403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 medical journal of birendra hospital.indd original articlejanuary-june, 2010/vol 9/issue 1 medical journal of shree birendra hospital 1 managing difficult fractures due to ballistic trauma with ilizarov ring fixation chand p1, shrestha rl2, kc br3, shah bc4, joshi a5, thapa bb6 1pankaj chand, consultant orthopedic surgeon, shree birendra hospital chhauni, 2roshan lal shrestha, consultant orthopedic surgeon, model hospital, kathmandu, 3bachu ram kc, senior consultant and orthopedic surgeon, 4bhanu chand shah consultant and orthopedic surgeon, 5amit joshi, orthopedic surgeon, 6bishnu bahadur thapa, consultant and orthopedic surgeon, shree birendra hospital chhauni abstract 20 fractures (7 femoral and 13 tibial) were treated with the illizarov apparatus between 2003 to 2006. all were old injuries, previously managed by internal fixation (intramedullary rods), external fixation (hoffman’s external fixators), or conservatively with traction and plaster of paris slabs. ilizarov fixators were applied to manage infected non-union with or without bone loss and malunion. corticotomy and bone transport was carried out in cases with significant bone loss. in others without any limb shortening and minimal bony defect, bone grafting and compression was carried out. in one case valgus deformity along with non-union was corrected. early weight bearing with range of motion exercises for ankle and knee joints were encouraged. average fracture healing time was 12 months (8 to18months). all fractures healed with <5º of malalignment. complications included pin site inflammation/ infection, muscle transfixation, knee and ankle joint stiffness and a wire fracture. the ilizarov device provided definitive fixation with acceptable results in all cases. key words: ilizarov ring fixator, distraction osteogenesis, bone transport, infective non-union, corticotomy introduction extremity injury as a result of blast trauma commonly results in severe soft-tissue and osseous injury. in one recent military review of soldiers injured in battle, 54% of all 3575 wounds involved the extremities and 82% of 915 long-bone fractures were open (1). the tibia and fi bula were the most commonly affected lowerextremity long bones. the treatment of open tibial fractures with aggressive débridement and intramedullary nail insertion followed by soft-tissue coverage has become the standard of care at most civilian trauma centers (2-6). severe open extremity fractures resulting from blast injuries during wartime and characterized by an "outside-in" mechanism with extensive contamination and delays in treatment due to evacuation are distinct injuries compared with civilian injuries and may be better treated by avoiding placement of internal fi xation. (7-12). their treatment, prognosis, and outcome are mainly determined by the mechanism of injury, degree of resulting comminution, soft tissue injury and displacement. fractures produced by indirect trauma have a better prognosis than those produced by direct trauma. the risk of delayed union and nonunion in closed and open treatment is increased with comminution. open fractures have a higher infection rate than closed fractures and the rate increases with the increasing address for correspondence: pankreena@hotmail.com medical journal of shree birendra hospital2 severity of the soft tissue injury. high-energy injuries have added to the number and complexity of fractures of long bones, especially those of tibia and so have the treatment modalities addressing them. war injuries are peculiar as they incorporate severe soft tissue trauma, with bacterial contamination, along with the possibility of a vascular injury. the fracture itself might be severely comminuted, with or without bone loss. almost always they are high velocity injuries. thus the orthopaedic surgeon is often faced with non-united or mal-united fractures, bones and soft tissue defects, persistent infections and sometimes the need for amputation. ilizarov method addresses most problems, allowing early weight bearing ambulation and joint mobilisation. progressive bone histogenesis following corticotomy and bone transport helps in fi lling bone gaps eradicating infection and promoting fracture union. infection control is achieved by radical debridement of the infected tissues including bone and followed by bone transport to reconstruct the residual bone defect. we evaluated the use of ilizarov device as the mode of fracture stabilization of these diffi cult fractures and present our experience of ilizarov fi xation in the treatment of established recalcitrant infected nonunions and gap non-unions of the tibia and femur and the suitability of this procedure with particular reference to bony union and to identify the factors infl uencing the functional outcomes. methods twenty patients with established infected non-union of the tibia (sixteen) and femur (four) were included for the study. one patient had an unacceptable varus angulation of 14º of the tibia. the patients were followed up over a 5 year period from the day of ilizarov fi xator application. clinical history including co-morbidities, social habits including smoking and alcohol consumption, previous treatment offered for the fracture, complications, duration of nonunion, were gathered. seventeen patients were serving soldiers, while the three female patients were all housewives. all the male patients were active and sole earners of their families with no additional source of income. the initial diagnosis was gustilo type ii open fracture in 1, type iiia in 5, iiib in 12 and type iiic in 2 patients. 10 patients had extensive bone loss at the time of initial injury. initially, after debridement, 8 patients had internal fi xation device [intra-medullary nail in 6 and plate and screw fi xation in 2] applied and, 10 had external fi xation with hoffman’s uniplanar fi xators while two were managed conservatively with plaster immobilization. all patients had preoperative full-length radiographs of the affected limb for assessment of the level and type of fracture nonunion, plane of deformity, bone quality and presence of sequestrum. they were counseled about the procedure to be performed, and the expected outcome of treatment. culture swabs from draining sinuses and open wounds were carried out in all patients and appropriate antibiotic therapy was initiated. this was repeated whenever necessary throughout the duration of treatment. 4 patients with internal fi xation had had fasciocutaneous or muscle fl ap coverage for the open wounds prior to application of ring fi xator. one, with a varus deformity underwent correction of the defect while in the ilizarov frame. for two patients who had femoral artery rupture, vascular reconstruction was carried out with autologus saphenous vein graft when they were fi rst brought in. the average duration of non-union and time of ilizarov fi xation was 7.8 months. limb shortening ranged from 2 – 11 cms and bone gap ranged from 2–9 cms. 15 patients had associated fi bular shaft fractures, which had healed at the time ilizarov application. pus culture in all patients obtained pre operatively, revealed a mixed a bacterial growth. the ilizarov frame was constructed pre-operatively in all patients. 15 patients with limb shortening and signifi cant bone loss had debridements combined with ring fi xator application as a single stage procedure. corticotomy was carried out in these patients followed by bone transport. all patients had bifocal osteosynthesis [compression of the fracture site with bone transport following corticotomy]. five of these were given additional bone graft when docking was achieved.. in four patients with no limb shortening and minimal bone loss, after debridement, the fracture site was freshened, and acute docking was carried out after instituting autogenous bone graft along with fi bular osteotomy. in one patient the ilizarov frame was applied to rectify valgus deformity along with the non union of the of the tibia. compression with bone grafting was carried out once deformity was corrected. 11 patients had proximal tibial and 5 patients had distal tibial corticotomies.all femoral osteotomies were performed proximally. postoperatively all patients medical journal of shree birendra hospital 3 s .n o a ge s ex ty pe b on e s id e in ju ry t yp e (g us til lo ) in iti al f ix at io n d ur at io n in il iz ar ov f ix at or (m on th s) d ur at io n in p t b / fe m or al br ac e( w ks ) ti m e to u ni on (c on so lid at io n) in m on th s c om pl ic at io ns tr ea tm en t m et ho d r es ul t (a s a m i) p in tr ac t in fe ct io n r es id ua l un ac ce pt ab le de fo rm ity s ho rt en in g bony functional 1 35 m g s t r iii -b e f 6. 5 6 8 + n il n il tr an sp or t e e 2 34 m g s t l iii -b e f 6. 5 6. 5 8 + n il 1. 5c m c om pr es si on g g 3 24 m ie d t r iii -a im n 6. 5 6 8 + n il 1. 