 and found overall surgical site infection (ssi) was 2.6% (n=17, n=638) while ssi in gynecology department was 1.8% (n=1, n=54).[12] reasons given for deliberate implementation of gynecological mis are complications, operative time, highly developed procedure with a long learning curve and higher cost.[13] another reason for the slow implementation is the long learning curve of the procedure which impacts on operating time, blood loss, complications and cost. several studies discuss the learning curve of lh as completed after approximately 30 procedures.[14] minimal invasive procedures are equally safe and learnable in due course of time, which we have experienced. as one of the reasons for delay implementation of gynecological mis is operative time with a long learning curve, future scope includes analysis of duration of surgery and experience of surgeons. conclusion: minimal invasive gynecological surgeries are being regularly performed in dh since 2004 and laparoscopic hysterectomies since 2011. we reviewed the shifting of surgical approaches in the field of gynecological surgeries over 8 years. there was definitely paradigm shift in conventional method to minimal invasive methods for major gynecological surgeries like hysterectomy, ovarian cystectomy, salpingectomy for ectopic pregnancy and endometrial samplings. acknowledgement: i would like to thank all staffs of department of obstetrics and gynecology of dhulikhel hospital. competing interests: the authors declare that no competing interest exists. source of funds: no funds were available. j. lumbini. med. coll. vol 7, no 2, july-dec 2019 tamrakar sr, tamrakar sr, et al. paradigm shift in gynecological surgeries over eight years in dhulikhel hospital.et al. paradigm shift in gynecological surgeries over eight years in dhulikhel hospital. 75 references: 1. tomov s, gorchev g, tzvetkov ch, tanchev l, iliev s. laparoscopic hysterectomy brief history, frequency, indications and contraindications. akush ginekol (sofiia). 2012;51(4):40-4. pmid: 23234025. 2. shakya b. hysterosalpingography vs hysteroscopy in the detection of intrauterine pathology in infertility. j nepal health res counc. 2009;7(14):6-9. doi: http://dx.doi. org/10.3126/jnhrc.v7i1.2271 3. sharma j, tiwari s. hysteroscopy in abnormal uterine bleeding vs ultrasonography and histopathology report in perimenopausal and postmenopausal women. j nepal medical assoc. 2016;55(203):26-8. doi: https://doi. org/10.31729/jnma.2834 4. saha r, shrestha ns, thapa m, shrestha j, bajracharya j, karki sc. experiences of gynecological laparoscopic surgeries in a teaching hospital. j nepal health res counc. 2013;11(23):49-2. pmid: 23787526 5. subedi s, narayan gc, lamichhane s, chhetry m. initial experiences of laparoscopic surgery at nobel medical college teaching hospital: a learning curve. journal of lumbini medical college. 2016;4(1):20-3. doi: https://doi. org/10.22502/jlmc.v4i1.77 6. bajracharya n, dangal g, karki a, pradhan h, shrestha r, bhattachan k, et al. experience of laparoscopic gynecological surgeries at kathmandu model hospital. nepal journal of obstetrics & gynaecology. 2017;12(1):225. doi: http://dx.doi.org/10.3126/njog. v12i1.18988 7. kim sm, park ek, jeung ic, kim cj, lee ys. abdominal, multi-port and single-port total laparoscopic hysterectomy: eleven-year trends comparison of surgical outcomes complications of 936 cases. arch gynecol obstet. 2015;291(6):1313-9. pmid: 25488157. doi: https://doi.org/10.1007/s00404-014-3576-y 8. steiner ra, fehr pm. minimal invasive surgery in gynaecology. ther umsch. 2005;62(2):12738. pmid: 15756923. doi: https://doi. org/10.1024/0040-5930.62.2.127 9. jacoby vl, autry a, jacobson g, domush r, nakagawa s, jacoby a. nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches. obstet gynecol. 2009;114(5):1041-8. pmid: 20168105. doi: https://doi.org/10.1097/ aog.0b013e3181b9d222 10. dolanbay m, kutuk ms, ozgun mt, uludag s, sahin y. laparoscopically-assisted vaginal hysterectomy for enlarged uterus: operative outcomes and the learning curve. ginekol pol. 2016;87(5):333-7. pmid: 27304647. doi: https://doi.org/10.5603/gp.2016.0003 11. tamrakar sr, dongol a, shakya s, kayastha b. minimal invasive gynaecological surgeries in dhulikhel hospital: one and half decade long experience. kathmandu university medical journal. 2018;16(4):333-7. available from: http://www.kumj.com.np/issue/64/333-337.pdf 12. shrestha s, wenju p, shrestha r, karmacharya rm. incidence and risk factors of surgical site infections in kathmandu univeristy hospital, kavre, nepal. kathmandu univ med j. 2016;14(54):107-11. pmid: 28166064 13. hunter ek. evidence-based implementation and increase in the rate of laparoscopic hysterectomy. aust nz j obstet gynaecol. 2015;55(2):112-5. pmid: 25537260. doi: https://doi.org/10.1111/ ajo.12280 14. tunitsky e, citil a, ayaz r, esin s, knee a, harmanli o. does surgical volume influence short-term outcomes of laparoscopic hysterectomy? am j obstet gynecol. 2010;203(1):24.e1–6. pmid: 20430354. doi: https://doi.org/10.1016/j.ajog.2010.01.070 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 7, no 1, jan-june 2019 ___________________________________________________________________________________ submitted: 23 february, 2019 accepted: 05 june, 2019 published: 21 june, 2019 a lecturer, department of pharmacology b associate professor, department of orthopedic surgery & traumatology c associate professor, department of obstetrics and gynecology d lumbini medical college & teaching hospital, pravas, palpa corresponding author: naresh karki e-mail: karki007naresh@gmail.com orcid: http://orcid.org/0000-0002-8788-6443_______________________________________________________ —–————————————————————————————————————————————— abstract: introduction: drug utilization research is an important tool to provide facility of rational use of drugs. in low income countries irrational use of drugs is a common problem like overuse of drugs and inappropriate use of antibiotics, leading to poor treatment outcome and increased burden of treatment. this study was conducted to provide understanding of drug utilization pattern by using who core prescribing indicator. methods: this study was conducted in orthopedics and obstetrics / gynecology departments. patients visiting these out patient departments with at least one drug on prescription form were included in the study. further, information related to who core prescribing indicators were collected in pre-designed proforma. results: average number of drugs prescribed per prescription was 2.6. means of number of drugs prescribed in orthopedics and obstetrics / gynecology departments were 2.9 and 2.3 respectively (p < 0.001). drugs prescribed in generic name and from essential drug list was 41.4% and 34.3% respectively. prescription forms with generic name in orthopedics department were significantly more compared to obstetrics / gynecology department (p = 0.00002). however, there was an increased tendency to prescribe drugs from essential drug list in obstetrics / gynecology department compared to orthopedics department (p < 0.001). conclusion: drugs were prescribed by generic name and from essential drug list, but this was not sufficient to meet the ideal values of who core prescribing indicator. therefore, prioritization on prescribing drugs by generic name and from essential drug list by respective departments to achieve the standards of who needs to be encouraged. keywords: drug utilization, essential drug list, generic drugs, polypharmacy —————————————————————————————————————————————— original research articlehttps://doi.org/10.22502/jlmc.v7i1.280 naresh karkia,d pravin prasada,d ruban raj joshib,d buddhi kumar shresthab,d drug utilization pattern by using who core prescribing indicators in orthopedics and obstetrics / gynecology departments of a tertiary care hospital introduction: drug utilization research (dur) is defined as “the marketing, distribution, prescription, and use of drugs in a society, with special emphasis on resulting medical, social and economic consequences.”[1] according to who estimation, more than 50% of drugs are prescribed, dispensed or sold irrelevantly.[2] in addition, about one-third of the world population do not have access to essential drugs.[2,3] in low-income countries, irrational use of drugs like overuse of drugs (polypharmacy), use of injectable drugs when not necessary and unnecessary use of antibiotics in non-bacterial infections are common problems.[3,4] this could lead to interactions in between drugs, adverse outcome of treatment, increased burden of treatment cost leading to mortality of patients.[4] hence, drug utilization studies are usually conducted in healthcare providing settings to analyze prescribing trend of medicines and to detect whether drugs prescribing patterns are rational or irrational.[4] generally, in how to cite this article: karki n, prasad p, joshi rr, shrestha bk. drug utilization pattern by using who core prescribing indicators in orthopedics and obstetrics / gynecology departments of a tertiary care hospital. journal of lumbini medical college. 2019;7(1):6 pages. doi: 10.22502/jlmc.v7i1.280. epub: 2019 june 21. http://orcid.org/0000-0002-8788-6443 https://doi.org/10.22502/jlmc.v7i1.280 karki n. et al. drug utilization pattern by using who core prescribing indicators jlmc.edu.npj. lumbini. med. coll. vol 7, no 1, jan-june 2019 orthopedics and obstetrics / gynecology (obgyn) departments, studies are mainly conducted on surgical procedures because of topic of interest. only limited studies are available on dur and rational use of drugs worldwide. similarly, some studies have been published in nepal in various departments of tertiary care hospital. however, there is insufficiency of literatures. therefore, this study aims to provide understanding of drug utilization pattern by using who core prescribing indicator in orthopedics and obgyn departments of tertiary care hospital. methods: a cross-sectional study was carried out in orthopedics and obgyn departments of lumbini medical college (lmc) after permission from institutional review committee (irc-lmc 02h/018) of the institute on 19/11/2018. the duration of study was three months from 15 november 2018 to 16 february 2019. the primary data were collected from health insurance department for about five weeks from 15 november 2018 to 22 december 2018. the inclusion criteria were: • patient attended orthopedics and obgyn out-patient departments (opd) for first time • follow up patient but encountered first time by research workers • patient prescribed at least one drug in opd prescription form the exclusion criteria were: • follow up patient encountered previously on first visit • patient prescribed no drug in opd prescription form • patient prescribed herbal medicines in opd prescription form information were retrieved from opd prescription forms and collected in pre-designed study proforma. the proforma included demographic profile and specific information necessary for measuring who core prescribing indicator. all the information gathered was kept confidential. sample size calculation: • sample size calculated by using following formula:[4] n = z2 p (1-p) / d2 where; p = estimate of proportion with inappropriate prescription pattern, 0.5 as there was no research finding related to estimate of inappropriate drug utilizing pattern in lmc n = sample size d = margin of sampling error tolerated, 0.05 z = standard normal value of confidence interval of 95%, that was equal to 1.96 after applying formula, the sample size calculated was 384. the who core prescribing indicator was used for dur and calculated as described below:[1,4] 1. average number of drugs prescribed per encounter to estimate the degree of polypharmacy. it was calculated by dividing the total number of drugs prescribed by the number of encounters done. 2. percentage of drugs prescribed by generic name was calculated to estimate the trend of drug prescription by generic name. it was calculated by dividing the number of drugs prescribed by generic name by total number of drugs prescribed, multiplied by 100. 3. percentage of encounters in which antibiotic was prescribed. it was calculated by dividing the number of encounters in which an antibiotic prescribed by total number of encounters done, multiplied by 100. 4. percentage of encounters with an injection prescribed. it was calculated by dividing the number of encounters in which an injection prescribed by total number of encounters done, multiplied by 100. 5. percentage of drugs prescribed from an essential drug list to estimate the degree to which practices conform to a national medicine policy as indicated in the national list of essential medicines nepal (fifth revision) 2016.[16] it was calculated by dividing number of drugs prescribed which were in essential drug list by total number of drug prescribed, multiplied by 100. all data were entered and coded in epidata, and then analyzed in statistical package for the social karki n. et al. drug utilization pattern by using who core prescribing indicators jlmc.edu.npj. lumbini. med. coll. vol 7, no 1, jan-june 2019 science (spss), version 16. data were presented as frequency, percentage, mean, and standard deviation (sd). mean values of continuous variables were compared with independent t-test. categorical variables were compared with chi-square test or fisher-exact test whichever was applicable. p value less than 0.05 was considered as statistically significant. result: a total of 444 data of patients were enrolled during the study period. equal numbers of records were taken from orthopedics (n = 222) and obgyn (n = 222) opds. 81.1% were female and 18.9% were male (table 1). mean ages of female and male were 37.4 years (sd = 14.7) and 42.6 years (sd = 19.8) respectively. the ages of male were significantly higher than female (t [n = 444, df = 105.3] = 2.26, p = 0.02). fracture was the most common diagnosis in orthopedics department (16.2%, n = 222) followed by soft tissue injury (15.3%). likewise, pregnancy was the most common condition in obgyn department (34.6%) followed by pelvic inflammatory disease (10.8%). total number of drugs prescribed in both departments was 1163. calcium was commonly prescribed (11.5%, n = 1163) in both departments followed by pantoprazole (9.8%, n = 1163). aceclofenac was commonly prescribed in orthopedics whereas calcium in obgyn. average number of drugs prescribed in prescriptions from both departments was 2.6 (table 2). means of number of drugs prescribed in orthopedics and obgyn departments were 2.9 (sd = 1.1) and 2.3 (sd = 1.1) respectively. the practice of prescribing number of drugs was slightly more in orthopedics department. however, the difference was statistically significant (t [n = 444, df = 441.40] = 5.47, p < 0.001). nearly about half of total drugs (n = 1163) were prescribed in generic name in both departments (table 2). prescription forms with generic name in orthopedics department were more than obgyn. this difference was statistically significant (x2 [n = 444, df =1] = 17.72, p = 0.00002); table 3. but, there was an increased tendency to prescribe drugs from essential drug list in obgyn department compared to orthopedics. this difference was also statistically significant (x2[n = 444, df =1] = 35.11, p < 0.001); table 3. in addition, parenteral drugs were not prescribed very commonly both in orthopedics and obgyn opds. however, the tendency of prescribing parenteral drugs was slightly more in obgyn opds and the difference was statistically significant (x2 [n = 444, df = 1] = 10.33, p = 0.001); table 3. discussion: in this study, we aimed to assess drug utilization pattern by using who core prescribing indicators. we found that average numbers of table 1. socio-demographic characteristics of patients (n = 444) characteristics numbers (%) age groups (in years) 1 ̶ 10 3 (0.7) 11 ̶ 20 42 (9.4) 21 ̶ 30 128 (28.9) 31 ̶ 40 98 (22.0) 41 ̶ 50 61 (13.8) 51 ̶ 60 61 (13.8) >60 51 (11.4) mean age ± sd (in years) 38.4 ± 15.9 gender female 360 (81.1) male 84 (18.9) domicile rural 371 (83.6) urban 73 (16.4) prescribing indicators orthopedic and obgyn (n = 444) orthopedic (n = 222) obgyn (n = 222) who standard values average number of drugs per encounter 2.6 2.9 2.3 1.6 ̶ 1.8 % of drugs prescribed by generic name 41.4 47.4 33.8 100% % of encounters with antibiotic 11.7 5.4 18 20.0 ̶ 26.8 % of encounters with injections 3.8 0.9 6.7 13.4 ̶ 24.1 % of drugs prescribed from essential drug list 34.3 17.2 56 100% table 2: who core prescribing indicators of drugs karki n. et al. drug utilization pattern by using who core prescribing indicators jlmc.edu.npj. lumbini. med. coll. vol 7, no 1, jan-june 2019 drug prescribed was marginally above who ideal value (2.0). few studies supported our finding and showed that there was practice of polypharmacy. [4,5] polypharmacy generally means concurrent use of more than one drug for a given patient. since this study was conducted at speciality department, so this finding could be justifiable. according to who, average of 44% of drugs are prescribed in generic name in nepal.[1] in our study also near about half of total drugs were prescribed in generic name. prescription of drugs by generic name is beneficial for rationalization and to decrease cost of drug therapy. besides this, generic prescriptions are clear to understand and reduce the risk of error during dispensing. in some studies it was found that there was zero prescription of drugs by generic name. table 3: comparison of variables between orthopedic and obgy departments (n = 444) variables orthopedic obgyn statistics gender female male 140 82 220 2 x2 = 93.96, df = 1, p < 0.001 prescriptions with generic name yes no 147 75 103 119 x2 = 17.72, df = 1, p = 0.00002 prescriptions with antibiotic yes no 12 210 40 182 x2 = 17.07, df = 1, p = 0.00003 prescriptions with injectable drugs yes no 2 220 15 207 x2 = 10.33, df = 1, p = 0.001 prescriptions with drugs from edl* yes no 93 129 155 67 x2 = 35.11, df = 1, p < 0.001 prescriptions with drugs from main list of edl yes no 90 132 148 74 x2 = 30.46, df = 1, p < 0.001 prescriptions with drugs from complementary list of edl yes no 1 221 3 219 fisher-exact p = 0.623 prescriptions with drugs from both main and complementary list of edl yes no 2 220 4 218 fisher-exact p = 0.685 prescriptions with fixed-dose drug combinations yes no 24 198 66 156 x2 = 24.58, df = 1 p < 0.001 *edl ̶ essential drug list karki n. et al. drug utilization pattern by using who core prescribing indicators j. lumbini. med. coll. vol 7, no 1, jan-june 2019 jlmc.edu.np [6,7,8] however, in few studies about two-third to half of total drugs were prescribed by generic name.[9,10]. since many pharmaceutical companies develop and manufacture better drugs in terms of efficacy and safety, so that they promote the practice of prescribing drugs by brand name among the doctors in order to return the cost of manufacturing of drugs. this may be the key factor for decreasing practice of generic prescription. although generic prescription is always cheaper and more effective, this doesn't hold true for each and every drug. inappropriate prescription of antibiotic can potentially lead to antibiotics resistance. antibiotic resistance increases necessity to require more costly antibiotics to manage common as well as serious type of infections which ultimately increases morbidity, mortality and burden of treatment. in our study, prescriptions with antibiotics were below who ideal value. in contrast, some studies showed that antibiotics were prescribed in about half to twothird of total prescriptions form.[11, 12] antibiotics must be used in case of bacterial infections and must be reserved for the future otherwise we may lose the most powerful tool to treat severe infections in future. regarding essential drugs, they satisfy the priority healthcare needs of the patients. general population should have access to essential drugs at all time in adequate amount at affordable price. in present study, approximately one-third of patients prescribed drugs from essential drug list. according to who, 100% of drugs should be prescribed from essential drug list.[1] contrary, we have found that more than 90% of drugs were prescribed from essential drug list.[12] while, in support to our study, about onethird to half of total drugs were prescribed from essential drugs list.