5c m c om pr es si on g f 4 40 m g s f r iii -b im n 9 6 10 + n il n il tr an sp or t e e 5 32 m g r.b l. t l iii -b im n 11 7 17 + n il n il tr an sp or t g g 6 40 f g r.b l t l iii -c e f 11 7 12 .5 + n il 2c m tr an sp or t f p 7 45 m g s f r iii -b e f 9. 5 8 9. 5 + n il 1. 5c m c om pr es si on g f 8 33 m ie d t r iii -a p o p 7. 5 6 8. 5 + n il n il va lg us co rr ec . f f 9 20 m g s t l iii -b e f 7 6. 5 8. 5 + n il 1. 5c m tr an sp or t f g 10 34 m g s f l iii -b e f 10 8 10 + n il n il tr an sp or t g g 11 28 m g s f r iii -a im n 8. 5 8 8. 5 + n il n il tr an sp or t e e 12 23 m ie d t l ii p o p 7. 5 6 9 + n il n il tr an sp or t e e 13 19 m g s f l iii -b e f 8 8 8 + n il 1. 5c m c om pr es si on f g 14 51 m ie d t r iii -b p la te 9. 5 6 11 + n il n il tr an sp or t f g 15 50 f g s t r iii -a p la te 7 6 8. 5 + n il n il tr an sp or t g p 16 20 m g s t r iii -b im n 10 7 11 .5 + n il n il tr an sp or t f f 17 51 m g s f r iii -b im n 12 6 12 + n il 1c m tr an sp or t f p 18 32 m g r.b l t l iii -c e f 14 6 15 .5 + n il 1. 5c m tr an sp or t f p 19 25 f g s t l iii -b e f 15 6 16 .5 + n il 2. 5c m tr an sp or t f p 20 30 m g s t r iii -a e f 9 6 11 + n il 1c m tr an sp or t g f medical journal of shree birendra hospital4 had radiographs of the affected limb taken for assessment of the corticotomy and position of the wires. corticotomy site distraction was initiated after 10 days at the rate of 1 mm per day. compression and distraction technique [accordian manoeuvre] was employed in 2 patients. follow up x-rays were done at 3 weeks for assessment of the regenerate and at 4 weeks interval thereafter until fracture union. in doubtful distraction rate was reduced to 0.5 mm/day until satisfactory appearance on x-rays. patients were mobilized with partial weight bearing, within comfort by a trained physiotherapist. they were discharged upon satisfactory compliance and followed up in the out patient department at monthly intervals for assessment of fracture union, regenerate progress and ensuring compliance with physiotherapy. fixator was retained further for the duration equal to the period of bone transport after bone docking in cases where bone transport was done. the fi xator was removed once union was confi rmed with conventional x-rays. the operated limb was protected in a functional cast brace for at-least 6 to 8 weeks after removal of fi xator. the period of follow up after fracture union ranged from 8-20 months [average 13 months]. the outcomes were assessed using the association for the study and application of methodology of ilizarov [asami] criteria. results the patients were followed-up for an average period of 13 months (8 to 20) after removal of the frame. the results were divided into bone and functional results, according to the criteria laid down by the association for the study and application of the method of illizarov (13, 14). this classifi cation is applicable for tibial and femoral non-unions. bone results were determined according to four criteria: union, infection, deformity and limb-length discrepancy. a fracture was considered to be united when there was no motion at the fracture site following removal of the illizarov frame and when there was radiological evidence of union. nine patients received bone grafts. the fracture united in all patients and there were no refractures following removal of the frame. the time to union ranged from eight months to eighteen months (average 12 months). one patient with an angular deformity of 14 degrees of the tibia underwent correction. there was some resultant limb length inequality in ten patients, as listed in the table. none required any procedure to correct the shortening. superfi cial pin-tract infections developed in all patients; these resolved with local care and oral antibiotics. in one patient, a broken half-pin was removed and in two patients a single wire was repositioned. all fractures healed with < 5º of malalignment. according to the protocol of the association for the study and application of the method of illizarov (asami), a bone result cannot be graded excellent unless union was achieved without the use of a bone graft. an excellent result was defi ned as union, no infection, deformity of less than 7° and a limb-length discrepancy of less than 2.5cm. a good result was defi ned as union and any two of the other three criteria; a fair result, as union and one of the other criteria; and a poor result, as non-union or refracture, or as union but none of the remaining three criteria. the authors used the above classifi cation to evaluate the results of the tibial and femoral non-unions. according to the system, the bone results were excellent in 4 patient, good in 7 patients, and fair in 9 patients. the functional results were based on fi ve criteria (asami); a signifi cant limp, stiffness of either the knee or the ankle (loss of more than 15° of full extension of the knee or 15° of dorsifl exion of the ankle in comparison with the normal contralateral ankle), soft tissue sympathetic dystrophy, pain that reduced activity or disturbed sleep and inactivity (unemployment or an inability to return to daily activities because of the injury). the functional results were considered excellent if the patient was active and none of the other four criteria were applicable; good, if the patient was active but one or two of the other criteria were applicable; fair, if the patient was active but three or four of the other criteria were applicable, and poor, if the patient was inactive regardless of whether other criteria were applicable. four patients were able to return to work and daily activities. six were active but had a limp with some pain and stiffness of the ankle and knee joints. another six, in spite of being active had persistent limb oedema and some degree of pain besides stiffness of the ankle and knee. five patients had to quit their jobs as they were unable to pursue an active lifestyle. according to these criteria, the functional result was excellent in 4 patients, good in 6 patients, fair in 5 patients and poor in 5 patients. medical journal of shree birendra hospital 5 type iii b fracture of tibia ilizarov ring fi xation infected non-union of left tibia compression with ilizarov fi xator bony union with functional brace type iiib open fracture initially managed with hoffman fi xator case-i ilizarov ring fi xator applied with corticotomy and bne transport case-i adequate length achieved,and docking done case-i medical journal of shree birendra hospital6 discussion numerous authors have concluded that intramedullary nail fi xation of type-iii tibial fractures is the preferred method of stabilization for patients at a civilian trauma center(2-6). kakar and tornetta(15) recently reported the results of 143 open tibial fractures treated with protocol-driven wound management and immediate unreamed intramedullary nail fi xation, which resulted in minimal complications and a low rate (3%) of deep infection. similarly, monoplanar external fi xation has been considered for use in tibial fractures characterized by severe soft-tissue injury because of its ease of placement and the preservation of existing blood supplies to the tibia. however, henley et al. (16) have found that use of monoplanar external fi xation often leads to higher rates of complications, including malunion, infection, and an increased number of operative interventions, and this type of fi xation is generally reserved for temporary stabilization. compared with injuries sustained in the civilian trauma setting, wounds sustained on the battlefi eld resulting from an "outside-in" injury mechanism are considered to be more contaminated.(17-19). moreover, the typical early débridement and coverage protocols espoused by fischer et al. (20), which lead to a lower rate of infectious complications, are not always possible because of delays associated with evacuation to defi nitive treatment facilities during wartime. these realities combined with the common occurrence of extensive retained blast fragments throughout the soft tissues in themselves complicate the injury management.. similar to many other institutions, we have observed the benefi ts of a protocol-driven approach non union with varus deformity case iii angulation almost corrected case iii union achieved to the treatment of these limb-threatening injuries, which includes frequent aggressive soft-tissue and osseous débridement, expeditious soft-tissue coverage, and delayed supplemental bone-grafting when needed.(26). a fracture non-union is a signifi cant problem to the patient and the surgeon. in most instances the patient has undergone one or more surgical procedures, has lost considerable time from his/her job or life style, and has been forced to alter his or her life style. furthermore, the psychological and physical trauma to the patient when faced with the prospect of another surgery is often underestimated. the problems facing the surgeon are no less formidable. in many instances consolidation of the non-union must be achieved with correction of axial and rotational mal-alignment (21). in our study, all patients with open fractures were being treated with other forms of defi nitive treatment before being opted for ring fi xation. the effects of smoking on the outcome of ring fi xation have been well documented (22). many of the patients in our study were smokers and consumed alcohol. despite being advised about the consequences of smoking and alcohol intake, it was diffi cult to ensure complete co-operation from the patients in this regard. the regenerate appearance was not on expected lines in some cases particularly with the distal corticotomies. in one particular case, there was no regenerate visible on the radiographs even at 4 weeks and an accordion man oeuvre was resorted to and distraction rate was reduced until satisfactory regenerate was visible. we have followed the criteria laid down by asami. the functional result is predetermined by the condition of the nerves, muscles, vessels, joints, and to a lesser medical journal of shree birendra hospital 7 benefi t of immediate weight-bearing without hardware retention after fracture-healing. references 1. owens bd, kragh jf jr, macaitis j, svoboda sj, wenke jc. characterization of extremity wounds in operation iraqi freedom and operation enduring freedom.j orthop trauma.2007 ; 21:254-7. 2. bone lb, kassman s, stegemann p, france j. prospective study of union rate of open tibial fractures treated with locked, unreamed intramedullary nails. j orthop trauma. 1994;8:459. 3. tielinen l, lindahl je, tukiainen ej. acute unreamed intramedullary nailing and soft tissue reconstruction with muscle fl aps for the treatment of severe open tibial shaft fractures. injury. 2007;38:906-12. 4. kakar s, tornetta p 3rd. open fractures of the tibia treated by immediate intramedullary tibial nail insertion without reaming: a prospective study. j orthop trauma. 2007;21:153-7. 5. gopal s, majumder s, batchelor ag, knight sl, de boer p, smith rm. fix and fl ap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. j bone joint surg br. 2000;82:959-66. 6. sanders r, jersinovich i, anglen j, dipasquale t, herscovici d jr. the treatment of open tibial shaft fractures using an interlocked intramedullary nail without reaming. j orthop trauma. 1994;8:50410. 7. jorgenson ds, antoine ga. advances in the treatment of lower extremity wounds applied to military casualties. ann plast surg. 1995;34:2. 8. lerner a, fodor l, soudry m. is staged external fi xation a valuable strategy for war injuries to the limbs? clin orthop relat res. 2006;448:217-24. 9. dubravko h, zarko r, tomislav t, dragutin k, vjenceslav n. external fi xation in war trauma management of the extremities—experience from the war in croatia. j trauma. 1994;37:831. 10. zeljko b, lovr z, am e, busi v, lovr l, markov i. war injuries of the extremities: twelve-year follow-up data. mil med. 2006;171:55-7. extent the bone (23). ankle pain with disability is the major source of residual disability after successful use of the ilizarov device for the treatment of tibial nonunion even after fracture union (24). no patient in our study had any residual neurovascular defi cits but the correlation between bony and functional results was poor. this is largely due to the soft tissue status particularly oedema and joint stiffness. in our study, all patients had varying degrees of knee, ankle and subtalar joint stiffness. though knee stiffness was largely overcome with physiotherapy, foot and ankle stiffness persisted and worsened despite bony union. this may account for the poor functional outcome in our cohort of patients. asami criteria defi ne unemployment as a poor result. majority of patients who were assessed for functional results did not go back to their original employment. most changed their jobs to a sedentary and less demanding work as they did not have any choice. other studies (25,26), have highlighted that patient satisfaction is more important than employment status in assessment of functional status. this is true in developed countries, where there is adequate government support for economic inactivity. in developing countries like nepal no such support exists. therefore the direct applicability of the asami criteria in the indian scenario may not be appropriate for a fi nite functional analysis. though many from our study were happy in that an amputation was avoided, most of them felt that this was at a 'heavy price' and some still preferred an amputation in the hope of early return to work and pain relief. conclusion our observations indicate that the ilizarov method is not a panacea but an important treatment method for surgeons, in situations such as osteomyelitis, osteopenia, complex deformities and signifi cant limblength inequalities. the drawbacks of this method are the time and resource, intensive nature of the treatment, the diffi culties of prolonged fi xator use and the potential major and minor complications. the surgeon should know when to offer an amputation as this is, in certain circumstances, the best option. therefore the treatment in these situations needs to be highly individualised. in conclusion, we believe that ilizarov ring fi xation that has resulted in a relatively low rate of complications and defi nite fracture union for severe open fractures of the long bones of the lower extremity resulting from war injuries. ring external fi xation in these patients appears to be a valuable form of treatment allowing the added medical journal of shree birendra hospital8 11. duman h, sengezer m, celikoz b, turegun m, isik s. lower extremity salvage using a free fl ap associated with the ilizarov method in patients with massive combat injuries. ann plast surg. 2001;46:108-12. 12. andersen rc, frisch hm, farber gl, hayda ra. defi nitive treatment of combat casualties at military medical centers. j am acad orthop surg. 2006;14(10 suppl):s24-31. 13. maiocchi ab, aronson j. non-union of the femur. in: operative principles of illizarov. fracture treatment, non-union, osteomyelitis, lengthening, deformity correction. baltimore: williams and wilkins; 1991: 245–62. 14. catagni m, villa a. non-union of the leg (tibia). in: operative principles of illizarov: fracture treatment, non-union, osteomyelitis, lengthening, deformity correction. baltimore: williams and wilkins; 1991: 199–214. 15. kakar s, tornetta p 3rd. open fractures of the tibia treated by immediate intramedullary tibial nail insertion without reaming: a prospective study. j orthop trauma. 2007;21:153-7. 16. henley mb, chapman jr, agel j, harvey ej, whorton am, swiontkowski mf. treatment of type ii, iiia, and iiib open fractures of the tibial shaft: a prospective comparison of unreamed interlocking intramedullary nails and half-pin external fi xators. j orthop trauma. 1998;12:1-7. 17. islinger rb, kuklo tr, mchale ka. a review of orthopedic injuries in three recent u.s. military confl icts. mil med. 2000;165:463-5. 18. hayda r, harris rm, bass cd. blast injury research: modeling injury effects of landmines, bullets, and bombs. clin orthop relat res. 2004;422:97-108. 19. covey dc. blast and fragment injuries of the musculoskeletal system. j bone joint surg am. 2002;84:1221-34. 20. fischer md, gustilo rb, varecka tf. the timing of fl ap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury. j bone joint surg am. 1991;73:1316-22. 21. kempf i, grosse a, rigaut p. the treatment of noninfected pseudarthrosis of the femur and tibia with locked intramedullary nailing. clin orthop. 1986;212:142–545. 22. mckee michael d, dipasquale dennis j, wild lisa m, stephen david jg, kreder hans j, schemitsch emil h. the effect of smoking on clinical outcome and complication rates following ilizarov reconstruction. j orthop trauma. 2003;17:663– 667. 23. paley d, catagni ma, argnani f, villa a, benedetti gb, cattaneo r. ilizarov treatment of tibial nonunions with bone loss. clin orthop relat res. 1989:146–65. 24. sanders dw, galpin rd, hosseini m, macleod md. morbidity resulting from the treatment of tibial nonunion with the ilizarov frame. can j surg. 2002;45:196–200. 25. patil s, montgomery r. management of complex tibial and femoral nonunion using the ilizarov technique, and its cost implications. j bone joint surg br. 2006;88:928–32. 