[13,14,15]. prescribing drugs from essential list is a rational practice. the practice of prescription of drugs from essential drug list is not sufficient to meet who criteria in our tertiary level hospital. however, this finding is justifiable because in tertiary level hospitals variety of cases are treated and only limited drugs are available in essential drug list. so it is not always necessary to prescribe drugs only from that list. the limitation of study is that who core prescribing indicator highlighted only major problem while prescribing drugs. but, it did not show the reason of existing problem. besides this, small sample size study was conducted for short duration in only one hospital which may not reflect the actual scenario of the country. however, we expect that this study may create a small basis for carrying study in larger sample and for longer duration in future. conclusion: the study concluded that the average number of drugs prescribed in this study was slightly over who standards. however, the tendency to prescribe drugs in generic name and from essential drug list didn’t meet the ideal values of who drug prescribing indicator. so this study emphasizes more on prescribing more drugs in generic name and from essential drug list to meet standards of who. acknowledgement: • department of orthopedics, lmcth • department of obgyn, lmcth • associate professor dr. vinod kumar verma, department of pharmacology, lmcth • health insurance section, lmcth • mr. keshav raj bhandari, statistician, lmcth conflict of interest: the authors declare that no competing interests exist. source of funds: no funds were available. references: 1. world health organization. introduction to drug utilization research, oslo: world health organization; 2003. available from: http://apps.who.int/medicinedocs/ pdf/s4876e/s4876e.pdf 2. world health organization. world health organization promoting rational use of medicine: core component. who policy and perspectives on medicine no. 5 document who/edm/2002.3.geneva: who; 2002. available from: http://apps.who.int/medicinedocs/pdf/ h3011e/h3011e.pdf 3. world health organization. how to investigate drug use in health facilities: selected drug use indicators. who/ dap/93.1.world health organization, geneva.1993:1-87. available from: http://www.apps.who.int/medicinedocs/ fr/d/js2289e/ 4. demeke b, molla f, assen a, melkam w, abrha s, masresha b, et al. evaluation of drugs utilization pattern using who prescribing indicators in ayder referral hospital, northern ethiopia. international journal of pharma sciences and research. 2015; 6(2):343347. available from: http://www.ijpsr.info/docs/ ijpsr15-06-02-038.pdf 5. banerjee i, bhadury t, agarwal m. prescribing pattern in orthopedic outpatient department of a medical college in india. international journal of basic & clinical pharmacology. 2015;4(6):1175-1177. doi: http://dx.doi. org/10.18203/2319-2003.ijbcp2015353 6. joychandra o, oinam j, debashree n, losica. to study the prescribing pattern of analgesics in the orthopaedic inpatient department of jawaharlal nehru institute of medical science (jnimc) hospital, imphal, manipur, india. international journal of pharmaceutical sciences and research. 2017;8(9):3923-3927. doi: http://dx.doi. org/10.13040/ijpsr.0975-8232.8(9).3923-27 7. ingle pk, patil ph, lathi v. study of rational prescribing and dispensing of prescriptions with non-steroidal ant-inflammatory drugs in orthopedic outpatient department. asian journal of pharmaceutical and clinical research. 2015;8(4):278-281. available from: https:// innovareacademics.in/journals/index.php/ajpcr/article/ view/6669 8. sarraf dp, rauniyar gp, misra a. drug utilization pattern in four major wards of a tertiary hospital in eastern nepal. health renaissance. 2015;13(2):50-65. doi: https://doi. org/10.3126/hren.v13i2.17554 9. saha a, bhattacharjya h, sengupta b, debbarma r. prescription audit in outpatient department of a teaching hospital of north east india. international journal of research in medical sciences. 2018;6(4):1241-1247. doi: http://dx.doi.org/10.18203/2320-6012.ijrms20181275 10. parveen z, gupta s, kumar d, hussain s. drug utilization pattern using who prescribing patient care and health facility indicators in a primary and secondary health care facility. national journal of physiology, pharmacy and pharmacology. 2016;6(3):182-186. doi: http://dx.doi. org/10.5455/njppp.2016.6.23122015108 11. desalegn aa. assessment of drug use pattern using who prescribing indicators at hawassa university teaching and referral hospital,south ethiopia: acrosssectional study. bmc health services research. 2013;13:170. pmid: 23647871 doi: http://doi. org/10.1186/1472-6963-13-170 12. tamuno i, fadare jo.drug prescription pattern in a nigerian tertiary hospital. tropical journal of pharmaceutical research. 2012;11(1):146-152. doi: http://dx.doi.org/10.4314/tjpr.v11i1.19 13. sunanda g, ali aii, suchitra j, narayana g, ramaiah d. assessment of who core drug use indicators and drug utilization pattern in obstetrics and gynaecology department of secondary care referral hospital. international journal of pharmacy practice & drug research. 2017;7(1):8-13. doi: http://dx.doi.org/10.21276/ ijppdr.2017.7.1.3 14. yadav s, evangeline gs. a study on prescribing pattern of drugs in pregnant women attending a teaching hospital. international journal of pharmacology and therapeutics. 2016;6(1):9-26. available from: http://www.earthjournals. in/ijpt_308.pdf 15. ghimire s, nepal s, bhandari s, nepal p, palaian s. a prospective surveillance of drug prescribing and dispensing in a teaching hospital in western nepal. journal of pakistan medical association. 2009;59(10):726731. pmid: 19813695 16. department of drug administrations. national list of essential medicines nepal (fifth revision) 2016. available from: www.dda.gov.np/download/finalnlem2016.pdf j. lumbini. med. coll. vol 7, no 1, jan-june 2019 jlmc.edu.np bhatta a. et al. trend of breastfeeding and its impact on morbidity in children http://apps.who.int/medicinedocs/pdf/s4876e/s4876e.pdf http://apps.who.int/medicinedocs/pdf/s4876e/s4876e.pdf http://apps.who.int/medicinedocs/pdf/h3011e/h3011e.pdf http://apps.who.int/medicinedocs/pdf/h3011e/h3011e.pdf http://www.apps.who.int/medicinedocs/fr/d/js2289e/ http://www.apps.who.int/medicinedocs/fr/d/js2289e/ http://www.ijpsr.info/docs/ijpsr15-06-02-038.pdf http://www.ijpsr.info/docs/ijpsr15-06-02-038.pdf http://dx.doi.org/10.18203/2319-2003.ijbcp2015353 http://dx.doi.org/10.18203/2319-2003.ijbcp2015353 http://dx.doi.org/10.13040/ijpsr.0975-8232.8(9).3923-27 http://dx.doi.org/10.13040/ijpsr.0975-8232.8(9).3923-27 https://innovareacademics.in/journals/index.php/ajpcr/article/view/6669 https://innovareacademics.in/journals/index.php/ajpcr/article/view/6669 https://innovareacademics.in/journals/index.php/ajpcr/article/view/6669 https://doi.org/10.3126/hren.v13i2.17554 https://doi.org/10.3126/hren.v13i2.17554 http://dx.doi.org/10.18203/2320-6012.ijrms20181275 http://dx.doi.org/10.5455/njppp.2016.6.23122015108 http://dx.doi.org/10.5455/njppp.2016.6.23122015108 http://doi.org/10.1186/1472-6963-13-170 http://doi.org/10.1186/1472-6963-13-170 http://dx.doi.org/10.4314/tjpr.v11i1.19 http://dx.doi.org/10.21276/ijppdr.2017.7.1.3 http://dx.doi.org/10.21276/ijppdr.2017.7.1.3 http://www.earthjournals.in/ijpt_308.pdf http://www.earthjournals.in/ijpt_308.pdf http://www.dda.gov.np/download/finalnlem2016.pdf j. lumbini. med. coll. vol 7, no 2, july-dec 2019 acharya s, acharya s, et al. efficacy of tranexamic acid in reducing blood loss in cesarean section: a comparative study.et al. efficacy of tranexamic acid in reducing blood loss in cesarean section: a comparative study. 44 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 12 july, 2019 accepted: 21 november, 2019 published: 07 december, 2019 a associate professor, department of obstetrics & gynaecology b professor, department of obstetrics & gynaecology cuniversal college of medical sciences, bhairahawa, nepal. corresponding author: sarita acharya e-mail: saritaacharya142@yahoo.com orcid: https://orcid.org/0000-0001-8446-3309_______________________________________________________ —–————————————————————————————————————————————— abstract introduction: obstetric hemorrhage is one of the major causes of maternal morbidity and mortality. blood loss during cesarean section is almost twice than that in vaginal delivery. the aim of this study was to evaluate the efficacy of tranexamic acid to reduce blood loss in cesarean section and its side effects. methods: a comparative study was done in 100 women undergoing cesarean section between december 2015 to january 2017. the study group of 50 women received one gram intravenous tranexamic acid and the control group of 50 women did not receive tranexamic acid. primary outcome measure was blood loss during cesarean section. secondary outcome measures were drop in post-operative hemoglobin and hematocrit, change in pulse rate and blood pressure, need of additional uterotonics, auxiliary procedures to stop bleeding, blood transfusion rate and maternal and neonatal side effects of the drug. results: mean intraoperative blood loss in the study group was 443.62± 86.73ml; and in control group, 667.40±131.01ml (p<0.001). mean postoperative drop in hemoglobin (g/dl) in the two groups were 0.82±0.27 and 1.86±0.64 respectively (p<0.001). mean postoperative drop in hematocrit in the two groups were 2.60±0.91 and 5.49±1.97 respectively (p<0.001). fourteen patients in the control group required additional uterotonics while none in the study group (p<0.001). there was no significant difference in the transfusion requirement (p=0.079). none of the mothers and the newborns had major side effects of drug. conclusion: tranexamic acid is a safe and effective drug to reduce blood loss in cesarean section. keywords: blood loss, cesarean section, tranexamic acid original research articlehttps://doi.org/10.22502/jlmc.7i2.292 sarita acharya,a,c seoji mishrab,c efficacy of tranexamic acid in reducing blood loss in cesarean section: a comparative study how to cite this article:how to cite this article: acharya s, mishra s.acharya s, mishra s. efficacy of tranexamic acid in reducing efficacy of tranexamic acid in reducing blood loss in cesarean section: a comparative study. journal blood loss in cesarean section: a comparative study. journal of lumbini medical college. 2019;7(2):44-49. doi: https://of lumbini medical college. 2019;7(2):44-49. doi: https:// doi.org/10.22502/jlmc.v7i2.292doi.org/10.22502/jlmc.v7i2.292 epub: 2019 december 07. epub: 2019 december 07. introduction: obstetric hemorrhage is one of the major causes of maternal morbidity and mortality in lowincome countries. it accounted for more than 27% of maternal deaths in low-income regions and approximately 16% in high-income regions.[1] postpartum hemorrhage (pph) can kill a healthy woman within two hours of delivery.[2] blood loss during cesarean section (cs) is almost twice than that in vaginal delivery and hence there is a need of a drug that reduces blood loss during cs. tranexamic acid is a synthetic derivative of the amino acid lysine that exerts its anti-fibrinolytic effect through the reversible blockade of the lysine binding sites on plasminogen molecules.[3] it inhibits conversion of plasminogen to plasmin by tissue plasminogen activators.[4] it has been proved to reduce blood loss in elective surgery, trauma patients, dentistry and menstrual blood loss. tranexamic acid given within three hours of injury to a large cohort of adults with acute traumatic bleeding significantly reduced death due to bleeding, with no apparent increase in vascular occlusive events.[5] the optimal dosage and the route of administration in obstetric patients is unknown. for general fibrinolysis, a single dose of 1 gm or 10 mg/ kg by slow intravenous injection is recommended. j. lumbini. med. coll. vol 7, no 2, july-dec 2019 acharya s, acharya s, et al. efficacy of tranexamic acid in reducing blood loss in cesarean section: a comparative study.et al. efficacy of tranexamic acid in reducing blood loss in cesarean section: a comparative study. 45 jlmc.edu.np [6] the aim of this study was to evaluate the efficacy of tranexamic acid to reduce blood loss after cesarean section and its adverse effects. methods: this was a comparative study carried out from december 2015 to january 2017 in the department of obstetrics and gynecology, universal college of medical sciences. ethical clearance was taken from the institutional review committee (ucms/irc/114 /15). written informed consents were obtained from the participants. sample size was calculated by using the formula, n= 2x [z (1-α/2) +z β] 2 xσ2 δ2 where, significance level (α) was taken as 0.05, the desired power (β) as 0.80, standard deviation (σ) as 1 and minimal clinically important difference (δ) as 0.55. the calculated sample size was 50.36, that is 51 in each group. all patients with singleton pregnancy at term undergoing elective or emergency cs, except those who met exclusion criteria were included in the study. exclusion criteria were concomitant uterine fibroid, active liver or kidney disease, bleeding disorders, patients on anticoagulants, antepartum hemorrhage, polyhydramnios, macrosomic baby, multiple pregnancy, allergy to tranexamic acid, pre-eclampsia, eclampsia, obstructed labour, previous two or more cs and cesarean under general anesthesia. primary outcome measure was blood loss during cs, from incision to the closure of the skin. secondary outcome measures were change in postoperative hemoglobin and hematocrit at 24 hours, immediate and six hours post cs pulse rate and blood pressure, need of additional uterotonics, need for auxiliary procedures to stop bleeding (b-lynch suture, uterine artery ligation, internal iliac artery ligation and hysterectomy), and blood transfusion rate, and maternal and neonatal side effects of the drug used. patients were assessed for selection criteria as soon as the decision for cesarean section was made. investigations like hemoglobin, hematocrit, platelet, bleeding time (bt), clotting time (ct), prothrombin time/ international normalized ratio (pt/inr) were sent. patients were randomized through random number tables into two groups: group one, the study group of 51 women receiving preemptive tranexamic acid and group two, the control group of 51 women without tranexamic acid. however, two patients one in each group were excluded from the final analysis because they underwent cs under general anesthesia due to failed spinal anesthesia. injection tranexamic acid one gram was given intravenously to the patient in group one just before spinal anesthesia. two separate suction jars were used to collect the amniotic fluid and the blood. blood loss after the placental delivery to closure of skin incision was noted from the suction jar. difference of weight of tetra used before and after surgery was noted and blood loss was calculated. pulse rate and blood pressure were recorded immediately and at six hours after cs. hemoglobin and hematocrit were measured 24 hours after the surgery. all data were collected in the preformed proforma and entered into ms excel program. statistical analysis was done using statistical package for the social sciences (spsstm ) software version 21. student's t-test and chi-square test were used for the comparison of quantitative and qualitative variables respectively between the two groups. p value <0.05 was considered statistically significant. results: both groups were comparable in terms of age, gravidity, parity and period of gestation (table 1). table 1. comparison of demographic variables between two study groups (n=100) variables group 1 (n=50) (mean ± sd) group 2 (n = 50) (mean ± sd) p value* age (years) 25.71±4.6 25.20±4.6 0.82 gravidity 1.56±0.73 1.6±0.78 0.79 parity 0.50±0.64 0.48±0.58 0.87 period of gestation 39.33±1.40 39.46±1.15 0.61 * p value calculated by student's t test. there were 11 cases of elective and 39 cases of emergency cesarean in study group while 13 elective and 37 cases of emergency cesarean in j. lumbini. med. coll. vol 7, no 2, july-dec 2019 acharya s, acharya s, et al. efficacy of tranexamic acid in reducing blood loss in cesarean section: a comparative study.et al. efficacy of tranexamic acid in reducing blood loss in cesarean section: a comparative study. 46 jlmc.edu.np control group (χ2 = 3.03, df =2 p=0.22). fetal distress and previous cesarean were the most common indications in emergency and elective cesareans respectively. pre-operative laboratory parameters including hemoglobin, hematocrit, platelet, pt/inr, aptt, bt, ct were comparable in both the groups (table 2). mean intraoperative blood loss during cs in the study group was 443.6 ml while in control group was 667.4ml which was significantly less (t=10.07, df=98, p<0.001). similarly, postoperative drop in hemoglobin and hematocrit were significantly less in the study group receiving tranexamic acid compared to the control group (table 3). there were no significant differences in the heart rate and blood pressures measured immediately and at sixth postoperative hour between two groups (table 4). fourteen patients in control group required additional uterotonics while none in the study group received additional uterotonics, which was statistically significant (p<0.001). none of the patients in both groups required auxiliary surgical procedures to arrest hemorrhage. table 2. comparison of preoperative laboratory parameters between the study groups (n=100). variables group 1 (n=50) mean ± sd group 2 (n=50) mean ± sd p value* hemoglobin (g/dl) 11.32±1.03 11.58±1.07 0.21 hematocr it (%) 34.07±3.09 33.79±6.64 0.78 platelets (x109/l) 2.02±0.41 2.56 ± 2.97 0.20 inr 1.4± 0.09 1.4±0.13 0.72 aptt (seconds) 34.4±1.22 34.15±1.14 0.32 bt (minutes) 1.48±0.34 1.55±0.37 0.28 ct (minutes) 4.14±0.47 4.11±0.77 0.85 * p value calculated by student's t test. three patients in control group required blood transfusion while none of them required in study group. table 3. blood loss and post-operative blood parameters (n=100). variables group 1 (mean ± sd) group 2 (mean ± sd) p value intraoperative blood loss(ml) 443.62± 86.73 667.40±131.01 <0.001 postoperative hemoglobin at 24 hour (g/dl) 10.52±1.05 9.72±1.23 0.001 postoperative drop in hemoglobin (g/dl) 0.82±0.27 1.86±0.64 <0.001 post-operative hematocrit at 24 hour (%) 31.21±3.78 28.64±5.88 0.011 postoperative drop in hematocrit (%) 2.60±0.91 5.49±1.97 <0.001 table 4. postoperative vital parameters (n=100). variables group 1 (mean ± sd) group 2 (mean ± sd) p value immediate post-operative pulse rate 81.50±6.95 82.8±7.24 0.36 six hours post-operative pulse rate 77.96±5.1 78.92±5.4 0.36 immediate post-operative systolic blood pressure 119.48±7.94 118.28±6.84 0.42 immediate post-operative diastolic blood pressure 72.28±7.2 72.48±6.78 0.88 six hours post-operative systolic blood pressure 118.64±5.74 116.76±6.73 0.13 six hours post-operative diastolic blood pressure 72.36±5.07 70.44±5.33 0.40 j. lumbini. med. coll. vol 7, no 2, july-dec 2019 acharya s, acharya s, et al. efficacy of tranexamic acid in reducing blood loss in cesarean section: a comparative study.et al. efficacy of tranexamic acid in reducing blood loss in cesarean section: a comparative study. 47 jlmc.edu.np none of the patients had major side effects of tranexamic acid while nausea, vomiting and dizziness were present in 16%, 6% and 2% respectively. there was no significant difference in apgar score of neonates in two groups at 5 and 10 minutes with p value of 0.36 and 0.40 respectively. one neonate in the study group developed seizure which was managed with anticonvulsant. discussion: postpartum hemorrhage is defined as blood loss of more than 500ml in vaginal delivery and 1000ml in cs but can occur even with lesser amount than this in previously compromised patients like in anemia. most of the maternal deaths occur soon after giving birth and almost all (99%) occur in low-income and middle-income countries.[7,8] one fourth of post partum maternal deaths is due to hemorrhage. hemorrhage following cs is not uncommon and reducing the amount of cs blood loss carries special sense in countries like nepal where many pregnant women are already anemic. following placental delivery, the level of fibrinogen and fibrin decreases and tissue plasminogen activator activity also increases converting plasminogen to plasmin. this activation can take up to six to ten hours in the postpartum period.[9] tranexamic acid which is a potent antifibrinolytic drug inhibits this conversion and helps in reducing blood loss following cs. the drug is cheaper, stable at room temperature, a fixed dose can be used without serious maternal and fetal side effects. the patients in the study group had significantly less amount of intraoperative blood loss (443.62ml) compared to those in the control group (667.40ml) (p<0.001). this observation was similar to the result of other large studies on the subject matter.[10,11] as the amount of blood loss was significantly higher in the control group, the drop in postoperative hemoglobin and hematocrit were also higher compared to the study group, which was statistically significant (p<0.001). tranexamic acid can increase the pulse rate especially in elderly women. in this study there was no significant difference in the pulse rate among the two groups of patients taken immediately and at six hours following cs. this study did not show any significant change in post cs systolic and diastolic blood pressures among the two groups. our results on the effect of tranexamic acid in postoperative vitals were consistent with other studies.[9,12] conventionally uterotonics are the only drugs used to reduce the postpartum blood loss in all modalities of deliveries and are effective as well. however, with the introduction of tranexamic acid which acts through different mechanism their use is declining. fourteen patients in control group compared to none in the study group required additional uterotonics, which was statistically significant (p<0.001). interestingly, none of the patients in either group required any auxiliary surgical procedures to arrest hemorrhage. although tranexamic acid reduced the amount of blood loss significantly it did not have significant impact on the transfusion requirement in large studies like woman trial.[13] in the current study, three patients in control group required blood transfusion while none of them required in study group (p=0.079). one of the most feared complications of tranexamic acid is the possibility of thromboembolism in the context of higher incidence of thrombosis during pregnancy and postpartum. the incidence of thrombosis during pregnancy and puerperium is five to six times higher than that in the general population and postpartum venous thromboembolism is more common than antepartum venous thromboembolism.[14] unlike this none of our patients had thromboembolic events. other large series also failed to demonstrate the increased risk of thromboembolism with the use of tranexamic acid during pregnancy.[13,15,16,17] minor side effects like nausea, vomiting and dizziness were present in 16%, 8% and 2% of patients respectively who received tranexamic acid. these minor symptoms did not increase the additional morbidity to the patients. in this study there was no maternal death in either group due to postpartum hemorrhage following cs. in a large series the use of tranexamic acid had significantly reduced maternal death due to postpartum hemorrhage without significant adverse effects.[13] tranexamic acid given to the mother did not show any adverse effects on neonatal outcome. there was no differences in apgar score at 5 mins and at 10 mins, seizure and thrombotic events in neonates of both the groups. these observations were similar to the results of another study.[10] j. lumbini. med. coll. vol 7, no 2, july-dec 2019 acharya s, acharya s, et al. efficacy of tranexamic acid in reducing blood loss in cesarean section: a comparative study.et al. efficacy of tranexamic acid in reducing blood loss in cesarean section: a comparative study. 48 jlmc.edu.np there are certain limitations of this study. firstly, the sample size is small in the context of increasing cs rate and the extent of the problem of post partum hemorrhage. secondly, the standard method of estimation of blood loss was not applied due to technical problems. conclusion: the preemptive use of tranexamic acid before cesarean section effectively reduces blood loss and need for transfusion without significant adverse effects in the mother and the new born. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. j. lumbini. med. coll. vol 7, no 2, july-dec 2019 acharya s, acharya s, et al. efficacy of tranexamic acid in reducing blood loss in cesarean section: a comparative study.et al. efficacy of tranexamic acid in reducing blood loss in cesarean section: a comparative study. 49 jlmc.edu.np references: 1. inter-agency and expert group on millennium development goals indicators. the millennium development goals report 2015. department of economic and social affairs of the united nations secretariat. 2015. available from: https://bit.ly/37kmtjt 2. who. the world health report: 2005: make every mother and child count. world health organization. 2005. available from: https:// bit.ly/2oqxwln 3. wellington k, wagstaff aj. tranexamic acid: review of its use in management of menorrhagia. drugs. 2003;63(13):1417-33. pmid: 12825966 doi: 10.2165/00003495200363130-00008 4. roberts i. tranexamic acid in trauma: how should we use it? j thromb haemost. 2015;13(suppl 1):s195–9. pmid: 26149023 doi: https://doi.org/10.1111/jth.12878 5. crash-2 trial collaborators, shakur h, roberts i, bautista r, caballero j, coats t, et al. effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (crash-2): a randomised, placebocontrolled trial. lancet. 2010;376(9734):23– 32. pmid: 20554319 doi: 10.1016/s01406736(10)60835-5 6. walker g, association of british pharmaceutical industry. abpi compendium of data sheets and summaries of product characteristics, 1998-99: with the code of practice for the pharmaceutical industry. london : datapharm publication; 1998. 7. ronsmans c, graham wj. maternal mortality: who, when, where, and why. lancet. 2006;368(9542):p1189–1200. doi:10.1016/s0140-6736(06)69380-x 8. say l, chou d, gemmill a, tuncalp o, moller ab, daniels j, et al. global causes of maternal death: a who systematic analysis. lancet glob health. 2014;2(6):e323–e33. pmid: 25103301 doi: 10.1016/s2214-109x(14)70227-x 9. gai my, wu lf, su qf, tatsumoto k. clinical observation of blood loss reduced by tranexamic acid during and after cesarean section: a multicenter, randomized trial. eur j obstet gynecol reprod biol. 2004;112(2):154–7. pmid: 14746950. doi: https://doi.org/10.1016/ s0301-2115(03)00287-2 10. bhavana g, abhishek mv, mittal s. efficacy of prophylactic tranexamic acid in reducing blood loss during and after cesarean section. international journal of reproduction, contraception, obstetrics and gynecology. 2016;5(6):2011-6. doi: 10.18203/2320-1770. ijrcog20161708 11. yehia ah, koleib mh, abdelazim ia, atik a et al. tranexamic acid reduces blood loss during and after cesarean section: a double blinded, randomized, controlled trial. asian pacific journal of reproduction. 2014;3(1):536. doi: 10.1016/s2305-0500(14)60002-6 12. gohel m, patel p, gupta a, desai p. efficacy of tranexamic acid in decreasing blood loss during and after cesarean section: a randomized case controlled prospective study. the journal of obstetrics and gynecology of india. 2007;57(3):227–30. available from: https:// bit.ly/37lddlj 13. woman trial collaborators. effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (woman): an international, randomised, double-blind, placebo-controlled trial. lancet. 2017;389:2105–16. doi: 10.1016/s01406736(17)30638-4 14. bekassy z, astedt b. treatment with the fibrinolytic inhibitor tranexamic acid-risk for thrombosis? acta obstetricia et gynecologica scandinavica. 1990;69(4):353–4. doi: 10.3109/00016349009036161 15. gungorduk k, asıcıoğlu o, yıldırım g, ark c, tekirdağ ai̇, besımoglu b. can intravenous injection of tranexamic acid be used in routine practice with active management of the third stage of labor in vaginal delivery? a randomized controlled study. am j perinatol. 2013;30(5):407–13. pmid: 23023559 doi: 10.1055/s-0032-1326986 16. svanberg l, astedt b, nilsson im. abruptio placentae-treatment with the fibrinolytic inhibitor tranexamic acid. acta obstericiat et gynecologica scandinavica. 1980;59(2):127– 30. doi: 10.3109/00016348009154628 17. movafegh a, eslamian l, dorabadi a. effect of intravenous tranexamic acid administration on blood loss during and after cesarean delivery. international journal of gynaecology & obstetrics. 2011;115(3):224–26. doi: https://doi.org/10.1016/j.ijgo.2011.07.015 j. lumbini. med. coll. vol 8, no 1, jan-june 2020 bajracharya s, et al. bajracharya s, et al. effectiveness of structured teaching program on menstrual hygiene among adolescent school girls. . licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 02 march, 2020 accepted: 24 may, 2020 published: 30 june, 2020 a assistant professor, department of obstetrics and gynecology b lumbini medical college teaching hospital, palpa, nepal. corresponding author: shreyashi aryal e-mail: shreyashiaryal@gmail.com orcid: https://orcid.org/0000-0002-6832-3530_______________________________________________________ —–———————————————————————————————————————————— abstract introduction: neonatal congenital anomalies are the 17th leading cause of global burden of disease. congenital anomalies in low-income countries are high due to prevalence of nutritional deficiencies, intrauterine infections, teratogenic exposure and unsupervised self-medication. this study aimed to find various antenatal risk factors for birth defects and the delays in health seeking behaviors in cases of still births with birth defects. methods: the records of mothers and neonates born with congenital anomalies during the period of 30 months were reviewed. consanguinity, intrauterine infections, presence of anemia, and history of drug intake were noted. in cases of stillborn with anomalies; mode of delivery, labor complications and the delays leading to morbidities were also noted. results: there were 65 congenital anomalies among 6984 consecutive deliveries during the study period with an incidence of 9.3 per 1000 births. out of all diagnosed anomalies, 43 were seen in live births and 22 in still births. the common anomaly noted amongst live births was of musculoskeletal system (n=11, 25.5%) whereas defects in nervous system was common in the still born fetus (n=10, 45.4%). a notable finding in the present study was consanguinity which was present in 30 parents (46.1%) whose newborn had a congenital defect. folic acid supplementation was taken by only 26 mothers (40%) in the present study. in cases of still births with anomalies, most deliveries were vaginal (97%) without any maternal complications. delay in deciding to seek care was observed in most cases (n=14, 63.6%) in the present study. conclusion: non consanguineous marriage and folic acid supplementation is useful in preventing congenital anomalies. encouraging early antenatal visits might help in early detection of anomalies. keywords: birth defect, folic acid, risk factors, still birth original research articlehttps://doi.org/10.22502/jlmc.v8i1.317 shreyashi aryal,a,b deepak shrestha a,b “overcoming the defect”: congenital anomalies in 6984 consecutive deliveries in a tertiary care center in nepal how to cite this article:how to cite this article: aryal s, shrestha d. “overcoming the defect”: congenital anomalies in 6984 consecutive deliveries in a tertiary care center in nepal. journal of lumbini medical college. 2020;8(1):7 pages doi: https:// doi.org/10.22502/jlmc.v8i1.317 epub: 2020 june 30. introduction: neonatal congenital anomalies are the 17th leading cause of global disease burden, and a traumatizing experience to a mother and an overwhelming encumber to the family.[1] congenital anomalies in low-income countries are high due to prevalence of nutritional deficiencies, intrauterine infections, exposure to teratogen and unsupervised self-medications.[2]recognizing the causative factors for still births and congenital anomalies play an important role in preventing these conditions. identifying both clinical and socio-demographic factors and further educating on preconceptional and prenatal risks will help in reducing the rate of still births and birth defects. this study was aimed to find various antenatal risk factors for birth defects and to evaluate the delays in health seeking behaviors in cases of still births with birth defects. methods: this was a retrospective study carried outin the department of obstetrics and gynecology of lumbini medical college and teaching hospital, j. lumbini. med. coll. vol 8, no 1, jan-june 2020 aryal s, et al. “overcoming the defect”: congenital anomalies in 6984 consecutive deliveries in a tertiary care center in nepal jlmc.edu.np nepal over a period of two months from february to march 2020. during this period,the records of neonates born with congenital anomalies during the period of thirty months (june 2016 to december 2019) were reviewed. neonatal records of all babies with congenital anomalies were studied and antenatal history reviewed. consanguinity, intrauterine infections, presence of anemia, history of drug intake, alcohol consumption and smoking during pregnancy were noted. in cases of stillborns with anomalies, mode of delivery, labor complications and the three delays leading to morbidities namely, delay in seeking care, reaching care and receiving care were also noted. still births were taken as birth of a baby with no signs of life after 22 weeks of gestation or weighing >500 grams, which included both antepartum and intrapartum still births. the present study included the congenital anomalies where the diagnosis was made by a pediatrician after thorough clinical evaluation. different types of birth defects classified according to their international classification of diseases (icd-10). all the collected socio-demographic and clinical information were recorded in a structured proforma. the data were then entered and analyzed using statistical package for social sciences (spsstm) software version 20. results were expressed as frequencies, percentages, mean, and standard deviations.this study was approved from institutional review committee (irc-lmc 03-j/019) of lumbini medical college teaching hospital. results: during the study period, there were 6984 total deliveries out of which 65 babies were born with congenital anomalies. the incidence was 9.3 per 1000 births. twenty-two babies (33.85%) were still births and the remaining 43 (66.15%) were born alive. the mean age of the mothers was 24.33 ± 4.31 years. table 1 shows the different types of birth defects classified according to their international classification of diseases (icd 10) codes. the most common birth defect was of the nervous system (24%) followed by musculoskeletal system (17%). anencephaly and talipes equinovarus were the most frequent anomalies in these systems. the most common anomaly in still births was that of thenervous system (n=10, 45.4%) and in live births wasthat of the musculoskeletal system (n=11,25.5%). birth defects were more common in female babies (n=34, 52.3%) than in males (n=31, 47.7%). out of all the babies born with birth defects, 39 (60%) were term pregnancies, 18(27.7%) were preterm and the rest were post term i.e. born after 42 weeks. antenatal risk factors for birth defects are shown in table 2. consanguinity was present in 30 (46.1%) of the cases and folic acid wastaken by 26(60%) mothers only. delivery was by vaginal route in 21 (94.5%) cases of still births with birth defects. delay in recognizing need of care was the most common table 1. type of birth defects in live and still births (n=65). type of birth defect icd codes live birth n=43 still birth n=22 total n (%) congenital malformations of the nervous system q00-q07 9 10 19 (29.2) congenital malformations of eye, ear, face and neck q10-q18 4 1 5 (7.6) congenital malformations of the circulatory system q20-q28 6 1 7 (10.7) congenital malformations of the respiratory system q30-q34 3 1 4 (6.1) cleft lip and palate q35-q37 4 1 5(7.6) other congenital malformations of the digestive system q38-q45 3 0 3(4.6) congenital malformations of the urinary system q60-q64 1 0 1 (1.5) congenital malformations and deformations of the musculoskeletal system q65-q79 11 6 17 (26.1) other congenital malformations q80-q89 1 1 2(3.0) chromosomal abnormalities, not elsewhere classified q90-q99 1 1 2(3.0) j. lumbini. med. coll. vol 8, no 1, jan-june 2020 aryal s, et al. “overcoming the defect”: congenital anomalies in 6984 consecutive deliveries in a tertiary care center in nepal jlmc.edu.np delay seen in 63.6% women (table 3). the causes for delayed care seeking were no knowledge of danger signs, family pressure to deliver at home, husband living abroad thus no family support, previous negative experience in health facility. causes for delay in reaching care were financial constraints and bad roads, unavailability of vehicles during monsoons and delayed referral from primary health centers. table 3. still births with birth defects and labor characteristics. (n=22). variables frequency (%) mode of delivery normal 20 (90.9) vaginal breech 1 (4.5) cesarean section 1 (4.5) pregnancy complications none 16 (72.75) intrauterine growth restriction 3 (13.6) hypertensive disease of pregnancy 1 (4.5%) polyhydramnios 2 (9.1%) delays causing morbidities delay in recognizing care 14 (63.6%) delay in seeking care 8 (36.4) delay in receiving care 0 (0) discussion: congenital anomalies are reported to account for 2.1–33.3% of stillbirths in lowand middleincome countries.[2]the frequency of anomalies in this study was 9.3 per 1000 births. the march of dimes data on birth defects in south east asian region shows nepal has the rate of 59.9 per 1000 live births.[3] in a prospective study in china, the prevalence of birth defects was 25.24 per 1000 perinatal infants with an uptrend over the past five years.[4] the frequency of congenital anomaly reported in other studies are 3.46% in bangladesh[5] and 0.81% and 0.3% in other centers in nepal.[6,7] in a community household survey in nepal, prevalence of congenital anomalies was 52 per 10,000.[8] the commonly reported anomalies are cleft lip and palate,[6] anomalies central nervous system[7] and genitourinary system.[9] our study too revealed common involvement of central nervous system and musculoskeletal system which was similar to a study conducted in nigeria.[10] frequency of birth defects in nepal is low compared to other countries. under reporting of cases could be a major cause. most of the congenital anomalies are reported from hospital data and anomalies in newborns delivered at home are missed. nepal still has 57% of home deliveries.[11] on the other hand, the incidence of birth defects in a rural setting should have been high as they are diagnosed late in pregnancy and the chances of early termination before the period of viability of 22 weeks is decreased. in a study done by s shrestha et al, among 99 anomalies, 29 (29.29%) were detected before the period of viability.[12] in the institute where this study is based, antenatal screening tests which are done routinely and have the potential to diagnose risk factors include blood sugar, venereal disease and ultrasonography. screening tests like thyroid function tests or tests for infections like torch and for down syndrome table 2. antenatal risk factors in birth defect cases. risk factors live births (n=43) n (%) still births (n=22) n (%) total (n=65) n(%) antenatal visits <4 22(51.5) 9 (40.9) 31 (52.3) consanguinity 19(44.2) 11 (50) 30 (46.1) folic acid not taken 28(65.1) 11 (50) 39 (60.0) alcohol during pregnancy 4(9.3) 3(13.6) 7 (10.7) maternal smoking during pregnancy 1 (2.3) 3(13.6) 4 (6.1) intrauterine infections 1 (2.3) 2(9.1) 3 (4.6) anemia 5(11.6) 8(36.4) 13 (20.0) history of drug intake 2(4.7) 0 (0.0) 2 (3.0) j. lumbini. med. coll. vol 8, no 1, jan-june 2020 aryal s, et al. “overcoming the defect”: congenital anomalies in 6984 consecutive deliveries in a tertiary care center in nepal jlmc.edu.np like triple test are still not affordable to all patients. two newborns with anomalies suspected to have chromosomal anomalies in this study could probably have been diagnosed with downs syndrome if these tests were made available. women coming to our institute also do not opt for these tests even when advised because of financial constraints. fetal echo has a prominent role in diagnosis of cardiovascular anomalies but again this is not accessible to women in this hilly region of the country so these anomalies are not detected in the antenatal period and maybe missed in the neonatal period if they are asymptomatic till late infancy. neonatal screening for inborn errors of metabolism is not available and few cases of suspected anomalies in the neonatal period refuse to undergo confirmatory tests and leave against medical advice. this is a discouraging issue for service providers as the chance of correct diagnosis and counseling for future pregnancy is missed. another major hurdle in the accurate diagnosis and cause of birth defect is the unavailability of fetal autopsy. this can be done only for medico-legal purposes and even if clinical autopsy maybe possible; patients do no give consent for the procedure due to cultural reasons. maternal diabetes mellitus is a well documented risk factor for birth defects.