26. marsh dr, shah s, elliott j, kurdy n. the ilizarov method in nonunion, malunion and infection of fractures. j bone joint surg br. 1997;79:273–9. doi: 10.1302/0301-620x.79b2.6636. medical journal of birendra hospital_10 gray.indd original article january-june, 2011/vol 10/issue 1 medical journal of shree birendra hospital6 reduction of acute anterior shoulder dislocation using intraarticular lidocaine(ial) and stimson’s technique thapa bb1, chand p1, kayastha n1, rana s1, kc nb1, joshi a1, singh bp1, shah bc1, kc br1 1shree birendra army hospital, chhauni, kathmandu, nepal abstract introduction: shoulder dislocation is common injury requiring urgent reduction. for the reason that patient is not nill orally and anesthetists are not available, reduction under intra venous anaesthesia is not possible. this study was aimed to evaluate the effectiveness of intraarticular lidocaine and stimson’s technique of shoulder dislocation, which could be performed without anesthetist and irrespective of nill orally status. methods: a prospective observational study was performed from december 2009 to december 2010. under all antiseptic precautions 20 ml of lidocaine was injected intraarticularly and reduction was performed by stimson’s technique. visual analogue score, time for reduction and failure to reduction by this technique was recorded. results: out of 27 dislocations 22 were successfully reduced and remaining required added scapular manipulation. the mean vas scor was 2.3±1.26 and the mean time of reduction was 17.96±1.9 minutes. conclusion: stimson’s method with intraarticular lidocaine is effective, safe, less costly and can be performed in periphery where anesthetist and monitoring facilities are not available. key words: anterior dislocation, stimson’s technique introduction most dislocations occurres in teenagers and young adults and are rare after 45 years of age2. shoulder joint dislocations constitute about 50% of all dislocations. the incidence of traumatic dislocation is increasing in our country because of industrialization leading to more road traffi c accidents. the dislocation must be reduced as soon as possible for two reasons. first, to minimize ongoing damage to the joint and its surrounding structures. second, to reduce pain and suffering. presently, shoulder dislocations are reduced under iv anesthesia, which requires anesthetist and other supportive equipments to administer iv anesthesia. our country is lacking not only instruments and equipments for iv anesthesia but also anesthetists. in various districts of our country we donot have anesthetist so reduction is to be performed by orthopedic surgeon with substantial risk. signifi cant central nervous system and respiratory depression can occur with intravenous analgesia and sedation; so close monitoring is essential. nausea, vomiting and lethargy may occur; requiring prolonged observation. intra-articular lignocaine(ial) has been advocated for manual reduction of acute anterior shoulder dislocation providing analgesia and subsequent muscle relaxation to the patients.this method is advantageous because it does not require intravenous anesthesia and thereby close monitoring. so only a short emergency stay is required resulting in fewer complications. the procedure is also cost effective3,4. there are various methods of reduction of acute anterior shoulder dislocation. in our study we used a stimson’s technique, needing no assistant. address for correspondence: name: dr. bishnu babu thapa e-mail: bishnubthapa1@hotmail.com ph. no.: 9841251030 medical journal of shree birendra hospital 7 methods this was a prospective discriptive study of to evaluate the outcome of reduction of acute anterior shoulder dislocation with the use of intraarticular lidocaine and stimson’s technique. all patients aged 16-70 years who attended shree birendra army hospital with acute anterior shoulder dislocation within 5 days were included in the study. patients with multiple trauma, fracture, recurrent dislocation, pregnancy, and associated co morbid condition were excluded from the study. all patient’s detailed history and clinical examination were taken. special tests like duga’s test, and hemilton’s ruler test were performed and neurovascular status noted. dislocation was confi rmed clinically and radiographically. a detailed performa was fi lled up. patients were placed in supine position on table during administration of intraarticular lidocaine. later patient was placed in prone position during reduction. the procedure was explained to each patient. the acromion and humeral head were palpated and approximate location of the axillary nerve was noted where it split the deltoid muscle laterally. an area 2 cm. inferior and directly lateral to the acromion,in the lateral sulcus formed by the absent of humeral head, was prepared with povidone iodine soaked swabs. then a 20 ml syringe was introduced directing it slightly caudad into the shoulder joint. aspiration of the joint was fi rst performed to remove fl uid if present resulting from a torn capsule or labrum. 20 ml of 1% lidocaine was drawn into the 20 ml syringe. the lidocaine was injected over a period of approximately 30 seconds5. the patient was allowed to relax in the supine position for about 5 minutes before the reduction manoeuvre was attempted. the patient was then placed prone on the stretcher with the affected arm hanging down and 4.5 kg of traction was applied by strapping it onto the arm. while in prone position the patient was asked to rate pain on vas scale of 0-104. when reduction occurred, patient tended to become comfortable and often could tell exactly when the shoulder relocated. reduction was confi rmed by palpation of reduced humeral head. after the shoulder was reduced, sling was applied. if not reduced within 25 minutes, scapular manipulation was performed in the same position4. if reduction was not achieved even after the scapular manipulation, reduction was performed by kocher’s method under intravenous sedation and analgesia. during the study period (sept.2008 to sept.2010) a total of 32 acute anterior shoulder dislocation patients were encountered in emergency department of our hospital.twenty seven were included in our study. in our study, age of the patients ranged form16 to 60yrs with mean of 29.59 yrs. majority of patients were in the age group of 21 to 40 yrs. males were involved mostly. table 1: demographic data sex male female side right left age age distribution <20 years 20-40 years >40 years mode of injury fall rta physical assault timing of presentation within 24 hrs after 24 hrs vas reduction time success rate stimson’s technique additional technique required 24 3 17 10 29.59 yrs 5 19 3 13 8 3 22 5 2.3±1.26 17.96±1.9 22 5 medical journal of shree birendra hospital8 discussion many techniques have been described for reducing anterior shoulder dislocations. the ideal reduction should be easily performed, effective,relatively painless, safe,and allow for expeditious discharge of the patient3. parental analgesics and sedations were used for reduction of shoulder dislocation which required anesthetist and equipment. our study showed that intraarticular lidocaine with stimson’s reduction method were very effective can be performed by orthopedic surgeon and doesnot need anesthetist to involved with minimal complication. the age of the patients at the time of initial dislocation has major effect on the incidence of redislocation. a total of 95% of primary traumatic dislocations recurred in teenagers and young. involvement of right shoulder dislocation is more. but danial e matthews’ study showed,that left side were involved more3. this may be due to difference in the modality of trauma. injury due to fall from height is more common in our part of the world as compared to road traffi c accidents in the developed world. during reduction, pain was measured in visual analogue score(vas) ranging from 1-106. the mean vas were 2.30; most falling in 1 to 3. some time vas is more so there is diffi culty in reduction and there fore will require intravenous analgesia.this is one of the complication of ial. in our study one patient had vas 4 and two had vas 6. in our study out of 27 cases, there were 5 failures with stimson’s method. they required scapular manipulation to achieve reduction. most of the failure cases were presented after 24 hours of injury. in our study 22 patients came to the hospital within 24 hours of injury. complication have been reported with kocher’s method, like near total rupture of pectoralis major tendon from its humeral attachment and iatrogenic fracture of humerus7,8. but, no such complication has been reported with stimson’s method. patient’s satisfaction with ial has been good, although some patients with prior shoulder reductions done under sedation may prefer the same treatment9. some patients may be fearful of sedation. ial provides another possible option in such cases. ial may be used in adjunct to sedation, allowing lower doses of sedative medications. conclusion intraarticular lidocaine represents a useful alternative to facilitate the reduction of anterior shoulder dislocation.from this study we came to the conclusion that reduction of anterior shoulder dislocation with ial and stimson’s method is effective, safe,less costly and can be performed in periphery where anesthetists and monitoring facilities are not available. references 1. louis s, dadid jw, selvadurai n. apley’s system of orthopaedics and feactures, mosby, 8th edition, 581. 2. samuel l t. orthopardics principles and their applications. vol ii 4th edition, 936. 