[13] this study did not see any cases of diabetes as the incidence is low in this part of the country and also because women present late in pregnancy and the diagnosis is missed. consanguinity is an established risk factor for birth defects. the location of this center in western nepal has more people with indigenous groups where consanguineous marriages are acceptable. it was present in 46.1% of cases in this study. in the study by rittler m et al., a significant association of consanguinity was observed for three congenital anomalies namely, hydrocephalus, hand polydactyly, and bilateral cleft lip or cleft palate.[14] in another study in north-eastern france, consanguineous mating was present in 1.21% in parents of babies with birth defects whereas control group had consanguinity in only 0.27% (p < 0.001). birth defects were 10.3 times more frequent in first degree consanguinity.[15] another study done in norway also showed that the relative risk of birth defects among children born with first degree consanguinity was about two.[16] our study did not evaluate the association of consanguinity with different types of birth defects. a larger study with evaluation of each anomaly with consanguinity could be a scope for future studies. folic acid supplementation helps in prevention of neural tube defects.[17] in this study only 40% women had taken folic acid. since all pregnancies are not planned, and even if they are, first antenatal visits are usually in the second trimester, this supplementation is not possible in our context. peri-conceptional use of folic acid is recommended after large randomized trials[18] but in the context of rural nepal, this is still a far-fetched goal due to lack of awareness. in a study by paudel p et al., only 5% women knew that folic acid is to be taken prepregnancy.[19] a large meta-analysis showed that folic acid fortification reduces the incidence of spina bifida. [20] food fortification with folate has not been as successful as pregnancy supplementation coverage in nepal.[21] therefore this aspect has to be strengthened. history of cigarette smoking and alcohol during pregnancy was present in only 10.7% mothers. this could be one reason for low incidence of birth defects. finnel r et al. states that approximately 3% to 5% of children born in the united states have birth defects out of which 2% and 3% are teratogeninduced malformations resulting from environmental or iatrogenic exposures during pregnancy.[22] this study showed low rate of birth defects and even lower rate of teratogenic exposure. this could mean that women in this low-income country are currently facing issues of lack of awareness in consanguinity and inadequate antenatal and nutritional care but if they face greater environmental exposure to teratogens, the rate is likely to increase in the near future. the three delays model (delay in recognizing need of care, reaching care and receiving care) has been used in assessing causes of maternal and neonatal morbidities and mortalities. [23,24] this study used the same model for understanding causes of still births with birth defects. delay in seeking care was the most common delay. this was the cause of inadequate peri-conceptional and antenatal care and delayed diagnosis. women in rural nepal, do not get optimal care due to unavailability of basic needs like family support or transportation facility. 63.6% j. lumbini. med. coll. vol 8, no 1, jan-june 2020 aryal s, et al. “overcoming the defect”: congenital anomalies in 6984 consecutive deliveries in a tertiary care center in nepal jlmc.edu.np of women with still births with anomalies who otherwise if had come to the facility in time could probably have had live births. if they had adequate knowledge on antenatal care, their babies could have been prevented from having birth defects or could have been timely diagnosed. primary health centers in nepal have been strengthened over time and most women coming for antenatal visits are suggested to go to a tertiary center for anomaly scan at 20 weeks. this increases the rate of early detection of anomalies. but those women coming late for antenatal check up cannot be helped much in preventing birth defects but proper counseling for present and future pregnancy is still an opportunity not lost. awareness regarding consanguineous marriage and folic acid intake before conception is necessary and can be done only if periconceptional visit to a heath center is reinforced. working on tackling the issue of delays in seeking care is seen as necessary so that birth defects are diagnosed in time. either early termination of pregnancy can be advised or screening tests can be planned or at least they can be referred to a center for rehabilitation for babies with deformities. in the context of limited availability of diagnostic tests and treatment, preconceptional use of folic acid and timely diagnosis during antenatal period is a possible way to decrease birth defects and its morbidities and to help mothers with a less traumatic birth experience. this study has a few limitations. this was a hospital based observational study. congenital anomalies need to be assessed in a larger study in patients with or without established risk factors. this study does not consider environmental and dietary factors which are major contributors to birth defects. degree of consanguinity can also be assessed in future studies as it is related to severity and involvement of different systems. conclusion: birth defects are common in this part of the country. factors like consanguinity and intake of folic acid are associated modifiable factors which can be useful in preventing congenital anomalies. encouraging early antenatal visits might help in early detection of anomalies. this will provide an opportunity for timely counseling so that it is less traumatic to the mother and the family. conflict of interest: authors declare that no competing interest exists. financial disclosure: no funds were available for the 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pmid: 12577128. doi: https://doi.org/10.1016/s1701-2163(16)30207-9 19. paudel p, wing k, silpakar sk. awareness of periconceptional folic acid supplementation among nepalese women of childbearing age: a cross-sectional study. prev med. 2012;55(5):511-3. pmid: 22975411. doi: https://doi.org/10.1016/j.ypmed.2012.09.001 20. callie ama, fiest km, frolkis ad, jette n, pringsheim t, st germaine-smith c, et al. global birth prevalence of spina bifida by folic acid fortification status: a systematic review and meta-analysis. am j public health. 2016;106(1):e24-34. pmid: 26562127. doi: https://doi.org/10.2105/ajph.2015.302902 21. victora cg, barros fc, assunção mc, restrepo-méndez mc, matijasevich a, martorell r. scaling up maternal nutrition programs to improve birth outcomes: a review of implementation issues. food nutr bull. j. lumbini. med. coll. vol 8, no 1, jan-june 2020 aryal s, et al. “overcoming the defect”: congenital anomalies in 6984 consecutive deliveries in a tertiary care center in nepal jlmc.edu.np 2012;33(2 suppl):s6–26. pmid: 22913105. doi: https://doi.org/10.1177/15648265120332s102 22. finnell rh. teratology: general considerations and principles. jallergy clin immunol. 1999;103(2 pt2):s337 s342. pmid: 9949334. doi: https://doi.org/10.1016/s00916749(99)70259-9 23. wilmot e, yotebieng m, norris a, ngabo f. missed opportunities in neonatal deaths in rwanda: applying the three delays model in a cross-sectional analysis of neonatal death. mater child health j. 2017;21(5):1121-29. pmid: 28214925. doi: https://doi.org/10.1007/ s10995-016-2210-y 24. barnes-josiah d, myntti c, augustin a. the “three delays” as a framework for examining maternal mortality in haiti. soc sci med. 1998;46(8):981-93. pmid: 9579750. doi: https://doi.org/10.1016/s0277-9536(97)10018-1 j. lumbini. med. coll. vol 7, no 2, july-dec 2019 koirala m, et al. koirala m, et al. risk factors for obesity in nepalese women: a cross-sectional study 93 jlmc.edu.np licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 18 july, 2019 accepted: 25 november, 2019 published: 21 january, 2020 a lecturer, college of nursing b nursing officer clecturer, department of community medicine dlumbini medical college teaching hospital, palpa, nepal. eunited mission hospital, palpa, nepal. fnorvic international hospital, kathmandu, nepal. corresponding author: mamta koirala e-mail: koirala.mamta10@gmail.com orcid: https://orcid.org/0000-0001-8822-8111 _______________________________________________________ —–————————————————————————————————————————————— abstract introduction: obesity is defined as an abnormal or excessive fat accumulation that may impair health. it is on the rise worldwide, not sparing developing countries. both demographic and socioeconomic factors play an important part in its causation. body mass index is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults. this study was done with objectives of assessing the prevalence of overweight and obesity and its associated factors among adult women attending selected outpatient departments of tertiary care centre in western region of nepal. methods: a descriptive cross-sectional study was conducted for six months. a total of 160 female respondents aged more than 20 years attending outpatient departments were included in the study using non-probability convenient sampling technique. data on socio-demographic status, dietary pattern, health risk behavior and presence of chronic illness were collected and anthropometric measurements were taken for all the respondents. results: the prevalence of overweight and obesity were 31.8% and 3.8% respectively. there was statistically significant association between obesity and overweight with age (p=0.044), educational status (p=0.017), frequency of consumption of fruits (p=0.029), dietary pattern (p=0.023), frequency of consumption of dairy products (p=0.019), marital status (p=0.020) and drinking alcohol (p=0.022). conclusion: age, educational status, frequency of consumption of dairy products, dietary habits, marital status and drinking habits were statistically associated with obesity and overweight among adult women. keywords: body mass index; obesity; prevalence; risk factors; women original research articlehttps://doi.org/10.22502/jlmc.v7i2.294 mamta koirala,a,d srishti bajracharya,a,d mohan laxmi koirala,b,e sarita neupane,b,f keshav raj bhandaric,d risk factors for obesity in nepalese women: a cross-sectional study how to cite this article:how to cite this article: koirala m, bajracharya s, koirala ml, neupane s, bhandari kr. risk factors for obesity in nepalese women: a cross-sectional study. journal of lumbini medical college. 2019;7(2):93-99. doi: . journal of lumbini medical college. 2019;7(2):93-99. doi: https://doi.org/10.22502/jlmc.v7i2.294. epub: 2019 january 21.https://doi.org/10.22502/jlmc.v7i2.294. epub: 2019 january 21. introduction: overweight and obesity are considered to be the fifth leading risk for global deaths, estimating that 2.8 million adults die each year as a result of being overweight or obese.[1] body mass index (bmi) is defined as a person’s weight in kilograms divided by the height in meters squared (kg/m2). the world health organization (who) definition states a bmi greater than or equal to 30 is obesity and a bmi greater than or equal to 25 is overweight.[2] obesity was initially most visible in developed countries but recent global figures indicated that it was increasing in the developing world as there was marked change in lifestyle.[3] therefore, who has emphasized in the importance of monitoring the prevalence and secular trends for overweight and obesity in each country.[4] women have higher rates of obesity than men globally, and positive association was seen with marriage, lower educational level, alcohol use and high socio-economic status.[5] the who monica project also stated that the lower education was associated with higher bmi in about half of the male and in almost all of the female populations.[6] the prevalence of obesity in women in south asian countries, nepal and bangladesh, between 1996 j. lumbini. med. coll. vol 7, no 2, july-dec 2019 koirala m, et al. koirala m, et al. risk factors for obesity in nepalese women: a cross-sectional study 94 jlmc.edu.np and 2006 showed increment from 1.6% to 10% and from 2.7% to 8.9%, respectively.[7] women, in particular, have a higher prevalence of obesity that increases with age.[1] in nepal dietary pattern has significantly changed in recent years and overweight and obesity among women were associated with fewer intakes of fruits in diet.[8] several national and international research studies were conducted in this topic and many national studies were limited to capital city kathmandu and eastern nepal but none of the studies were documented for western nepal.[9,10] identifying the risk factors associated with obesity and overweight may help to determine the target groups for prevention. so, this study aimed to assess the prevalence of overweight and obesity among the adult women and its risk factors in western hilly regions of nepal. methods: this was a descriptive cross-sectional study conducted in lumbini medical college and teaching hospital (lmcth) from july to december, 2017, after receiving permission from institutional review committee of lumbini medical college and teaching hospital (irc-lmc 121641/070/071). sample size was calculated using the formula n= z2p(1-p)/d2 where n = sample size, z = 2.58, at level of confidence of 99%, p= 40.1%,[10] and d = 0.01 with desirable error of 10%. the sample size was calculated to be 159. for the present study the sample size was taken to be 160. a total of 160 female respondents above 20 years of age attending outpatient departments (opds) of obstetrics & gynecology and medicine were enrolled in the study using non-probability convenient sampling technique. pregnant, nonconsenting and physically disabled females were excluded from the study. data collection tool for the present study was a structured questionnaire which was pre-tested in 10% of the anticipated sample. all the respondents were interviewed by the principal investigator. the questionnaire consisted of two parts: • part one included sociodemographic data consisting of age, ethnicity, educational status, occupation, marital status, menstrual cycle, parity and anthropometric measurement (weight and height). • part two consisted of factors associated with obesity including dietary behavior, health risk behavior and presence of chronic illness. weight was taken by an electronic bathroom scale and the same scale was used for all the participants. before measurement, the scale of the machine was set to zero and respondents were asked to remove any ‘heavy’ items (key, mobile, hand bag etc.) before taking weight. respondents were weighed barefoot and dressed in the lightest clothes possible. while measuring weight they were asked to look straight ahead and stay still on the scale. the height of the respondents was measured with a standard stadio-meter, brand roks+ and model mi20. bmi was calculated for each respondent. overweight was defined as having a bmi between 25.0 and 29.9 kg/m2 and obesity as having a bmi equal or greater than 30.0 kg/m2.[5] separate room was used for data collection to maintain the confidentiality of the respondents. data was collected using face to face interview technique and then entered and analyzed using statistical package for social sciences (spsstm) software version 16. descriptive statistics were measured by mean, median and standard deviation (sd), whereas inferential statistics like chi square test was used for association-values and odds ratios (or) and their 95% confidence intervals (ci) were computed. analysis was done with binary logistic regression analysis with obesity as the dependent variable and other factors as the independent variables. p-value <0.05 was considered to be significant. results: the study included 160 females with a mean age of 40.17 ± 12.49 years, of which the most belonged to the age range of 21-39 years. majority of the respondents were janajati (45%). more than half of the respondents were job holders, businesswomen/ shopkeeper, students and engaged in farming (61.3%) and 38.7% were housewives. majority of the respondents were janajati (45%), hailed from rural locality (63.7%) and were multi para (82.9%) (table 1). j. lumbini. med. coll. vol 7, no 2, july-dec 2019 koirala m, et al. koirala m, et al. risk factors for obesity in nepalese women: a cross-sectional study 95 jlmc.edu.np the mean bmi of the respondents was 23.81±3.42 kg/m2. there were 64.4% respondents with normal bmi whereas 31.8% and 3.8% of respondents were overweight and obese respectively. the combined prevalence of overweight and obesity was 35.6% (table 2). based on the result for association of bmi with independent variables, age (p=0.044), educational status (p=0.017), frequency of consumption of fruits (p=0.029), dietary pattern (p=0.023), frequency of consumption of dairy products (p=0.019), marital status (p=0.020) and drinking alcohol (p=0.022) were found to be independently associated with bmi (table 3). analysis of risk factors with overweight and obesity showed that those women who consumed fruits more than three times a week were 80% less likely to get overweight/obese than those who consume fruits once a week (or=0.192, 95% ci:0.044-0.838, p=0.028) (table 4). the overall model significant value for those variables is <0.001. the covariates which were found as the risk factors of obesity had an impact of 19 to 26 percent in overall study. (table 5) discussion: the present study revealed the prevalence of overweight and obesity in nepalese women of western hilly region to be 35.7% which is consistent with another nepalese study conducted by vaidya a et al. where the prevalence of obesity was 33%.[9] similar findings were noted among turkish women where prevalence of overweight/obesity was 35%. [11] there was positive association between age of the respondents and overweight/obesity which was in line with the study conducted by vaidya a, et al.[9] such high incidence in prevalence of overweight and obesity may be due to urbanization, lifestyle and nutritional pattern. but negative association was reported by the study conducted by ghorbani r, in iranian women and shahi m et al., in nepal.[4,8] education is an important factor for women to be healthy. similar to our findings, saeed et al. also noted significant association between level of education and overweight/obesity.[12] literate women are more health conscious and less likely to be overweight/obese than illiterate woman. however, a nepalese study noted negative association of education with obesity.[8] the present study did not show significant association between place of residency (urban versus rural) and overweight and obesity, the findings of which are similar to studies conducted in iranian middle aged women.[4] a study conducted by weng hh et al., 7% increase in risk of obesity was noted for each additional child, which is in contrast to the recent study which shows parity is not associated with overweight and obesity.[13] likewise, this study revealed that there is table 1. socio-demographic distribution of the study population (n=160) variables frequency n (%) age 21-39 years 96 (60.0) 40-59 years 55 (34.4) ≥ 60 years 9 (5.6) ethinicity janajati 72 (45.0) dalit 20 (12.5) brahmin/ chhetri 68 (42.5) education illiterate 19 (11.9) literate 141 (88.1) occupation housewife 62 (38.7) business/shopkeeper 37 (23.1) student 12 (7.5) job holder 22 (13.8) farming 27 (16.9) marital status married 146 (91.3) unmarried 14 (8.7) parity (n=146) primipara 16 (10.9) multipara 121 (82.9) nullipara 09 (6.2) menstrual cycle yes 101(63.1) no 59 (36.9) residence rural 102 (63.7) urban 58 (36.3) diet vegetarian 26 (16.2) nonvegetarian 134 (83.8) table 2: distributions of respondent’s bmi (n=160) bmi classification frequency n(%) mean ± sd normal weight 103 (64.4) 3.81 ± 3.423overweight 51 (31.8) obese 6 (3.8) j. lumbini. med. coll. vol 7, no 2, july-dec 2019 koirala m, et al. koirala m, et al. risk factors for obesity in nepalese women: a cross-sectional study 96 jlmc.edu.np statistically significant association between dietary habit of respondents and overweight / obesity which is dissimilar to the previous study conducted by almeida silva et al.[14] the present study showed the association between the frequency of consumption of fruits and overweight/ obesity is significant at p=0.029 which is supported by the study conducted by shahi m et al.,[8] but it is has different results from the study conducted by sharma sk et al., which reports that more the fruit intake higher the prevalence of obesity.[3] the current study showed the association between frequency of dairy products and overweight/ obesity (p=0.019) which is comparable with the study conducted by joyce n in kenya.[15] dietary pattern is also associated with the obesity. the study reveals that vegetarian are less likely to be obese than non-vegetarian.[16] this study reveals that there is strong association between marital status and overweight/obesity (p=0.020), this may be defined as consumption of more calories and less physical activities and this result is supported by study conducted in spain.[17] other socio-demographic variable including table 3: association between socio-demographic variables and respondent’s bmi (n=160) variables bmi classification (frequency) x2 df p value normal (< 25kg/ m2 ) overweight/ obese(≥ 25kg/m2 ) age 21-39 years 69 27 6.231 2 0.044 40-59 years 30 25 above 60 years 04 05 education status illiterate 07 12 12.003 4 0.017 literate 15 06 primary 20 14 secondary 33 19 higher secondary 28 06 marital status married 90 56 5.427 1 0.020 unmarried 13 01 type of diet vegetarian 23 05 0.031 1 0.023 nonvegetarian 80 52 frequency of consumption of fruits once a week 05 10 9.013 3 0.029 twice a week 28 18 thrice a week 39 19 > thrice a week 31 10 frequency of consumption of dairy product once a week 16 19 9.957 3 0.019 twice a week 16 13 thrice a week 41 15 > thrice a week 29 11 drinking habits of respondents yes 14 16 5.049 1 0.022 no 89 41 j. lumbini. med. coll. vol 7, no 2, july-dec 2019 koirala m, et al. koirala m, et al. risk factors for obesity in nepalese women: a cross-sectional study 97 jlmc.edu.np ethnicity, occupation, parity, residency (rural and urban) and menstrual cycle didn’t show statistically significant association with obesity/ overweight in current study. these results confirm the finding from some previous studies.[8,18,19] age of the respondents, marital status, level education, dietary pattern, consumption of fruits, frequency of consumption of dairy products and alcohol consumption were found to have statistically significant association with obesity. [9,11,15,20,21,22] this study confirms the findings of other study in associating increasing bmi with age.[12,23] except the variable, frequency of fruits consumption, all other independently associated factors didn’t show any association with overweight /obesity with binary logistic regression. the present study is not without limitations. as data were collected conveniently, it may not be generalized outside of western region of nepal. the results did not show statistically significant association between ethnicity, resident, type of occupations, parity and menstrual status. finding of this study cannot be generalized to male respondents. a comparative study between male and female regarding the prevalence and it impact in health of both gender and factors affecting can be conducted. however, this study also may create a small basis for conducting large population-based studies in the future. conclusion: the combined prevalence of overweight and obesity in the present study is 35.6%. increasing age, educational status, frequency of consumption of fruits and dairy products, dietary pattern, habits of drinking alcohol and marital status were strongly detected risk factors of obesity and overweight among the adult women. the finding highlights overweight and obesity is more in women of middleaged group. it is paramount for health care service provider to create awareness regarding the impact of overweight and obesity on health and sensitize them for lifestyle modification. conflict of interest: authors declare that no competing interest exists. funding: no funds were available for the study. table 4: risk factors associated with obesity (n=160) variables p-value exp (b) / odds ratio 95% c.i. for or lower upper age 21-39 years 0.194 40-59 years 0.080 2.037 0.918 4.522 above 60 years 0.404 2.226 0.339 14.609 education illiterate 0.211 literate 0.211 0.456 0.133 1.560 frequency of consumption of fruits once a week 0.175 twice a week 0.165 0.380 0.097 1.488 thrice a week 0.106 0.322 0.082 1.274 > thrice a week 0.028 0.192 0.044 0.838 frequency of consumption of diary product once a week 0.208 twice a week 0.733 0.823 0.269 2.520 thrice a week 0.055 0.361 0.128 1.022 > thrice a week 0.271 0.538 0.178 1.624 drinking habits drinking 0.103 0.453 0.175 1.174 type of diet diet 0.097 2.586 0.842 7.942 marital status 0.218 0.260 0.031 2.219 constant 0.240 3.757 table 5: model summary cox & snell r2 nagelkerke r2 p value 0.192 0.264 <0.001 j. lumbini. med. coll. vol 7, no 2, july-dec 2019 koirala m, et al. koirala m, et al. risk factors for obesity in nepalese women: a cross-sectional study 98 jlmc.edu.np references: 1. ellulu m, abed y, rahmat a, ranneh y and faisal a. epidemiology of obesity in developing countries: challenges and prevention. global epidemic obesity. 2014;2:2. doi: http://dx.doi. org/10.7243/2052-5966-2-2 2. world health organization. obesity and overweight factsheet from the who. who. fact sheet no. 311, 2018. available from: http:// 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https://doi.org/10.1159/000435826 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited.j. lumbini. med. coll. vol 7, no 1, jan-june 2019 ___________________________________________________________________________________ submitted: 03 june, 2019 accepted: 16 june, 2019 published: 26 june, 2019 a assistant professor, department of psychiatric nursing b assistant professor, department of psychiatry c college of nursing, lumbini medical college and teaching hospital, pravas, palpa d lumbini medical college and teaching hospital, pravas, palpa corresponding author: bandana pokharel e-mail: anupbandana@gmail.com orcid: https://orcid.org/0000-0002-2320-2786_______________________________________________________ —–————————————————————————————————————————————— abstract: introduction: elderly people suffer from many acute and chronic illnesses and also show higher prevalence of depression. the trend of old age homes is rising in nepal. the aim of this study was to assess depression in the residents of a geriatric home and compare it to that in the elderly population living in their own homes. methods: this was an observational cross-sectional study in which residents of a geriatric home above 60 years of age were selected as cases, and those living in their own homes were selected from the local community as a comparison group. depression was measured with geriatric depression scale comprising 30 questions. chi-square (or fisher exact) test was used to compare categorical variables. results: there were 52 participants in both groups. thirty-six (69.2%) participants from the study group had depression whereas only 10 (19.2%) from the comparison group had depression. this difference was statistically significant, the odds ratio being 9.45. conclusion: depression is significantly high in elderly population living in a geriatric home as compared to those living in their own homes. keywords: depression, geriatric —————————————————————————————————————————————— original research articlehttps://doi.org/10.22502/jlmc.v7i1.285 bandana pokharela,c bhaskkar sharmab,d depression and its associated risk factors among residents of a geriatric home in western nepal introduction: aging is the process of growing older, a process that includes physical change and sometimes mental changes.[1] as per who definition, people aged 60 years and above are elderly.[2] the population of the world is estimated to have reached 7.6 billion of which 7.9% is elderly.[3] elderly people have a tendency of suffering from acute and chronic illnesses and these sub-population show higher prevalence of depression. who estimates that depression will rank second to heart disease by 2020 in terms of global disability.[4] various studies have shown that a range of biological and social factors like increased age, economic status, social reaction, dissatisfaction with the old age, behavior of family members, gender, history of physical illness etc. are significant factors associated with depression in elderly.[3,5,6] the trend of old age homes is in rise in nepal. these homes provide residential care to the elderly who are destitute or homeless and not able to function independently in various aspects of their daily life. people in these homes are generally neglected by their family and relatives and suffer mental illness, depression being a common one.[6] very few studies have been conducted in nepal to understand the problem of residents of old age home. we have tried to assess depression and its associated factors in these population. how to cite this article: pokharel b, sharma b. depression and its associated risk factors among residents of a geriatric home in western nepal. journal of lumbini medical college. 2019;7(1):5 pages. doi: 10.22502/jlmc. v7i1.285. epub: 2019 june 26. https://orcid.org/0000-0002-2320-2786 pokharel b, sharma b. depression and its associated risk factors among residents of a geriatric home jlmc.edu.npj. lumbini. med. coll. vol 7, no 1, jan-june 2019 methods: this was an observational cross-sectional study conducted over a period of two weeks from 1st may, 2019. ethical approval was taken from institutional review committee of lumbini medical college (irc-lmc 03-c/019) before starting the study. consent was also taken from the head of the ‘geriatric home’ and chairman of the corresponding wards from where cases and comparison group were selected. people 60 years of age or older residing in ‘shiva parbati geriatric home’ at ramdi of syangja district, nepal were included. as a comparison group, sex and age (± five years) matched individuals were selected at ratio of 1:1 from tansen municipality ward nine. people who did not consent to the study or were unable to communicate and complete the interview process were excluded. sample size calculation: there were a total of 59 elderly in the geriatric home fulfilling the inclusion criteria but not all of them were available throughout the study period. using slovin formula, n/(1+ne2) for finite population, where n is the total population and e is sampling error, minimum sample size was 52 with 5% error. hence, we included 52 participants for the cases by census enumeration technique. similarly, 52 sex and age (± five years) matched comparison group were included. consent was taken from each respondent after explaining the purpose of the study. we developed a semi-structured questionnaire in nepali language to collect data on socio-demographic characteristics and other relevant information. depression of the participants was scored with long form of ‘geriatric depression scale’ (gds) comprising 30 questions, widely used in south east asian countries in more than 30 languages.[7] the cutoff score of the gds is the original scoring method i.e. normal= 0-9; mild depression = 10-19; severe depression = 20-30. the scale was translated into nepali language by forward and backward translation with the help of available language experts. both the questionnaire and scale were pretested on six participants (10% of the study sample size) of tansen municipility, ward number eight of palpa district for completeness, comprehensiveness and appropriateness, and required changes were made by the language expert. these participants were not included in the study. data collection was done by the researcher herself with the help of maid of the geriatric home. a comfortable and confidential environment was chosen for interview. the researcher introduced herself to the respondents, established rapport with them and explained the purpose of the study. data were collected in demographic questionnaire and the depression scale by face to face interview technique. data were collected from the comparison group in similar fashion. respondents were appreciated for their participation and co-operation. the data were preserved in a file to prevent from damage. they were then entered into statistical package for social sciences (spsstm) software version 16 for analysis. descriptive statistics were presented as frequency and percentages. relationship of depression with various categorical variables was analyzed with chi-square test and fisher exact test whichever was appropriate. odds ratio of presence of depression among old age home to that among comparison group was calculated. p value less than 0.05 was considered statistically significant. results: there were 52 respondents in each group. their demographical details is presented in table 1. the table reveals that the relationship between literacy and geriatric home stay is statistically significant. similarly, relationship between having children and geriatric home stay is also statistically significant. among the participants from the geriatric home, 36 (69.2%) had depression whereas, among those residing in their own home, only 10 (19.2%) had depression as shown in table 2. this difference is statistically significant (x2=26.4, df=1, p<0.001). the or (odds ratio) of depression among geriatric home to that of general community was 9.45. hence, people residing in old age home were 9.45 times more likely to have depression compared to those residing in own home. to analyze the risk factors of geriatric home depression, we studied the data of geriatric home only. thus, we calculated data of 52 old age residents of the geriatric home. their results are presented in table 3. the table shows that gender is statistically associated with depression. females are more likely to have depression in old age home. other factors like literacy status, family type, whether they have pokharel b, sharma b. depression and its associated risk factors among residents of a geriatric home jlmc.edu.npj. lumbini. med. coll. vol 7, no 1, jan-june 2019 children, visit by relatives in the geriatric home, and their health status were not statistically significant. discussion: so that illiterate elderly are more likely to be in geriatric home. similarly, relationship between having children and geriatric home stay was also statistically significant, meaning those who are childless are more likely to stay in geriatric home. demographic findings of the study revealed that nearly half of the respondents (48%) belonged to the age group 70-79 years which is consistent with the study done in mangalore, india where (48%) belonged to the same age group.[8] with regards to the gender, more than half of the respondents 73.1% were female, similar to the study done in west bengal, india, where 67.08% of total respondents were female.[9] regarding length of stay in geriatric home, 57.7% of the respondents lived in the old age home for more than one year which is consistent with the study of narkhede v. et al.[10] current study revealed that 44.2% of the respondent lived in geriatric home due to lack of family caregivers. this finding is supported by the study of sharma k. et al., in which majority (80%) of the respondents lived in geriatric home due to lack of family caregivers. [11] but other factors like literacy status was not statistically significant with depression of people variables geriatric home (n=52) own home (n=52) statistics age group, n (%) 60 69 18 19 70 79 22 23 80 89 9 9 90 and above 3 1 gender, n (%) male 14 14 female 38 38 ethnic group, n (%) brahmin/chhetri 41 31 janajati 11 20 dalit 0 1 literacy literate 18 39 x2=17.1, df=1, p<0.001 illiterate 34 13 type of family nuclear 23 17 joint 29 34 extended 0 1 having children yes 34 51 x2=16.6, df=1, p<0.001 no 18 1 table 1: demographic details of the participants of geriatric home and own home level of depression own homes (n 52) geriatric home (n 52) no depression 42 (80.76%) 16 (30.76%) mild depression 10 (19.23%) 33 (63.46%) severe depression 0 (0%) 03 (5.76%) total 52 (100%) 52 (100%) table 2: level of depression in elderly of geriatric home and those living in own homes this study is aimed to determine the level of depression of geriatric population of geriatric home and compare them with those living in their own homes. the study found that the people going to geriatric home were more likely to be illiterate than those living in their own homes. relationship between geriatric home stay and literacy was statistically significant. this might be due to the impact of education on their quality of life and support of family members, decision making ability j. lumbini. med. coll. vol 7, no 1, jan-june 2019 jlmc.edu.np pokharel b, sharma b. depression and its associated risk factors among residents of a geriatric home variables depression statistics absent, n present, n gender male 8 6 x2=6.26, df=1, p=0.01 female 8 30 literacy literate 8 10 x2=2.4, df=1, p = 0.12 illiterate 8 26 family type nuclear 8 15 x2=0.3, df=2, p=0.058 joint 8 21 have children yes 12 22 x2=0.94, df=1, p=0.33 no 4 14 visit by relatives yes 8 19 x2=0.03, df=1, p=0.85 no 8 17 health status good 15 31 p=0.4 fisher exactpoor 1 5 table 3: relationship between various factors and depression among the geriatric home population (n=52) in geriatric home. this might be due to irrespective of their education the participants had the pattern in life to balance themselves positively in different hurdles of life. having children, visit by relatives in the geriatric home, and their health status were not statistically significant. among the participants from the geriatric home, 36 (69.2%) had depression whereas, among the general community only 10 (19.2%) had depression. this difference was statistically significant (x2=26.4, df=1, p<0.001). the or of depression among geriatric home to that of general community was 9.45. hence, people residing in old age home were 9.45 times more likely to have depression compared to those residing in own homes. this finding is supported by the findings of chalise hn, where prevalence of depression was 57.8%. [11] there were similar findings with prevalence rate of depression as 52.73% in old-age home and 25.45% in community[12]. also, another study of d’souza l. et al. showed 109 (51.9%) elderly were depressed.[13] present study showed that there was no statistically significant association between the level of depression and having children (p=0.3).this finding is consistent with those of the studies done in nepal and china where suffering from depression and having children was not statistically significant. [6,14] this study also showed that there was no significant association (p=0.66) between the level of depression and age of respondents. this finding is supported by the finding of the study of subba r. et al.[7] gender was statistically associated with depression, i.e. females were more likely to have depression in old age home. this finding is similar to that of the study by d’souza l. et al. and another study by suganathan s. where level of depression was statistically significant with the female gender of elderly respondents (p<0.001 in both studies) respectively.[13,15] limitations: the study population was taken from a single center. inclusion of multi-centric population would increase the external validity of the study. conclusion: this study revealed that more than half of the respondents of geriatric home had depression whereas, among the general community only one third of the residents had depression. gender was associated with depression at statistically significant references: 1. sharma m, paudel k, gautam r. essential text book of medical surgical nursing, 2015;8ed. 2. sharma e, seelan s. a descriptive study to assess the level of depression among the elderly residing in selected old age home at jammu. indian journal of recent scientific research. 2017;8(11):21781-85. doi: http://dx.doi. org/10.24327/ijrsr.2017.0811.1140 3. mohan u, gupta a, singh s, tiwari s, singh v. study of depression in geriatric population: old age home and community in lucknow india. international journal of epidemiology. 2015;44(supplement 1):i97-i97. doi: https://doi.org/10.1093/ije/dyv096.032 4. maktha ms, kumar mv. study on level of depression among elderly residing in an old age home in hyderabad, telangana. the international journal of indian psychology. 