3. matthews de, roberts t. intraarticular lidocaine vs iv analgesia for the reduction of acute anterior shoulder dislocation. university of mississippipe. the american journal of sports medicine.1995;23(1):5458. 4. miller s, cleeman e, auerbach j, flatow e. comparsion of intraarticular lidocaine and intravenous sedation for reduction of shoulder dislocation. jbjs. 2002;84-a:2135. 5. steven js, lee vt. intraarticular lidocaine for the reduction of posterior shoulder dislocation. can j emerg med 2005;7(6);423-426. 6. acupuncture in medicine. measuring pain,adrian white ;1998:vol-16,no.2. 7. pimpalnerkar a et.al. an unusual complication of kocher's manoeuvre. bmj 2004; 329;1472-1473. 8. riaz a. iatrogenic fracture of humerus, complication of diagnostic error in a shoulder dislocation. journal of medical case reports. 2007 july. 9. kosnik j. shamsa f. raphael e. anesthetic methods for reduction of acute shoulder dislocations: a prospective randomized study comparing intraarticular lidocaine with intravenous analgesia and esdation. am j emerg med. 1999 oct; 17(6): 566-70. 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 mjsbh journal.indd editorial it is my honor and privilege to edit volume x-issue ii of the medical journal of shree birendra hospital (mjsbh). we have been receiving more and more arti cles over the years and since a year back we have started publishing this journal biannually. however, we are sti ll facing diffi culty ge ng suffi cient quality arti cles ranging from original research arti cles, case reports and systemati c reviews. it is not that we lack materials but need to focus on pu ng our clinical work on paper and start publishing. the academic atmosphere at shree birendra hospital has defi nitely increased aft er being one of the pg training centre for nati onal academy for medical sciences and more so with the coming up of nepal army insti tute of health sciences-college of medicine and college of nursing. i request all to spend a bit more ti me doing research works and publishing standard original arti cles in the forth coming issues in accordance with the mjsbh guidelines and format for which the administrati on is ready to provide all the support. we need to sti ll put much eff ort for mjsbh to be an indexed journal for which original and high quality contents as well as ti mely publicati ons are required. i am confi dent that with all our eff orts we can achieve this in the near future. i would like to express my sincere thanks to all those who have contributed to this issue, specially the editorial team who have put in so much of ti me and eff ort. many thanks also go to the pharmaceuti cal and medical companies for the adverti sement. editor in chief brig. gen. dr.kishore jb rana mjsbh journal.indd 17 medical journal of shree birendra hospital abstract introducti on: paediatric anaesthesia deals with examinati on under anaesthesia to complicated surgical interventi ons. most of the minor surgeries can be performed with bag valve mask venti lati on which avoids complicati ons of endotracheal intubati on . methods: a retrospecti ve randomized control study was undertaken in 654 paediatric surgeries performed at shree birendra hospital, chhauni (april 2005-march 2010). the children underwent minor general, ear nose throat and orthopaedic surgery to compare spontaneous bag valve mask venti lati on in 503 pati ents (bvm group) and controlled venti lati on in 151 pati ents (cv group). the bvm group was done under spontaneous mask venti lati on and cv group under endotracheal intubati on. anaesthesia was induced and maintained with oxygen and halothane, using a mapleson f system with spontaneous venti lati on and a rendell-baker face mask. the durati on of anaesthesia was less than one hour. results: in this study we noted the complicati ons like trauma to face and lips, dental trauma, laryngospasm, perforati on of tracheaor esophagus, pulmonary aspirati on of gastric contents or foreign bodies and post extubati on complicati ons. conclusions: it is concluded that the need of controlled venti lati on with endotracheal tube is limited to only a few procedures and many of the paediatric surgeries can be performed with spontaneous mask venti lati on. therefore anaesthesia with oxygen and halothane with spontaneous mask venti lati on is a sati sfactory method for minor procedures in children . keywords: bvm, controlled venti llati on, paediatric surgery. bag valve mask venti lati on versus controlled venti lati on for minor pediatric surgery. sunita panta1, nagendra bahadur kc1. 1department of anaesthesiology, shree birendra hospital. kathmandu, nepal. correspondence: lt. col. dr. sunita panta department of anaesthesiology, shree birendra hospital kathmandu, nepal. email: sunitapanta@gmail.com phone: +977-9843069824 introduction paediatric anaesthesia embraces pati ents from the premature, naeonate to the adolescent. children require anesthesia for a variety of procedures from minor to major surgeries. there remains a debate whether to go for spontaneous mask venti lati on or controlled tube venti lati on. tracheal intubati on requires experti se and has more consequences in children. minor surgeries can be carried out under spontaneous mask venti lati on which reduce opioid requirements, opioid related side eff ects and recovery ti me thus enabling pati ent to early discharge. although both these techniques are in practi ce for a long ti me there are only a limited studies comparing these techniques. since most of the paediatric procedures can be undertaken on mask venti lati on we chose to take original arti clejan-june 2012/vol.11/issue1 original arti cle 18 medical journal of shree birendra hospital up this study to evaluate the effi cacy of spontaneous mask venti lati on and the rate of complicati ons in minor paediatric surgeries. the aim of this study was to to determine whether bag mask valve venti lati on is as effi cacious as endotracheal intubati on to provide anaesthesia for minor paediatric surgery and to compare the complicati ons in abovementi oned methods. methods this was a retrospecti ve randomized control study in 654 paediatric surgery in shree birendra hospital, chhauni (april 2005-march 2010). the study groups were divided into two groups namely, bag mask valve (bvm) venti lati on group and controlled venti lati on (cv) group. all minor paediatric general, ent and orthopaedic surgeries were included. pati ent older than16 years, belonging to asa iii and asa iv physical status and surgery lasti ng more than 60 minutes were excluded from the study. results were analyzed using microsoft excel. pre anaestheti c assessment of the children was done. the parents or guardians were well explained about the procedure and writt en informed consent was taken. pati ents were kept nil per oral four hours prior to surgery. on arrival in operati on theater intravenous cannula was inserted in the waiti ng room in laps of parents. they were premedicated with oral midazolam 0.5 mg. aft er taking them to the operati on theater the children were injected with pethidine 0.5 mg/ kg, induced with propofol 2mg/kg. suitable sized rendall baker face mask was applied and venti lated with the mapleson f circuit. the spontaneous mask group was thereaft er maintained with halothane 1-2%. the controlled venti lati on group was injected with inj. vecuronium 0.1 mg/kg and aft er 3 minutes intubated with suitable sized tube. inj. vecuronium was topped up as per requirement and they were reversed at the end of surgery with inj. neosti gmine 50 mcg/kg and atropine 20 mcg/kg. we also noted the complicati ons like trauma to face and lips, dental trauma, laryngospasm, perforati on of tracheaor oesophagus, pulmonary aspirati on of gastric contents or foreign bodies and post extubati on complicati ons. aft er completi on of procedure, pati ents were transferred to recovery room.in recovery room pati ents vitals are monitored and any other complicati ons like nausea, vomiti ng, were noted. when pati ent was fully conscious and well oriented they were shift ed to postoperati ve wards. results the children ranged between 4 months to 15 years for bvm group and 1 year to 14 years for cv group. regarding sex distributi on, in bvm group out of 503 pati ents 318 (63%) were male and 185 (36%) were female, where as in cv group out of 151 pati ents, 71 were male(47%) and 80 were female (52 %) and p value is 0.35 which is not signifi cant. mostly the general, orthopaedic and ear and throat surgeries were included in the study. surgeries requiring muscle relaxati on and prolonged durati on were taken into cv group and most of the implant removals and examinati ons were carried out in bvm due to the paediatric age group. the comparision between the complicati ons among these two procedures were the crux of this study. the complicati ons noted were bradycardia, dental trauma, hypoxemia, laryngospasm and soft