2015;3(1):12-17. available from: http://oaji. net/articles/2015/1170-1447397985.pdf 5. ranjan s, bhattarai a, dutta m. prevalence of depression among elderly people living in old age home in the capital city 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available from: https:// www.biomedscidirect.com/433/depression_and_its_ determinants_in_the_rural_elderly_of_westbengal_a_ cross_sectional_study/articlescategories 10. narkhede v, likhar s, rana a. a study on depression in elderly inmates living in old age homes in gujarat. indian journal of research and reports in medical sciences. 2012;2(3):21-3. available from: http://ijrrms.com/pdf/ july-sep%2012.pdf#page=26 11. chalise hn. depression among elderly living in briddashram (old age home). advances in aging research. 2014;3(01):6-11. doi: http://dx.doi.org/10.4236/ aar.2014.31002 12. ghimire h, pokharel pk, shyangwa pm, baral dd, aryal a, mishra ak. are elderly people living in old-age home, less depressed than those of community? findings from a comparative study. journal of chitwan medical college. 2013;1(2):5-8. available from: https://www.researchgate. net/publication/317357816_are_elderly_people_living_ i n _ ol d age _ home _ l e ss _ d e pre ss e d _ t han _ t ho s e _ of _ community_findings_f rom_a_comparative_study/ download 13. d’souza l, ranganath ts, thangaraj s. prevalence of depression among elderly in an urban slum of bangalore, a cross sectional study. international journal of interdisciplinary and multidisciplinary studies (ijims). 2015;2(3):1-4. available from: https://pdfs.semanticscholar. org/bc89/7fca1c4b60b8e3b148bb636830dc771d54e6.pdf 14. cong l, dou p, chen d, cai l. depression and associated factors in the elderly cadres in fuzhou, china: a community-based study. international journal of gerontology. 2015;9(1):29-33. doi: https://doi. org/10.1016/j.ijge.2015.02.001 15. suganathan s. a study on depression among elderly in a rural population of tamil nadu, india. international journal of community medicine and public health. 2016;3(9):2571-4. doi: http://dx.doi.org/10.18203/23946040.ijcmph20163074 j. lumbini. med. coll. vol 7, no 1, jan-june 2019 jlmc.edu.np pokharel b, sharma b. depression and its associated risk factors among residents of a geriatric home level. conflict of interest: the authors declare that no competing interests exist. source of funds: no funds were available. http://dx.doi.org/10.24327/ijrsr.2017.0811.1140 http://dx.doi.org/10.24327/ijrsr.2017.0811.1140 https://doi.org/10.1093/ije/dyv096.032 http://oaji.net/articles/2015/1170-1447397985.pdf http://oaji.net/articles/2015/1170-1447397985.pdf https://doi.org/10.3126/hren.v11i3.9634 http://jiom.com.np/index.php/jiomjournal/article/download/702/652 http://jiom.com.np/index.php/jiomjournal/article/download/702/652 https://doi.org/10.3126/jcmc.v5i1.12568 https://doi.org/10.3126/jcmc.v5i1.12568 https://www.biomedscidirect.com/433/depression_and_its_determinants_in_the_rural_elderly_of_westbengal_a_cross_sectional_study/articlescategories https://www.biomedscidirect.com/433/depression_and_its_determinants_in_the_rural_elderly_of_westbengal_a_cross_sectional_study/articlescategories https://www.biomedscidirect.com/433/depression_and_its_determinants_in_the_rural_elderly_of_westbengal_a_cross_sectional_study/articlescategories https://www.biomedscidirect.com/433/depression_and_its_determinants_in_the_rural_elderly_of_westbengal_a_cross_sectional_study/articlescategories http://ijrrms.com/pdf/july-sep 12.pdf#page=26 http://ijrrms.com/pdf/july-sep 12.pdf#page=26 http://dx.doi.org/10.4236/aar.2014.31002 http://dx.doi.org/10.4236/aar.2014.31002 https://www.researchgate.net/publication/317357816_are_elderly_people_living_in_old-age_home_less_depressed_than_those_of_community_findings_from_a_comparative_study/download https://www.researchgate.net/publication/317357816_are_elderly_people_living_in_old-age_home_less_depressed_than_those_of_community_findings_from_a_comparative_study/download https://www.researchgate.net/publication/317357816_are_elderly_people_living_in_old-age_home_less_depressed_than_those_of_community_findings_from_a_comparative_study/download https://www.researchgate.net/publication/317357816_are_elderly_people_living_in_old-age_home_less_depressed_than_those_of_community_findings_from_a_comparative_study/download https://www.researchgate.net/publication/317357816_are_elderly_people_living_in_old-age_home_less_depressed_than_those_of_community_findings_from_a_comparative_study/download https://pdfs.semanticscholar.org/bc89/7fca1c4b60b8e3b148bb636830dc771d54e6.pdf https://pdfs.semanticscholar.org/bc89/7fca1c4b60b8e3b148bb636830dc771d54e6.pdf https://doi.org/10.1016/j.ijge.2015.02.001 https://doi.org/10.1016/j.ijge.2015.02.001 j. lumbini. med. coll. vol 7, no 2, july-dec 2019 pandey br, pandey br, et al. otomycosis and its predisposing factors in out-patient department of otorhinolaryngology in a tertiary care center.et al. otomycosis and its predisposing factors in out-patient department of otorhinolaryngology in a tertiary care center. 76 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 9 july, 2019. accepted: 4 december, 2019. published: 29 december, 2019. a lecturer, department of otorhinolaryngology b -associate professor, department of otorhinolaryngology c lecturer, department of microbiology dlumbini medical college and teaching hospital, palpa, nepal. corresponding author: bhuwan raj pandey e-mail: mrpandey@hotmail.com orcid: https://orcid.org/0000-0002-4698-1946_______________________________________________________ abstract: introduction: otomycosis is a fungal infection of external auditory canal frequently encountered by otorhinolaryngologists. it causes discomfort to patients with varied symptoms of pruritus, otorrhea, aural fullness and earache. people with a habit of using unnecessary ear drops, cleaning ear with unsterilized objects and those who use mustard oil are all prone to otomycosis. this study aims to find out the association between otomycosis and its predisposing factors. methods: this study was undertaken in the department of otorhinolaryngology of a tertiary hospital from march 2018 to february 2019 and a total of 300 clinically diagnosed cases of otomycosis were enrolled for the study. results:the mean age ±sd of the patients was 37.7 ± 18.8 years. females (n=172, 57.3%) were more prone to otomycosis than males (n=128, 42.7%). the most common presenting symptom was pruritus only (n=95, 31.7%) with unilateral involvement being more common. the most common predisposing factor was mustard oil instillation (n=124, 41.3%). aspergillus niger was the most common fungus causing otomycosis in this study (n=104, 34.7%). positive fungal cultures were observed in 285 specimens (95%). the fungal growth (n=285) was high in patients with the history of instilling mustard oil (42.8%) into the ear, 34.0% in topical steroid containing ear drops and 23.2% in self-cleaning group. conclusion: otomycosis is common in people using unnecessary steroid containing ear drops, cleaning ear with unsterilized objects and instillation of mustard oil. keywords: otitis externa, otomycosis, predisposing factor original research articlehttps://doi.org/10.22502/jlmc.v7i2.291 bhuwan raj pandey,a,d madan mohan singh,b,d kishor bajracharyac,d otomycosis and its predisposing factors in outpatient department of otorhinolaryngology in a tertiary care centre how to cite this article:how to cite this article: pandey br, singh mm, bajracharya k. otomycosis and pandey br, singh mm, bajracharya k. otomycosis and its predisposing factors in out-patient department of its predisposing factors in out-patient department of otorhinolaryngology in a tertiary care centre. journal of lumbini otorhinolaryngology in a tertiary care centre. journal of lumbini medical college. 2019;7(2):76-80. doi: http://medical college. 2019;7(2):76-80. doi: http://doi.org/10.22502/doi.org/10.22502/ jlmc.v7i2.291jlmc.v7i2.291 epub: 2019 december 29. epub: 2019 december 29. introduction: otomycosis is a superficial fungal infection that can affect external auditory canal, middle ear and post-operative mastoid cavity. it accounts for approximately 10 % to 30.4% of otitis externa.[1,2] it is common in hot and humid climate. it occurs when protective lipid/acid balance of ear is lost.[3] patients presenting with symptoms of ear itching, discharge, earache, ear fullness, hearing loss and tinnitus along with otoscopic findings of black, grey, green, yellow or whitish discharge with debris resembling wet newspaper are considered to have clinical otomycosis. the definitive diagnosis is made by fungal growth. the treatment for otomycosis is ear toileting, removal of the debris and use of antifungal ear drops. unnecessary use of topical, especially steroid containing antibiotic ear drops, self-cleaning and use of mustard oil for the treatment of otitis externa have been linked to an increased prevalence of otomycosis.[4] the aim of this study was to find out the association between otomycosis and these predisposing factors. methods: this was an observational cross-sectional study conducted in the out-patient department (opd) of otorhinolaryngology, lumbini medical j. lumbini. med. coll. vol 7, no 2, july-dec 2019 pandey br, pandey br, et al. otomycosis and its predisposing factors in out-patient department of otorhinolaryngology in a tertiary care centreet al. otomycosis and its predisposing factors in out-patient department of otorhinolaryngology in a tertiary care centre 77 jlmc.edu.np college and teaching hospital over a period of one year from march 2018 to february 2019. ethical approval was obtained from the institutional review committee of the institution. a total of 1130 patients with otitis externa attended the opd of which 300 patients were clinically diagnosed as otomycosis. informed consent was taken from the study participants. the sample size was calculated using the following formula: n=z2pq/e2 where, z= 1.96; prevalence of otomycosis (p) =23% [7]; q=1-p and margin of error (e) =5%. the minimum sample size thus calculated was 273. all patients presenting to the opd with symptoms of ear itching, discharge, fullness, and earache were evaluated. those with usage of steroid containing ear drops, self-cleaning and mustard oil instillation were included. if more than one predisposing factor were present, the patient was asked what the first thing they used was. patients with previous diagnosis of otomycosis, acute or chronic suppurative otitis media, diabetes mellitus, tuberculosis and generalized fungal infection were excluded. ear canal was examined with an otoscope and clinical diagnosis was made based upon the history and clinical examination. clinical symptoms at time of presentation, demographic variables and predisposing factors were noted. patient’s ear canal was cleaned by dry mopping method with cotton on jobson horne probe with ring curettage. materials from ear canal were taken using sterile swab and sent to department of microbiology for processing within half an hour of collection. swab was subjected to microscopic examination with 10% potassium hydroxide (koh) preparation which was used to reveal fungal elements like hyphae and budding yeast cells and then inoculated in sabourauds dextrose agar media at 25 o c to 30 o c until there were visible colonies. cultures were examined frequently, at least three times a week, and then were examined macroscopically which resembled the colonies along with surface pigmentation. lactophenol cotton blue mount was performed for identification of fungal structure and gram staining for candida species. all patients received clotrimazole antifungal ear drops, three drops daily for two weeks. they were asked to avoid predisposing factors and followed up in two weeks. data was entered to and analyzed with statistical package for social sciences (spsstm) software version 16. descriptive statistics was presented as frequencies, percentage, mean and standard deviation (sd). categorical variables were analyzed using chi square test. p-value less than 0.05 was considered statistically significant. results: a total of 300 patients clinically diagnosed with otomycosis were enrolled in the study. the mean age of the patients was 37.7±18.8 years. the sample consisted of 172 females (57.3%) and 128 males (42.7%) with a female: male ratio of 1.3:1. right ear (n=160, 53.3%) was affected more than the left (n=110, 36.7%) with bilateral involvement being only 10% (n=30) (table 1). table 1. clinical characteristics of patients (n = 300) variables frequency (%) laterality distribution right ear 160 (53.3) left ear 110 (36.7) both ear 30 (10.0) symptoms pruritus only 95 (31.7) pruritus and otorrhea 77 (25.7) otorrhea only 35 (11.7) aural fullness 26 (8.7) hearing loss 25 (8.3) earache 30 (10.0) tinnitus 12 (4.0) predisposing factors mustard oil instillation 124 (41.3) topical antibiotic (containing steroid) ear drop 106 (35.3) self-cleaning 70 (23.3) fungal organism aspergillus niger 104 (34.7) candida 78 (26.0) aspergillus flavus 55 (18.3) aspergillus fumigates 40 (13.3) no growth 15 (5.0) mixed growth 8 (2.7) pruritus only was the most common presenting symptom in patients with otomycosis in our study. it was the most common symptom in j. lumbini. med. coll. vol 7, no 2, july-dec 2019 pandey br, pandey br, et al. otomycosis and its predisposing factors in out-patient department of otorhinolaryngology in a tertiary care centreet al. otomycosis and its predisposing factors in out-patient department of otorhinolaryngology in a tertiary care centre 78 jlmc.edu.np patients with self cleaning and also in patients with mustard oil instillation. however, pruritus with otorrhea was the most common presenting complaint in the patients who used topical ear drops (table 2). table 2. distribution of pre-disposing factors with fungal organism and clinical characteristics (n = 300). fungal organism self cleaning mustard oil instillation topical antibiotic ear drop aspergillus niger 35 (50.0%) 40 (32.3%) 29 (27.4%) candida 12 (17.1%) 29 (23.4%) 37 (34.9%) aspergillus flavus 3 (4.3%) 30 (24.2%) 22 (20.8%) aspergillus fumigates 16 (22.9%) 20 (16.1%) 4 (3.8%) no growth 4 (5.7%) 2 (1.6%) 9 (8.5%) mixed growth 0 3 (2.4%) 5 (4.7%) symptoms pruritus 22 (31.4%) 43 (34.7%) 30(28.3) pruritus and otorrhea 11 (15.7%) 27 (21.8%) 39 (36.8%) otorrhea 8 (11.4%) 18 (14.5%) 9(8.5%) aural fullness 8 (11.4%) 11(8.9%) 7(6.6%) hearing loss 8 (11.4%) 8(6.5%) 9(8.5%) tinnitus 4 (5.7%) 4 (3.2%) 4(3.8%) earache 9 (12.9%) 13 (10.5%) 8(7.5%) the most common predisposing factor was mustard oil instillation (n=124, 41.3%). similarly, aspergillus niger was the most common fungus causing otomycosis in this study (n=104, 34.7%). aspergillus niger (n=35, 50.0%) and aspergillus fumigates (n=16, 22.9%) were common in self-cleaning group, aspergillus niger (n=40, 32.3%) and aspergillus flavus (n=30, 24.2%) were common in mustard oil instillation group. candida was the most common causative agent (n=37, 34.9%) in patients using steroid containing antibiotic ear drops (table 2). fungal growth was seen in 285 patients (95%) with the highest growth in patients with mustard oil instillation (n=122, 42.8%) (table 3). table 3. association of fungal growth with predisposing factors(n=300) fungal growth predisposing factors statistics self cleaning mustard oil instillation topical steroid containing ear drops x2 = 5.789, df = 2, p = 0.055 yes 66 (23.2%) 122 (42.8%) 97 (34.0%) no 4 (26.7%) 2 (13.3%) 9 (60.0%) discussion: otomycosis is a superficial fungal infection that can affect external auditory canal, middle ear and post-operative mastoid cavity. it is a common condition encountered by otorhinolaryngologists. this paper aimed to study the predisposing factors of otomycosis and their association. in this study, the prevalence of otomycosis was high in the middle age with mean age of 37.7 ± 18.8 years. the higher prevalence in these patients may be due to their active working conditions and more concern regarding their health, thereby visiting hospital for further treatment. in our study, females were affected more by otomycosis similar to that reported by pontez zb et al.,[5] and fasunla j et al.[6] other studies also showed higher prevalence of otomycosis in female while in some studies there was male predominance of otomycosis.[7,8] otomycosis is usually a unilateral disease and bilateral involvement is very low. our study showed right sided predominance (53.3%) compared to the left side (36.7%). bilateral involvement was seen in only 10% which is similar to the study by ho t et al.[1] right ear is more commonly involved because of more frequent self-cleaning of right ear with unsterile objects as most people are right handed. the most common symptom of otomycosis is pruritus. in our study too, pruritus was the main symptom. the study by paulose et al.[9] and jia x et al.[10] also showed the presence of pruritus was most common. ear scratching with wooden sticks or metal wax picks to clean cerumen and rubbing of ear to get relief from itching can cause minor skin j. lumbini. med. coll. vol 7, no 2, july-dec 2019 pandey br, pandey br, et al. otomycosis and its predisposing factors in out-patient department of otorhinolaryngology in a tertiary care centreet al. otomycosis and its predisposing factors in out-patient department of otorhinolaryngology in a tertiary care centre 79 jlmc.edu.np trauma of external auditory canal with deposition of fungal spore in the wound that later can cause fungal infection.[10] in our study, nearly one fourth (23.2%) of the patients with otomycosis had habit of self-cleaning of ears which is comparable to findings of prasad sc et al.[11] there is a popular belief that instillation of mustard oil relieves itching and cures ear problems. our study showed 42.8% of patients with otomycosis had used mustard oil similar to the result of pradhan b et al.[7] oil has been reported to be sporostatic and a study by jain sk et al.,[12] showed aspergillus species to be present in mustard oil. the presence of bacterial infection with or without treatment by topical or systemic antibiotic appears to change the physiochemical environment of the meatus and facilitate fungal growth. it was found that patients who used unnecessary steroid containing ear drops had more chances of having otomycosis. normal flora of external auditory canal is one of the host defense mechanisms against fungal infection and this mechanism is altered in patients using antibiotic ear drops thus making them more susceptible to otomycosis.[13] in the present study 34.0% of patients with otomycosis had used ear drops. in the study by fasunla j et al.,[6] 13.76% patients had prior topical antibiotic treatment following misdiagnosis. similar results were shown in the study by munguia et al.[4] in the present study growth was seen in 95% of cases. in the study by pradhan b et al.[7] 81.3% had positive fungal cultures. the incidence of growth of fungal growth was high in patients with the history instilling mustard oil (42.8%) into the ear, 34.0% in topical steroid containg ear drops and 23.2% in self-cleaning group which was similar study done by prasad sc et al.,[11] whose studied showed 42% in mustard oil instillation, 20% using topical steroid containg ear drops and 32% self-cleaning. it was observed that aspergillus niger species was cultured most commonly (34.7%) in the present study, which correlates with the findings of the study by paulose et al.[9] this is in contrast to the study done by kaur rk et al.,[8] which showed aspergillus fumigatus was the most common in otomycosis. candida species have hydrolytic enzyme and protease activity helping in invasion of host tissue thus playing an important role in the pathogenesis of otomycosis.[3] it colonizes the skin and penetrates the host cells which causes infection to ear.[14] in our study there were 26% of cases with candida infection. in the study by jia x et al.