ti ssue injury. bradycardia was noted in both bvm and cv groups. but in bvm group the incidence of bradycardia was less than cv group. in cv group 21 (13.90%) among 151 pati ents developed bradycardia whereas in bvm group the value was 7 (1.39 %). dental trauma was infl icted on 5 pati ents (3.31%) in the cv group whereas it was none in the bvm group. hypoxemia was noti ced in both the groups but the incidence was higher in the cv group. in cv group 7 children (4.63%) developed hypoxemia and in bvm group the number was 8 (1.59%). the second most important complicati on was laryngospasm which was very high in the cv group, 15 in number (9.93%) as compared to 4 in the bvm group which is (2.98%). finally soft ti ssue injury was noted among 8 (5.29%) of the pati ents in the cv group whereas the value was 5 (0.99%) in bvm group. table 1.types of operati ons operati on ga count iva count appendectomy 51 1 circumcision 4 83 debridement 4 8 eua 0 5 excision 18 16 explorati on 4 1 herniotomy 8 125 incision and drainage 2 27 19 medical journal of shree birendra hospital k wire fixati on 7 16 laparotomy 10 0 mua 7 39 myringoplasty 11 1 or&if 72 9 orchidopexy 2 4 others 33 20 removal of implant 13 20 tonsillectomy 19 14 table 2. complicati ons complicati ons cv bvm p value bradycardia 21 7 0.043 dental trauma 5 0 hypoxemia 7 8 laryngospasm 15 4 soft tissue injury 8 5 discussion in 1854, a singing teacher named manuel garcia (1805– 1906) became the fi rst man to view the functi oning glotti s in its enti rety1. aft er world war i, further advances were made in the fi eld of intratrachealanesthesia by sir ivan whiteside magill2,3. sir robert reynolds macintosh (1897– 1989) also achieved signifi cant advances in techniques for tracheal intubati on when he introduced his new curved laryngoscope blade in 19434.the most widely used curved laryngoscope blade is named aft er macintosh5-7. tracheal intubati on (orotracheal, nasotracheal, cricothyrotomy, or tracheotomy) is indicated under any circumstances where the airway is unprotected8. bagvalve-mask (bvm) venti lati on is an essenti al emergency skill. this basic airway management technique allows for oxygenati on and venti lati on of pati ents. bvm venti lati on is also appropriate for electi ve venti lati on in the operati ng room when intubati on is not required. in our study 503 pati ents were operated under spontaneous bag mask venti lati on and only 151 pati ents needed endotrachael intubati on .this explains that most of the paediatric minor surgeries can be carried out with bvm method. bvm venti lati on requires a good seal and a patent airway. practi ce with this important skill increases the clinician’s ability to provide eff ecti ve venti lati on. adjuncts such as oral and nasal airways can aid with venti lati on by relieving physiologic obstructi on and by opening up the hypopharynx. the masks come in many sizes, including newborn, infant, child, and adult. choosing the appropriate size helps to create a good seal and, therefore, aids eff ecti ve venti lati on. bags for bvm venti lati on also come in diff erent types. newer bags are equipped with pressure valve. some bags have one-way expiratory valves to prevent the entry of room air; these allow for delivery of greater than 90% oxygen to venti lated and spontaneously breathing pati ents. there are signifi cant diff erences in airway anatomy and respiratory physiology between children and adults. aft er about 8 years, airway diff erence between adults and children mainly refl ect size diff erence. these anatomical and physiological diff erences gradually become less signifi cant as the human body approaches a mature age and body mass index9. several anatomic diff erences make respirati on less effi cient for infants. the smaller diameter of the airways,high compliance and poor support by sorrounding structures lead to functi onal airway closure10. also the high oxygen consumpti on and increased work of breathing explain the high respiratory rate and the rapid oxygen desaturati on11. in our study hypoxemia was noti ced in both the groups but the incidence was higher in the cv group. in cv group 7 children (4.63%) developed hypoxemia and in bvm group the number was 8 (1.59%). endotracheal intubati on being an invasive procedure, there may be problems if the airway is diffi cult. there are a number of devices specially designed for assistance with diffi cult tracheal intubati on in pediatric pati ents12. many a ti mes injuries may occur while att empti ng intubati on. soft ti ssue injury was noted among 8 (5.29%) of the pati ents in the cv group whereas in the bvm group the value was 5 (0.99%). dental trauma was infl icted on 5 pati ents (3.31%) in the cv group whereas it was none in the bvm group. the durati on of endotracheal intubati on att empts is also important as the paediatric pati ents tend to develop bradycardia along with hypoxemia. although bradycardia was noted in both bvm and cv group in our study the incidence was lower in bvm than cv group. in cv group 21 (13.90%) among 151 pati ents developed bradycardia whereas in bvm group the value was 7 (1.39 %). because the airway of a child is narrow, a small amount of edema can produce severe obstructi on. edema can easily be caused by forcing in a tracheal tube that is too large relati ve to the diameter of the trachea. conversely, an excessive leak can someti mes be corrected through the placement of a larger (0.5 mm larger in internal diameter) tracheal tube, and in diffi cult-to-venti late pediatric pati ents children it is oft en necessary to use cuff ed tubes to allow for high pressure venti lati on if the leak is too great to overcome with the venti lator. in our study the second most important complicati on was laryngospasm which was very high in the cv group, 15 in number (9.93%) as compared to 4 in the bvm group which is (2.98%). that explains the higher risk of airway manipulati ons as opposed to simple bag mask venti lati on. 20 medical journal of shree birendra hospital conclusions bag valve mask venti lati on is an eff ecti ve method of anaesthesia. with this technique endotracheal intubati on related complicati ons like laryngospasm, bronchospasm, reintubati on and residual eff ect of paralyzing agents can be avoided. there is an added advantage of minimal drug use as less depth of anaesthesia is needed and the recovery is faster. references 1. stanley sw. the cheerful centenarian, or the founder of laryngoscopy.essays on the fi rst hundred years of anaesthesia. 1961 2:95–113. 2. rowbotham e, magill i. anaestheti cs in the plasti c surgery of the face and jaws. proc r soc med.1921;14 (1):17–27. 3. magill i. the provision for expirati on in endotracheal insuffl ati ons anaesthesia. the lancet. 1923:68–9. 4. macintosh rr. a new laryngoscope. the lancet.1943;1:205. 5. scott j, baker pa. how did the macintosh laryngoscope become so popular? paediatric anesthesia. 2009;19:24–9. 6. agrò f, barzoi g, montecchia f. tracheal intubati on using a macintosh laryngoscope or a glidescope in 15 pati ents with cervical spine immobilizati on. britj of anaes. 2003;90 (5):705–6. 7. cooper rm, pacey ja, bishop mj, mccluskey sa. early clinical experience with a new videolaryngoscope (glidescope) in 728 pati ents. can j of anes. 2005;52(2):191–8. 8. american college of surgeons committ ee on trauma. airway and venti latory management. atls. chicago, illinois: 2004;7:pp41–68. 9. cravero jp, cain zn. paediatric anesthesia. clinanes. 2009;6:1206-20. 10. anthonisen nr, danson j, robertson pc. airway closure as a functi on of age.respir physiology.1969;8:58-65. 11. cross kw, tizard jpm, trythall d. the gasseous metabolism of the newborn infant. actapaediatrscand. 1957;46:265-85. 12. borland lm, caselbrant m. the bullard laryngoscope: a new indirect oral laryngoscope (paediatric version). anesthesia& analgesia.1990; 70 (1):105-8. medical_journal_year2.pdf   38   bhandari bb1, hamal bk2 1dr. bharat bhandari, consultant urologist ,2dr. bhairab kumar hamal, professor and consultant urologist,shree birendra hospital address for correspondence: drbharatbhandari@yahoo.com abstract aims : a retrospective evaluation and statistical analysis of outcome in patients who underwent bulbar end to end anastomosis for stricture of bulbar urethra in army hospital. methodology: 50 patients with average age of 35 years who underwent bulbar end to end anastomosis between 2005 and 2009 at army hospital were analyzed. mean follow up was 24 months. stricture etiology was catheter induced 40%, perineal trauma 30%, infection 13%, instrumentation 10% and unknown in 7%. stricture length was 1cm (59%), 1 to 2 cm (37%) and above 2cm (4%). 30% of the patients were previously subjected to multiple dilatations and internal urethrotomy and clinical outcome was considered failure if postoperative instrumentation was required. postoperative sexual dysfunction was judged using nonvalidated questionnaire. results: of the 50 cases, 80% were successful and treatment failure was 20 %. failed cases are there sexual function out of which 5 had ejaculatory dissatisfaction, 3 with compromised erection and 2 had decreased glans sensitivity. conclusion: bulbar end to end anastomosis has success rate of 80%, with better outcome in fresh cases than in previously intervened cases. sexual outcome is successful in 80%. key words: bulbar urethra, stricture, anastomosis, outcome introduction the anterior urethra is subject to blunt and penetrating injuries, of which blunt trauma predominates.1 of these injuries, straddle injury, in which the immobile bulbar urethra is crushed against the under surface pubic symphysis, is most common.2 the primary morbidity is urethral stricture formation.3 when a patient presents acutely after injury, one should obtain a history of the mechanism of injury and of the post injury voiding pattern. suspicious clinical signs include blood at the meatus, gross hematuria, perineal hematoma, urinary retention and frank urethral extrusion through the skin. 4 surgical treatment of urethral strictures includes numerous options such as dilation, vision internal urethrotomy, stent and reconstructive surgical techniques.5 the etiology, site, length and density management. the surgical technique used in the repair of the bulbar urethral stricture is selected according to stricture length.6 contusions are generally managed by temporary urethral catheterization.7 short uncomplicated strictures are generally amenable to complete excision with primary anastomosis. longer strictures are managed using augmented roof strip anastomosis or substitution only graft urethroplasty. for patients with strictures associated with local adverse conditions, 2-stage urethroplasty might be suggested. end-to-end anastomosis is the most successful treatment for bulbar urethral strictures with a reported high success rate and low postoperative morbidity.8 11 materials and methods shree birendra army hospital caters the nepal army personnel and their families. in the past 15 years, the hospital had to manage most of the casualties urethral stricture, mostly iatrogenic, was one of the most common complications encountered. urethral stricture cases were managed depending upon stricture types with dilatation, optical internal urethrotomy and reconstructive surgical techniques. a retrospective analysis of 50 patients who underwent bulbar end to end anastomosis from 2005 january to 2009 december for post traumatic stricture was done. all the 50 cases were performed by the same surgeon following the standard technique. catheter was kept for a week and removed. micturating cystourethrogram was performed after 2 weeks along with urine culture. patients were told to review immediately in opd if they experienced decrease in follow up after four months. if any instrumentation including dilatation was required, outcome of the urethroplasty was considered a failure. failed cases were managed with oiu and buccal mucosal graft and are being followed up. our aim was primarily to assess the outcome of urethroplasty in terms of urinary function and sexual function, which were recorded on the basis of patients’ post operative complaints and indirect questions including penile erection, ejaculation and sensation, which were recorded on a performa.  39 results from 2005 to 2009 a total of 50 patients with average age of 35 (figure 1) years underwent bulbar end to end anastomosis. stricture etiology was catheter induced in 40% cases, perineal injury in 30% cases, infection 13%, instrumentation 10% and unknown in 7% (figure 2). stricture length was less than 1cm (59%), 1 to 3 cm (37%) and above 3 cm (4%) (figure 3). 30% of the patients were previously subjected to multiple dilatations and internal urethrotomy. all the 50 patients were managed with end to end bulbar urethroplasty and followed up. if any instrumentation including dilatation was required, outcome of the urethroplasty was considered a failure. of 50 cases, 40 were successful and 10 were considered failure. analysis of the stricture etiology revealed 98% success in infective pathology, 90% in urethral instrumentation, 90 % in unknown etiology, 85% in catheter induced and only 70% in trauma induced (figure 4). in the age distribution, 2 patients each from the age group less than 19, 30 – 39, 40 – 49 and 50 or more failed while 3 patients from age group 20 – 29 were considered failure. 5 of the patients had stricture length less than 1 cm, 4 had 1 – 3 cm and 1 had more than 3 cm. 80 % of the patients had satisfactory sexual with their sexual function, out of which 5 had ejaculatory dissatisfaction, 3 with compromised erection and 2 had decreased glans sensitivity. 2 patients each were from 50 years or more, 30 – 39 years and 20 – 29 years, 4 patients were 40 – 49 years. figure 1 : age distribution of the patients 12 18 7 10 3 0 2 4 6 8 10 12 14 16 18 20 less t han 19 years 20 29 years 30 39 years 40 49 years 50 or more figure 2 : etiology of stricture of bulbar urethra 40 figure 3 : length of the stricture 37% 59% 4% less t han 1 cm 1 3 cm more than 3 cm figure 4 : outcome of bulbar urethroplasty according to etiology discussion since most of patients in our series were trauma victims during the insurgency, who was either managed as mass casualty victims, the cause of the stricture was injury and idiopathic was more as compared to infectious pathology. the length of the stricture in our study was not consistent with most of the series published mentioning longer strictures which has been explained due to urine extravasation into the spongiosum, leading to 12 this is because most of our patients were in service army men, where urethral injury was diagnosed earlier and early suprapubic diversion for total or partial urethral disruption was carried out. with early suprapubic diversion, the limited and the severity of residual stricture is mitigated. 12 outcome. guralnick and webster asserted, that this operation should be limited to stricture of 1 cm or less, as excision of a 1 cm urethral segment with opposing 1 cm proximal and distal spatulations results in a 2cm urethral shortening, which may be accommodated by the elasticity of the bulbar urethra without chordee. they hypothesized that excision of a longer urethral segment risks penile shortening or chordee.13 however morey and kizer suggested that urethral reconstructability is proportional to the length and elasticity of the distal urethral segment.14 our study was consistent with the latter report. outcome of the stricturoplasty, which is consistent with other larger studies published in literature.15 in the literature interpretation of the urethroplasty success rate based on previous treatment was controversial. with the highest likelihood of success in reconstructive patients.9,11,16,17all of the failure cases in our series had undergone multiple dilatations and internal urethrotomy previously.  41 sexual satisfaction was found to be unsatisfactory in elderly age group in our series. this probably was due to other physiological and psychological factors apart from the operative etiology. the cause of sexual dissatisfaction has been explained as due to surgical damage to the branches of the perineal nerves or bulbospongiosum muscles which has a urine.18 conclusions end-to-end anastomosis of the bulbar urethra is an effective surgical option for patients with bulbar stricture. age should not be a factor from withholding a patient from bulbar end to end anastomosis. multiple previous manipulations to the urethra decrease the possibility of success of urethroplasty. references 1. monga m, moreno t, hellstorm wj. gunshot wounds ot the male genitalia. j trauma 1995; 38: 855. 2. lim ph, chng hc. initial management of acute urethral injuries. br. j urol 1989; 64: 165. 3. trifa m, njeh m, bahloul a, jemal s, mhiri mn. traumatic rupture of the anterior urethra. ann urol 1997; 31 : 313. 4. witherington r, mc kinney je. an unusual case of anterior urethral injury. j urol 1983; 130:564. 5. peterson ac and webster gd: management of urethral stricture disease: developing options for surgical intervention. bju int 2004; 94: 971. 6. barbagli g, palminteri e, lazzeri m and guazzoni g: anterior urethral strictures. bju int 2003; 92: 497. 7. armenakas na, mcaninch jw. acute anterior urethral injuries: diagnosis and initial management. traumatic and reconstructive urology. ed. jw mcaninch, philadelhia: wb saunders cp. chapt 45, pp 543 – 550, 1996. 8. macdonald mf, al-qudah hs and santucci ra: minimal impact urethroplasty allows same-day surgery in most patients. urology 2005; 66: 850. 9. santucci ra, mario la and mcaninch jw: anastomotic urethroplasty for bulbar urethral stricture: analysis of 168 patients. j urol 2002; 167: 1715. 