[10] it was 16.52%. so most of the time patients are infected either with aspergillus or candida in otomycosis. this study was conducted only with patients using mustard oil. other types of oil usage could have been included. conclusion: otomycosis commonly presented with clinical symptoms of pruritus, and combination of pruritus and ear discharge. it was found to be more common in people who instilled mustard oil into the ears, used unnecessary ear drops and cleaned ears with unsterilized objects. there is a need to educate patients about the consequences of using such remedies for ear problems. conflicts of interest: authors declare that no competing interest exists. source of funds: no funds were available. j. lumbini. med. coll. vol 7, no 2, july-dec 2019 pandey br, pandey br, et al. otomycosis and its predisposing factors in out-patient department of otorhinolaryngology in a tertiary care centreet al. otomycosis and its predisposing factors in out-patient department of otorhinolaryngology in a tertiary care centre 80 jlmc.edu.np references: 1. ho t, vrabec jt, yoo d, coker nj. otomycosis: clinical features and treatment implications. otolaryngology head and neck surgery. 2006;135(5):787–91. pmid: 17071313. doi: https://doi.org/10.1016%2fj.otohns.2006.07.008 2. kurnatowski p, filipiak a. otomycosis: prevalence, clinical symptoms, therapeutic procedure. mycoses. 2001;44(11–12):472–9. pmid: 11820260. doi: https://doi.org/10.1046/ j.1439-0507.2001.00689.x 3. jadhav vj, pal m, mishra gs. etiological significance of candida albicans in otitis externa. mycopathologia. 2003;156(4):313–5. pmid: 14682457. doi: https://doi.org/10.1023/ b:myco.0000003574.89032.99 4. munguia r, daniel sj. ototopical antifungals and otomycosis: a review. international journal of pediatric otorhinolaryngology. 2008;72(4):453–9. pmid: 18279975. doi: https://doi.org/10.1016/j. ijporl.2007.12.005 5. pontes zb, silva adf, lima ede o, guerra mde h, oliveira nm, carvalho mde f, et al. otomycosis: a retrospective study. braz j otorhinolaryngol. 2009; 75(3):367–70. pmid: 19649486 6. fasunla j, ibekwe t, onakoya p. otomycosis in western nigeria. mycoses. 2008;51(1):67–70. pmid: 18076598. doi: https://doi.org/10.1111/ j.1439-0507.2007.01441.x 7. pradhan b, tuladhar nr, amatya rm. prevalence of otomycosis in outpatient department of otolaryngology in tribhuvan university teaching hospital, kathmandu, nepal. annals of otology, rhinology, laryngology. 2003;112(4):384–7. doi: https://doi.org/10.1177 %2f000348940311200416 8. kaur r, mittal n, kakkar m, aggarwal ak, mathur md. otomycosis: a clinicomycologic study. ear, nose & throat journal. 2000;79(8):606– 9. pmid:10969470. doi: https://doi.org/10.1177 %2f014556130007900815 9. paulose ko, al khalifa s, shenoy p, sharma rk. mycotic infection of the ear (otomycosis): a prospective study. the journal of laryngology and otology. 1989;103(1):30–5. pmid: 2921549. doi: https://doi.org/10.1017/s0022215100107960 10. jia x, liang q, chi f, cao w. otomycosis in shanghai: aetiology, clinical features and therapy. mycoses. 2012;55(5):404–9. pmid: 21999222. doi: https://doi.org/10.1111/j.14390507.2011.02132.x 11. prasad sc, kotigadde s, shekhar m, thada nd, prabhu p, d’ souza t, et al. primary otomycosis in the indian subcontinent: predisposing factors, microbiology, and classification. int j microbiol. 2014;2014:636493. pmid: 24949016. doi: https://doi.org/10.1155/2014/636493 12. jain sk, agrawal sc. sporostatic effect of some oils against fungi causing otomycosis. indian j med sci. 1992;46(1):1–6. pmid: 1452224 13. thrasher rd, kingdom tt. fungal infections of the head and neck: an update. otolaryngol clin of north am. 2003;36(4):577–94. pmid: 14567054. doi: https://doi.org/10.1016/s00306665(03)00029-x 14. arsovic na, banko av, dimitrijevic mv, djordjevic vz, milovanovic jp, arsenijevic va. protease activities of candida spp. isolated from otitis externa: preliminary result. acta chir iugosl. 2009;56(3):113–6. pmid: 20218114. doi: https:// doi.org/10.2298/aci0903113a j. lumbini. med. coll. vol 7, no 2, july-dec 2019 acharya s, acharya s, et al. role of ultrasound scan in non-traumatic acute abdomen presenting in surgery department of a tertiary care center.et al. role of ultrasound scan in non-traumatic acute abdomen presenting in surgery department of a tertiary care center. 56 licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 15 july, 2019 accepted: 21 november, 2019 published: 29 december, 2019 a assistant professor, department of radiodiagnosis bassociate professor, department of radiodiagnosis cresident, department of surgery dlumbini medical college and teaching hospital, palpa, nepal. corresponding author: sumnima acharya e-mail: doctorsumnima@gmail.com orcid: https://orcid.org/0000-0001-8612-671x____________________________________________________ abstract introduction: an acute abdomen is defined as a clinical condition characterized by severe abdominal pain developing suddenly over several hours or less. ultrasonography (usg) helps the managing surgeons arrive at early diagnosis and rule out alternative diseases, thus reducing negative laparotomy rate. this study analyzed the diagnostic yield of usg in patients with non-traumatic acute abdomen presenting to surgery department via emergency department/outpatient department of a tertiary hospital. methods: this cross-sectional observational study included 110 patients with non-traumatic acute abdominal pain who were sent for usg examination. the percentage concordance of usg diagnosis with the final diagnosis at discharge was determined in terms of sensitivity, specificity, positive and negative predictive values for acute abdomen. results: of 110 patients, correct clinical diagnosis was made in 83 patients (75%) while usg made a correct diagnosis in 101 patients (91%). hence, with the help of usg, accuracy of diagnosing cause of acute abdomen increased by 16 %. the sensitivity and specificity of usg in diagnosis of acute appendicitis were 87.7% and 98.3% respectively. conclusion: usg is easily available and non-invasive modality without radiation exposure and requiring minimal patient preparation. usg should therefore be an important routine diagnostic investigation in patients presenting with acute abdomen. keywords: acute abdomen, sensitivity, specificity, ultrasonography original research articlehttps://doi.org/10.22502/jlmc.v7i2.293 sumnima acharya,a,d awadhesh tiwari,b,d rupesh sharma,a,d santosh paudelc,d role of ultrasound scan in non-traumatic acute abdomen presenting in surgery department of a tertiary care centre how to cite this article:how to cite this article: acharya s, tiwari a, sharma r, paudel s. role of ultrasound acharya s, tiwari a, sharma r, paudel s. role of ultrasound scan in non-traumatic acute abdomen presenting in scan in non-traumatic acute abdomen presenting in surgery department of a tertiary care centre. journal of surgery department of a tertiary care centre. journal of lumbini medical college. 2019;7(2):56-60. doi: http://lumbini medical college. 2019;7(2):56-60. doi: http://doi.doi. org/10.22502/jlmc.v7i2.293.org/10.22502/jlmc.v7i2.293. epub: 2019 december 29. epub: 2019 december 29. introduction: an acute abdomen is defined as a clinical condition characterized by severe abdominal pain that develops suddenly over several hours or less.[1] it is one of the most common clinical conditions that brings the patient to emergency department (ed). about 4–5% of the patients present to ed with acute abdominal pain which includes acute appendicitis, pancreatitis, ureteric colic, diverticulitis, cholecystitis, bowel obstruction and sometimes nonspecific causes that may not be ascertained clinically. the causes vary from benign self-limiting diseases to life threatening conditions. perforated viscus and bowel ischemia are rare but serious causes of acute abdomen with high chances of mortality if not addressed in time. however, it is often difficult to pin the exact cause of abdominal pain based upon only history, clinical examination and laboratory findings. to minimize the misdiagnosis and negative laparotomies in acute abdomen, imaging plays an important role.[2,3] ultrasonography (usg) is commonly used in the diagnostic work-up of patients with acute abdomen that can delineate alimentary tract along with its peristalsis and blood flow. furthermore, maximal point of tenderness can be correlated with its help. it is easily available, non-invasive, cost j. lumbini. med. coll. vol 7, no 2, july-dec 2019 acharya s, acharya s, et al. role of ultrasound scan in non-traumatic acute abdomen presenting in surgery department of a tertiary care centreet al. role of ultrasound scan in non-traumatic acute abdomen presenting in surgery department of a tertiary care centre 57 jlmc.edu.np effective, portable, with no known side effects. it also requires minimal patient preparation and does not have radiation exposure. however, operator variability may co-exist.[4] this study was conducted with the aim to determine the role of usg in the diagnosis of nontraumatic acute abdomen in terms of sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv). methods: this observational cross-sectional study was carried out in the department of radiodiagnosis, lumbini medical college and teaching hospital (lmcth), nepal over a period of seven months from 1st june, 2018 to 31st december, 2018. a total of 110 patients were seen during this period. ethical approval from institutional review committee of the institute was obtained prior to enrollment of the patients. hospital records (patient’s file sent to radiology department for usg) were reviewed from 110 patients who were sent from ed or surgery out-patient department (opd) with provisional diagnosis of acute abdomen. patients with traumatic acute abdomen and females with suspected gynecological or obstetrical cause of acute abdomen were excluded. all the observations during the study of each patient were recorded in an individual case proforma containing all the information regarding admission details, demographic parameters, clinical features, examination findings and provisional diagnosis. investigation reports including blood hemoglobin level, leucocyte count and other relevant reports were noted. all the usg scans were performed by the radiologist using acuson nx3 usg machine (siemens, germany) with both curvilinear (2-5 mhz) and linear (4-12 mhz) array probes. grey scale imaging was done in all cases of acute abdomen and any detected lesions were additionally evaluated with color doppler. the patients were admitted in the surgery ward. other relevant investigations like computed tomography (ct) scans and intra-operative findings were recorded at the time of discharge. final diagnosis was based on clinical findings, laboratory values, ct findings, intra-operative findings, clinical followup with histopathological report. eventually, usg diagnosis was compared with the final (standard) diagnosis and clinical diagnosis. the data collected in proforma were entered into statistical package for social sciences (spsstm) version 16 and used for the statistical analysis. data relating to qualitative variables were presented in frequency and percentages, and that to quantitative variables were expressed in means with standard deviation (sd). the diagnostic yield of usg was determined in terms of sensitivity, specificity, ppv and npv. results: among 110 patients enrolled into the study, there were 64 males (58%) and 46 females (42%). the mean age of presentation was 35 years (sd=1.79). table 1. distribution of sites of pain in acute abdomen (n=110). sites of pain frequency n (%) right iliac fossa pain 28 (25.5) periumbilical pain 20 (18.2) epigastric pain 17 (15.5) diffuse pain 16 (14.5) right hypochondrial pain 12 (10.9) right lumbar pain 5 (4.5) central abdominal pain 4 (3.6) bilateral hypochondriac pain 4 (3.6) left iliac fossa pain 2 (1.8) left lumbar pain 2 (1.8) right iliac fossa was the most common site of pain accounting for 25.5% (n=28), followed by periumbilical region constituting 18.20% (n=20) of the patients (table 1). a majority of the patients (31%) presented to our hospital within the first day of acute abdomen. the mean day of presentation of pain abdomen was 4.9 days (sd=2). table 2 presents the frequency distribution of causes of acute abdomen according to usg findings. j. lumbini. med. coll. vol 7, no 2, july-dec 2019 acharya s, acharya s, et al. role of ultrasound scan in non-traumatic acute abdomen presenting in surgery department of a tertiary care centreet al. role of ultrasound scan in non-traumatic acute abdomen presenting in surgery department of a tertiary care centre 58 jlmc.edu.np the most common cause of acute abdomen was appendicitis (n=44, 40%) followed by nsap (n=22, 20%). table 2. causes of acute abdomen based on usg findings (n=110). usg findings frequency n (%) appendicitis 44 (40) nsap 22 (20) calculous cholecystitis 12 (10.9) urinary calculus 10 (9) malignancy (small bowel lymphoma) 1 (0.9) pancreatitis 5 (4.5) hernia 4 (3.6) liver abscess 2 (1.8) intestinal obstruction 2 (1.8) miscellaneous 8 (7.2) *nsap: non-specific abdominal pain table 3 presents the frequency of causes of acute abdomen shown by various methods. the most common cause of acute abdomen either diagnosed clinically or by usg or as per final diagnosis was acute appendicitis followed by nsap. table 3. frequency comparison of causes of acute abdomen by different modalities (n=110). clinical diagnosis usg diagnosis final diagnosis appendicitis 41 44 49 nsap 39 22 13 calculous cholecystitis 10 12 12 ureteric colic 8 10 10 miscellaneous 2 8 8 pancreatitis 4 5 6 hernia 4 4 4 liver abscess 1 2 3 malignancy (lymphoma) 1 2 intestinal obstruction 1 3 total 110 110 110 out of 110 patients, definite correct clinical diagnosis was made in 83 patients (75%) and usg made a correct diagnosis in 101 patients (91%). hence with the help of usg, accuracy of diagnosing cause of acute abdomen increased by 16%. among total 49 cases of acute appendicitis, 43 were correctly diagnosed and were proved by histopathology and one was over diagnosed by usg, which turned out to be normal appendix in histopathology. six cases were diagnosed by ct which were retro-caecal appendicitis. of the six cases of pancreatitis, five were diagnosed by usg and one by ct. among 22 cases of nsap in usg, further investigations gave final correct diagnosis. table 4 shows sensitivity and specificity of usg in diagnosing different causes of acute abdomen. table 4. sensitivity and specificity of usg in diagnosing different cause of acute abdomen. causes of acute abdomen sensitivity (95% ci) specificity (95% ci) ppv (95% ci) npv (95% ci) appendicitis 87.7 (75.23 95.37) 98.36 (91.2 99.96) 97.73 (85.59 99.67) 90.9 (82.52 95.4) cholecystitis 100 (73.5100) 100 (96.3100) 100 100 ureteric colic 100 (69.15100) 100 (96.38100) 100 100 pancreatitis 83.3 (35.899.5) 100 (96.5100) 100 99.1 (94.5699.84) discussion: acute abdomen is a commonly encountered clinical condition in ed. this study compared clinical and usg findings with the final diagnosis based upon the laboratory values, cect abdomen and intraoperative findings, and follow-up of patients with histopathological reports in relevant cases. prasad et al.[5] observed the most common cause for pain abdomen as acute appendicitis (24.3%) followed by nonspecific pain abdomen (18.9%) with correct clinical diagnosis in 70.9% of the cases. usg diagnosed correctly in 78.4% of acute abdominal pain that increased diagnostic accuracy by 8%. j. lumbini. med. coll. vol 7, no 2, july-dec 2019 acharya s, acharya s, et al. role of ultrasound scan in non-traumatic acute abdomen presenting in surgery department of a tertiary care centreet al. role of ultrasound scan in non-traumatic acute abdomen presenting in surgery department of a tertiary care centre 59 jlmc.edu.np similarly, alleman et al.[6] also saw diagnostic accuracy increased by 13% with usg in comparison to clinical diagnosis which is almost comparable to our findings. kc et al. found the sensitivity, specificity, ppv and npv of usg in diagnosis of acute appendicitis as 95.12%, 88.88%, 97.5% and 80% respectively.[7] similarly, tauro et al. mentioned the sensitivity, specificity, ppv, npv of usg in diagnosis of acute appendicitis as 91.37%, 88.09%, 91.37% and 88.09% respectively.[8] a different diagnostic accuracy of 24.4 % was observed in the study done by garba et al. for the diagnosis of acute appendicitis.[9] this could be attributed to observer’s error and possibly low resolution of the usg machine and inappropriate probes with unsuitable frequencies, and poor clinical history to guide the operator particularly in cases of selfreferral by patients.[10] in our study, most of the procedures were performed by the first author with a high resolution usg machine that reduced the observer’s error which led to the high diagnostic accuracy. usg is the preferred imaging modality for the diagnosis of acute cholecystitis and is the first method used when the clinical presentation is suggestive of biliary pathology.[11] prasad et al. showed the sensitivity and specificity of usg in diagnosing acute cholecystitis as 92.3% and 100% respectively.[5] similarly, a study from philadelphia found 97% sensitivity and 95% specificity in their study that corresponds to our findings.[12] the sensitivity and specificity of usg in diagnosing acute pancreatitis was 89.6% and 87.5% respectively in a study by pandey et al.[13] while galarraga et al. reported as 100% and 85% respectively that almost corroborates our findings. [14] the sensitivity and specificity were both 100 % in a study conducted by ashaolu et al. for cases of renal colic.[15] prasad et al. showed that the sensitivity and specificity of usg in diagnosing ureteric colic were 84.6% and 98.4% respectively. [5] our study had 12 false negative cases (six cases of retrocaecal appendicitis, one case of pancreatitis, one case of liver abscess, one case of malignancy (lymphoma of small intestine), three cases of intestinal obstruction) and showed them as no abnormalities and classified them as nsap. all the missed cases were diagnosed by cect abdomen. usg has poor sensitivity in detecting retrocaecal appendicitis and pancreatitis as they are difficult to visualize due to obscuration by overlying gas shadow from caecum and transverse colon forming poor acoustic window. it may miss early abscess with subtle echogenic changes especially in the left lobe of liver. also, it is not specific in diagnosing intestinal obstruction as nonspecific findings like dilated, prominent bowel loops and abnormal peristalsis are the common findings in intestinal obstruction, which can also be noted in other abdominal pathologies.[5] poor performance of usg in the cases with perforated viscus was observed. the latter often results in massive intraperitoneal free air. intraperitoneal free air in turn leads to scattering of the usg waves at the interface of the soft tissue and the air which is accompanied by reverberation of the waves between the transducer and the air.[16] this, typically, results in a high-amplitude linear echo (increased echogenicity of a peritoneal stripe) accompanied by posterior artifactual reverberation echoes with characteristic comet-tail appearance. this may explain why diagnostic accuracy of usg could be low. maneuvers that can help improve usg sensitivity in cases with perforated viscus include positional change and the use of linear-array of transducers.[16,17] however, the indirect evidence of peritonitis such as free fluid and decreased peristalsis can be detected by usg. x-ray abdomen is found to be superior to usg in detecting pneumoperitonium. for few miscellaneous conditions such as abdominal aorta aneurysm, mesenteric lymphadenitis, and intraabdominal cyst the number of cases were very less to comment in our study. conclusion: ultrasonography is an outstanding imaging modality and has high sensitivity, specificity, and diagnostic accuracy in acute abdomen which has helped the managing surgeons in arriving at early diagnosis. hence, it can be an important routine diagnostic investigation in patients presenting with acute pain abdomen in ed /opd. conflict of interest: the authors declare that no competing interests exist. financial disclosure: no funds were available. j. lumbini. med. coll. vol 7, no 2, july-dec 2019 acharya s, acharya s, et al. role of ultrasound scan in non-traumatic acute abdomen presenting in surgery department of a tertiary care centreet al. role of ultrasound scan in non-traumatic acute abdomen presenting in surgery department of a tertiary care centre 60 jlmc.edu.np references: 1. diethelem ag. the acute abdomen. in: sabiston dc jr. 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io. spectrum of disease and diagnostic value of ultrasound in adult patients with non traumatic acute abdomen in a nigerian tertiary health facility. niger j surg. 2015;21(1):612. pmid: 25838758. doi: https://dx.doi. org/10.4103/1117-6806.152731 16. hefny af, abu-zidan fm. sonographic diagnosis of intraperitoneal free air. journal of emergencies trauma, and shock. 2011;4(4):511– 3. available from: http://www.onlinejets.org/ text.asp?2011/4/4/511/86649 17. chadha d, kedar rp, malde hm. sonographic detection of pneumoperitoneum: an experimental and clinical study. australas radiol. 1993;37(2):182–5. pmid: 8512509. doi: https://doi.org/10.1111/j.1440-1673.1993. tb00046.x 81j. lumbini. med. coll. vol 7, no 2, july-dec 2019 shrestha p. et al. a study on variations of nutrient foramen of femur and its clinical implications. licensed under cc by 4.0 international license which permits use, distribution and reproduction in any medium, provided the original work is properly cited. ___________________________________________________________________________________ submitted: 3 june 2019. accepted: 21 november, 2019. published: 30 december, 2019. a lecturer, department of anatomy b lumbini medical college and teaching hospital, palpa, nepal. c universal college of medical sciences, bhairahawa, nepal. corresponding author: sudikshya kc e-mail:sudi801@gmail.com orcid: https://orcid.org/0000-0003-1743-4270 _____________________________________________________ —–———————————————————————————————————————— abstract: introduction: face has priority in identification of an individual. nose occupying the middle of face is an important sense organ that helps in respiration. nose and face can be classified into different types according to nasal index and facial index. the aim of this study was to analyze nose and face type and find out its dominance in different sex of nepalese and indian population. methods: this was a quantitative observational study conducted on 156 medical students. data were collected then nasal index and facial index were calculated. descriptive statistical data i.e. mean, standard deviation, together with the independent samples t-test results for anthropometric variables of nasal and facial parameters in sex and nationality (nepalese and indian) were analyzed. results: all the measurement values were more in males compared to females, but the sexual dimorphism in nasal index (male 76.25 ± 7.75, female 75.70 ± 8.05) and facial index (male 85.77 ± 8.1, female 82.97 ± 7.63) is not statistically significant. chi square test revealed significant difference in face type among nepalese and indian population. mesorrhine was the most common type of nose in both the population. nepalese had commonly euryprosopic type of face while indians had hypereuryprosopic type of face. conclusion: sexual dimorphism was not significant in both nasal and facial parameters while type of face was helpful in differentiation of nepalese and indian population. key words: anthropometric, facial index, nasal index, sexual dimorphism original research articlehttps://doi.org/10.22502/jlmc.v7i2.287 sudikshya kc,a,b subina shrestha,a,b laxmi bhattaraia,c nasal parameters and facial index in medical undergraduates: a cross sectional study introduction: the face is part of front of head, between the ears and from hairline to chin. it includes the forehead, eyes, nose, mouth, and chin.[1] external nose is one of the most important factors characterizing the face and serves cosmetic function by enhancing an individual’s personality and beauty. [2] the size and shape of face and external nose vary in individuals, and primarily are determined by genetic and developmental factor, but other factors such as gender, race and ethnicity, climate, socioeconomy and nutrition also play an important role in their variation.[3] the nasal index (ni), the ratio of nasal width to the nasal height multiplied by 100 is useful in sex determination, distinguishing racial and ethnic differences, nasal analysis, and rhinoplasty.[4,5] the facial index (fi), the ratio of facial length to the maximum width of face multiplied by 100 is also another important parameter to determine the sex, genetic counseling, reconstructive surgery, for orthodontists and forensic investigation.[4,6] how to cite this article: kc s, shrestha s, bhattarai l. nasal parameters and facial index in medical undergraduates: a cross sectional study. journal of lumbini medical college. 2019;7(2):81-87. doi: doi.org/10.22502/ jlmc.v7i2.287 epub: 2019 december 30. j. lumbini. med. coll. vol 7, no 2, july-dec 2019 kc s. et al. nasal parameters and facial index in medical undergraduates: a cross sectional study jlmc.edu.np82 the aim of this study was to evaluate the significance of the nasal and facial indices in determination of sex in nepalese and indian students. it also helped to classify the type of nose and face among them. as the proportions of the nose and face is important esthetically and functionally, the present study could help plastic and reconstructive surgeons, maxillofacial and cosmetic surgeons, to plan preoperative and postoperative surgical strategies especially during treatment of traumatic injuries and secondary deformities in cleft lip and palate patients. methods: this was an observational, cross-sectional study conducted on 156 undergraduate medical students (nepalese and indian), aged between 17-25 years, in december 2018. after obtaining the ethical clearance from institutional review committee of lumbini medical college (irc-lmc 014-h/018), the data was collected in department of anatomy. all the consenting students were involved in the study who had no history of congenital naso-facial deformities, past and existing craniofacial and nasal trauma or surgery. participants whose, either parents and/or grandparents (both maternal and paternal) had intercaste marriage were excluded. the aim of study and measurement procedures were explained verbally to each participant and consent obtained. they were seated on a chair, in relaxed position, with their head held out in frankfort’s plane. nasal length (nl) was measured from nasion to pronasale, nasal height (nh) was measured from nasion to subnasale, nasal breadth (nb) was considered as maximum breadth at right angle to the nasal height from ala to ala (i.e. the most laterally placed points on the nasal wings), and nasal depth (nd) was taken from pronasale to subnasale. similarly, facial height (fh) was measured between nasion to gnathion and facial breadth (fb) was measured between two zygomatic prominences. a standard digital sliding caliper “gyros digi-science accumatic pro digital electronic caliper” was used for measurements. all the measurements were recorded in millimeter. to maintain the accuracy, the measurements were taken by same observer thrice and the mean value was considered for further analysis. the measurements were made with a permissible error of one mm. after measurements were taken, nasal index and facial index were calculated. the nose and face types were classified according to respective index. human nose can be classified according to ni as: [7] hyperleptorrhine (excessively long and narrow) with ni of 54.9 and less. leptorrhine (moderately long and narrow nose) with ni between 55 and 69.9. mesorrhine (medium nose) with ni between 70 and 84.9. platyrrhine (moderately broad nose) with ni between 85 and 99.9. hyperplatyrrhine (very broad nose) with ni 100 and above. face can be classified into five categories according to fi: [7] hypereuryprosopic (very broad, short face) with fi of 79.9 and less. euryprosopic (broad, short face) with fi between 80 and 84.9. mesoprosopic (normoprosopic: average face) with fi between 85 and 89.9. leptoprosopic (long, narrow face) with fi between 90 and 94.9. hyperleptoprosopic (very long, narrow face) with fi of 95 and above. the data was entered and analysis done using statistical package for social sciences (spsstm) software version 16. basic descriptive statistics i.e. mean (m), standard deviation (sd) were calculated in different sex and nationality. further analysis were done to test the significance of the variables by using independent sample t-test and chi square test. p value <0.05 was considered to be statistically significant. results: there were 97 nepalese students (56 male and 41 female) and 59 indian students (25 male and 34 female). descriptive statistical data for anthropometric variables of nasal and facial parameters in sex (male and female) and in nationality (nepalese and indian) are given in tables 1 and 2 respectively. the nasal and facial measurements compared between males and female (table 1) showed larger mean values for all anthropometric variables in male j. lumbini. med. coll. vol 7, no 2, july-dec 2019 kc s. et al. nasal parameters and facial index in medical undergraduates: a cross sectional study jlmc.edu.np83 than in female; however, all parameters were not statistically significant in both sexes. table 1. nasal and facial parameters in males (n=81) and females (n=75). anthropometric variables sex mean ± sd p value * nasal breadth male 3.72 ± 0.23 0.07 female 3.45 ± 0.28 nasal height male 4.91 ± 0.35 0.11 female 4.58 ± 0.28 nasal length male 4.67 ± 0.35 0.24female 4.30 ± 0.32 subnasleprognathion (nasal depth) male 1.51 ± 0.22 0.13female 1.44 ± 0.19 nasal index male 76.25 ± 7.75 0.50female 75.70 ± 8.05 facial breadth male 13.08 ± 1.01 0.97female 12.43 ± 0.96 facial height male 11.15 ± 0.61 0.15female 10.25 ± 0.50 facial index male 85.77 ± 8.31 0.41female 82.97 ± 7.63 * p value calculated by student's t test in table 2, comparison of nasal index between nepalese and indian students (both sexes together) indicate that indians (77.62 ± 8.30) had a higher mean nasal index than nepalese (75.00 ± 7.48). facial index in nepalese was 85.98 ± 8.33 and in indian, 81.87 ± 7.02. there was no significant difference in both nasal and facial index between two populations. nasal length was significantly higher in nepalese (4.58 ± 0.39) in comparison to indian (4.35 ± 0.32) while facial breadth was significantly higher in indian (13.01 ± 0.89) than in nepalese (12.62 ± 1.09). these differences showed that nepalese had slightly longer nose as compared to indians, and indians had slightly broader face as compared to nepalese. overall, mean nasal breadth, nasal height, nasal length and facial height were found to be larger in nepalese while mean nasal depth, nasal index, facial breadth and facial index were larger in indian. table 2. nasal and facial parameters in nepalese (n=97) and indian (n=59). anthropometric variables nationality mean ± sd p value * nasal breadth nepalese 3.61 ± 0.28 0.75 indian 3.57 ± 0.31 nasal height nepalese 4.83 ± 0.35 0.19 indian 4.62 ± 0.32 nasal length nepalese 4.58 ± 0.39 0.03indian 4.35 ± 0.32 subnasleprognathion (nasal depth) nepalese 1.45 ± 0.20 0.89 indian 1.52 ± 0.21 nasal index nepalese 75.00 ± 7.48 0.28indian 77.62 ± 8.30 facial breadth nepalese 12.62 ± 1.09 0.03indian 13.01 ± 0.89 facial height nepalese 10.78 ± 0.72 0.64indian 10.61 ± 0.69 facial index nepalese 85.98 ± 8.33 0.26indian 81.87 ± 7.02 * p value calculated by student's t test j. lumbini. med. coll. vol 7, no 2, july-dec 2019 kc s. et al. nasal parameters and facial index in medical undergraduates: a cross sectional study jlmc.edu.np84 in both sexes, mesorrhine nose type was the dominant (male: 62.97%, female: 62.67%) while platyrrhine nose type was found the least (male: 16.04%, female: 13.33%). leptorrhine nose type in male was 20.99% and in female, 24%. the most common face type in male and female was euryprosopic (male: 24.69%, female: 29.33%) and hypereuryprosopic (male: 19.75%, female: 30.67%) respectively. the least common face type was leptoprosopic in male (16.05%) and hyperleptoprosopic in female (9.33%). chi square test indicated both the nose type and face type were not significant between male and female i.e. 0.83 and 0.28 respectively. higher incidence of mesorrhine nose (nepalese: 65.97%, indian: 57.62%) followed by leptorrhine (nepalese: 22.68%, indian: 22.04%) and platyrrhine (nepalese: 11.35%, indian: 20.34%) was found in both nepalese and indian, which was not nationality nose type face type total (%) p valuevaluehypereuryprosopic (%) euryprosopic (%) mesoprosopic (%) leptoprosopic (%) hyperleptoprosopic (%) nepalese leptorrhine 1 (4.54%) 3 (13.63%) 4 (18.19%) 5 (22.73%) 9 (40.91%) 22 (100%) .001 mesorrhine 13 (20.32%) 16 (25%) 16 (25%) 9 (14.05%) 10 (15.63%) 64 (100%) platyrrhine 3 (27.28%) 7 (63.64%) 1 (9.08%) 0 (0%) 0 (0%) 11 (100%) indian leptorrhine 2 (15.39%) 5 (38.46%) 4 (30.76%) 0 (0%) 2 (15.39%) 13 (100%) .27 mesorrhine 15 (44.12%) 8 (23.54%) 4 (11.76%) 6 (17.64%) 1 (2.94%) 34 (100%) platyrrhine 5 (41.66%) 3 (25%) 2 (16.67%) 2 (16.67%) 0 (0%) 12 (100%) table 4. comparative studies between nose type and face type in nepalese and indian. table 3. comparative studies between nose type and face type in different sex sex nose type face type total (%) p value hypereuryprosopic (%) euryprosopic (%) mesoprosopic (%) leptoprosopic (%) hyperleptoprosopic (%) male leptorrhine 0 (0%) 1 (5.88%) 4 (23.53%) 4 (23.53%) 8 (47.06%) 17 (100%) .001 mesorrhine 12 (23.53%) 12 (23.53%) 12 (23.53%) 8 (15.69%) 7 (13.72%) 51 (100%) platyrrhine 4 (30.77%) 7 (53.85%) 1 (7.69%) 1 (7.69%) 0 (0%) 13 (100%) female leptorrhine 3 (16.67%) 7 (38.89%) 4 (22.22%) 1 (5.55%) 3 (16.67%) 18 (100%) .19 mesorrhine 16 (34.04%) 12 (25.53%) 8 (17.02%) 7 (14.90%) 4 (8.51%) 47 (100%) platyrrhine 4 (40%) 3 ( 30%) 2 (20%) 1 (10%) 0 (0%) 10 (100%) j. lumbini. med. coll. vol 7, no 2, july-dec 2019 kc s. et al. nasal parameters and facial index in medical undergraduates: a cross sectional study jlmc.edu.np85 statistically significant (p value = 0.29). table 3 shows the comparative study of nose type along with face type in male and female. there was significant relation between nose type and face type in male (p = 0.01) while in female it was not significant (p = 0.19). in male euryprosopic face with platyrrhine nose was predominant (53.85%), while in female hypereuryprosopic face with platyrrhine nose was predominant (40%). present study (table 4) shows nepalese population have significantly euryprosopic face with platyrrhine nose (p = 0.001) while indian population have hypereuryprosopic face with platyrrhine nose, which was not significant (p = 0.27). in indian, hyperleptoprosopic face was least and in nepalese leptoprosopic face was least common. in the present study, nose type designated as hyperleptorrhine and hyperplatyrrhine were not observed in either sex of nepalese and indian population. discussion: anthropological studies of different regions of body help to compare variations in different age group, sex, race, and ethnicity. such studies help not only anthropologists, anatomists, reconstructive surgeons but also forensic medicine experts for identification. the study of nasal and facial parameters are considered important factors from ancient time to classify racial, sexual and environmental variations.[8] the nasal index and facial index in different studies, have shown sexual dimorphism and racial differences between different populations.[2,3,9-12,16-21] in present study, less nasal index and more facial index was found in nepalese when compared to indian students (table 2). the most common nose type in present study was mesorrhine followed by leptorrhine and platyrrhine which resembles with south indian and north indian population.[10] earlier studies have shown majority of caucasians have long and narrow nose, indo aryan and european has fine nose.[11] in a study conducted on rai and limbu ethnic groups of nepal; limbu females had broader nose in comparison to male counterpart. in the same study, when the parameters were compared between two ethnic groups; it was observed that the rai had broader nose.[12] tharu and mongoloid ethnic groups of nepal exhibited sexual dimorphism along with significant nasal height.[13] both of these studies had contrasting results to our study in nepalese population which may be due to variation in ethnicity. the nigerian nose type was platyrrhine with significant sexual dimorphism.[2] in andoni and okrika tribes of rivers state, nigeria; platyrrhine nose type was common in okrikas while the andonis had mesorrhine nose type. nasal index was significant in andoni ethnic group but insignificant in the okrika ethnic group for sexual dimorphism. [14] a study in nasofacial index among malay, chinese, and indian university students showed the nasal index in all three races were mesorrhine type, but sexual dimorphism in all of them were statistically not significant. the result is comparable to our study in which most common nasal type is mesorrhine followed by leptorrhine and platyrrhine in both sex of nepalese and indian population and it was not statistically significant as well. the leptoprosopic face type was dominant for the malays and indians, while it was mesoprosopic type in chinese. sexual dimorphism for the facial index in malay population was significant. in present study, common face type in indian population is hypereuryprosopic which is contrasting to this study. the combine nasofacial relation found in indian was leptoprosopic face with mesorrhine nose which is contrasting to present study in indian population i.e. hypereuryprosopic face with platyrrhine nose.[15] the contrast in result of these study may be due to variation in sample size and participants selected may be of different places of india. all of above studies had total absence of hyperleptorrhine and hyperplatyrrhine nose which is a similar finding to the present study. the most common face type in present study was euryprosopic in male and in nepalese population, while in female and in indian population it is hypereuryprosopic. sexual dimorphism in the facial index of present study was insignificant. a study of facial index among malay population showed significant sexual dimorphism with mesoprosopic face type.[16] the mean facial index in chinese male and female was 89.02 ± 4.92 and 88.52 ± 4.89 respectively and the dominant face type was mesoprosopic.[17] comparative study between indian and malaysian students concluded both races j. lumbini. med. coll. vol 7, no 2, july-dec 2019 kc s. et al. nasal parameters and facial index in medical undergraduates: a cross sectional study jlmc.edu.np86 have mesoprosopic face type which was significant in sexual dimorphism in malay population while it was insignificant in indian population.[18] in similar comparative study among malay, chinese, and indian sexual dimorphism was significantly seen in indian population only.[22] the research in the adult population of central serbia concerning the total facial index, face shape showed complete absence of euryprosopic and hypereuryprosopic face which was a different result from other studies.[3] the results of our study are at variance with other studies, could be due to small sample size from different geographic location and of multiple races. conclusion: the mean nasal index and facial index in both sexes of nepalese and indian population have been identified. the study showed nepalese population have comparatively longer nose than indian population while indians have broader face in comparison to nepalese population. these results are useful reference material for anthropometric records and in forensic medicine as well as for different surgical purposes. the present findings are based on study in mixed sample size of nepalese and indian population from different regions of respective countries. further studies in different specific ethnic groups would help for data updates regarding classification of nose and face type. conflict of interest: the authors declare that no competing interest exits. source of funds: no funds were available. references: 1. sinnatamby cs. last’s anatomy: regional and applied. 12th ed. edinburgh churchill livingstone, 2011;349:503–12. 2. ukoha uu, egwu oa, ndukwe gu, akudu ls, umeasalugo ke. anthropometric study of the nose in a student population. ann bioanthropol.2016;4(1):8. doi: 10.4103/23157992.190461. 3. jeremic d, kocic s, vulovic m, sazdanovic m, sazdanovic p, jovanovic b et al. anthropometric study of the facial index in the population of central serbia. arch biol sci. 2013;65(3):11638. doi: 10.2298/abs1303163j 4. gray h. sexual and geographic variation in the skull. in: standring s. gray’s anatomy. the anatomical basis of clinical practice. 39 ed. london: churchill livingstone elsevier, 2008;488p. 5. franciscus rg, long jc. variation in human nasal height and breadth. am j phys anthropol. 1991;85(4):419‐27. pmid: 1928315. 6. kumari kl, babu pv, kumari pk, nagamani m. a study of cephalic index and facial index in visakhapatnam, andhra pradesh, india. int j res med sci. 2015;3(3):656-8. 7. martin r, saller k. lehrbuch der anthropologie, 3rd ed. gustav fischer verlag: stuttgart; 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