10. santucci ra, mcaninch jw, mario la, rajpurkar a, chopra ak, miller ks et al: urethroplasty in patients older than 65 years: indications, results, outcomes and suggested 11. eltahawy ea, virasoro r, schlosemberg sm, mccammon ka and jordan gh: long-term followup for excision and primary anastomosis for anterior urethral strictures. j urol 2007; 177: 1803 12. park s, mc aninch jw. straddle injuries to the bulbar urethra : management and outcomes in 78 patients. the journal of urology 2004; 171: 722725. 13. guralnick ml and webster gd: the augmented anastomotic urethroplasty: indications and outcome in 29 patients. j urol 2001; 165: 1496. 14. morey af and kizer ws: proximal bulbar urethroplasty via extended anastomotic approach what are the limits? j urol 2006; 175: 2145. 15. santucci ra, mcaninch jw, mario la, rajpurkar a, chopra ak, miller k setal: urethroplasty in patients older than 65 years: indications, results, outcomes and suggested 16. barbagli g, palminteri e, lazzeri m, guazzoni g and turini d: long-term outcome of urethroplasty after failed urethrotomy versus primary repair. j urol 2001; 165: 1918. 17. culty t and boccon-gibod l: anastomotic urethroplasty for posttraumatic urethral stricture: previous urethral manipulation has a 2007; 177: 1374. 18. yucel s and baskin ls: neuroanatomy of the male urethra and perineum. bju int 2003; 92: 624. medical journal of birendra hospital.indd original articlejanuary-june, 2010/vol 9/issue 1 medical journal of shree birendra hospital 9 evaluation of immunochromatographic rapid diagnostic test versus peripheral blood smear for diagnosis of malaria in nepal pande pr1, kc i2 1prakash raj pande, senior consultant physician, 2indu kc, physician, shree birendra hospital abstract malaria is one of the most important parasitic diseases of humans. it is the major vector disease with occasional focal outbreaks in nepal. annually more than 60,000 clinical cases of malaria occur out of that about 10,000 cases are confirmed cases of which about 1200 happen to be plasmodium falciparum cases. several factors predispose to transmission of deadly / resistant strains to local population which in turn leads to cerebral malaria having both high mortality and morbidity. as it is well known that peripheral blood smear remains the “gold-standard” in diagnostic measure apart from compatible history but circumstances and situations like in periphery of developing country like ours we can not overlook the advantage of rapid diagnostic tests (rdts) like optimal test which detects parasitic lactate dehydrogenase in a drop of patient’s blood. this study showed that the malaria detected by optimal have sensitivity 96% and specificity of 100% amongst 50 cases of malaria, the optimal is able to detect 48 positive cases. despite the cost of the test, it’s sensitivity and specificity are two remarkable factors in diagnosing the disease rapidly even in case of slide/smear negative ones. the utility of rdts are not enough studied in our part of world especially in our country where even sufficient trained manpower is always a rarity. the importance of this test emphasize the easy-to-use tool for early diagnosis and prompt institution of appropriate therapy to reduce both mortality, morbidity and in return reducing hospital stay and increasing working hour of productive manpower. address for correspondence: prakash.pande@live.com malaria a protozoan disease transmitted by the bite of infected anopheles mosquitoes is one of the most important parasitic diseases of humans, with transmission in 103 countries affecting ≥ 1 billion people causing between 1 and 3 million deaths each year. malaria has now been eliminated from north america, europe, and russia but despite enormous control efforts, has resurged in many parts of tropics. however increasing problem of drug resistance of the parasite and insecticide resistance of the vectors in endemic areas are major concern. malaria even today, as it has been for centuries, remains a heavy burden on tropical communities, a threat to non-endemic countries, and a danger to travelers.1 in nepal. every year more than 60,000 clinical cases of malaria occurs as occasional focal outbreaks out of that about 10,000 cases are confi rmed cases of which about 1200 happen to be plasmodium falciparum (pf) cases. in 1990s many focal outbreak have occurred which led to some death as well. the rising incidence of malaria and the increasing resistance to treatment with conventional antimalarial drugs and the susceptibility of vectors to the available insecticides is posing challenge to and has added burden to the public health experts and scientists engaged in malaria control programme. thus global malaria control strategy, rbmi, and national malaria and kala-azar control programs have set the following objective for malaria control: medical journal of shree birendra hospital10 o prevention of mortality due to anaemia o progressive reduction of malaria morbidity, endemicity, and transmission to a level that will not hinder socioeconomic development of the country o prevention and control of malaria epidemics o containment of p.falciparum epidemics o sustained capacity building and support control activities through operational research o public / private / community partrnership for improved malaria control. following lab tests are available to confi rm malaria as per need. o giemsa stained pbs-thick and thin smear: “gold standard” o acridine orange stained pbs –[good {has some limitations}] o quantitative buffy coat assay [excellent {has only few limitations}] o rapid diagnostic tests: pfhrp-ll and pldh o pcr (polymerase chain reaction) while addressing malaria in nepal one should not forget the points including population distribution & epidemiological changes [terai region, open border with india] and security troops [contribution of troops from nepalese army, police and armed -forces in peace keeping mission in endemic parts of african continent] endemic area visit. along with several other factors those aforementioned factors are again predisposing to the transmission of deadly / resistant strains to local population which in turn leads to cerebral malaria having both high mortality and morbidity. rdts use should be evaluated for early diagnosis and prompt institution of therapy is an important determinant of outcome especially in case of severe falciparum malaria. important factors to be considered while opting rdt’s are; (i) commercial availability (ii) plasmodium species to be detected (p.falciparum / pan-specifi c), (iii) cost (including transport, training, and quality control), (iv sensitivity, (v). shelf-life and temperature stability in intended conditions of storage and use, (vi) ease of use including format of the test (e.g. cassette, dipstick, car) and (vii) requirement for post -treatment testing of patient. this study was carried out with pldh based rapid diagnostic tests (rdts) to be evaluated in diagnosis of malaria, probable / suspected malaria cases visiting shree birendra hospital. as it is well known that peripheral blood smear remains the” goldstandard” in diagnostic measure apart from compatible history but circumstances and situations like in periphery of developing country like ours we can not overlook the advantage of rapid diagnostic tests (rdts) like opti mal test. despite the cost its sensitivity and specifi city are two remarkable factors in diagnosing the disease rapidly even in case of situations like slide/smear negative ones. even the sporadic endemic have great toll in the health cost of developing countries like ours. presentation of disease is usually similar to enteric fever or even hepatitis which not only imparts diagnosticdilemma but also delays in institution of therapy timely to eradicate the parasite from blood. this results increase in number of hospital stay and thereby delaying their recovery and ultimately reducing the working hours. as implication of rapid tests/ rdts are not enough studied in our part of world especially in our country where suffi cient trained manpower in technical fi eld is always a rarity! at times availability of microscopy and electricity may not only be impossible but also time consuming and cumbersome procedure in endemic situations. we need to develop skill and keep us standby with the easy alternative method to tackle such cases in emergency and unconventional situations without hurdles and promptly. subject and methodology this was a hospital based descriptive case study carried out at medical and pathology department of shree birendra hospital, chhauni, ktm, involving the sample size 50case of highgrade fever with history of travel to endemic area and with or without malaria prophylaxis. as this hospital covers patients/army personnel from various parts of nepal including terai region where the prevalence of malaria is high. further, the nepalese army personnel also travel overseas to serve in the united nations missions including that in africa and malaria is severe there as well. this study also involved any patients / army personnel serving in malaria endemic zone inside nepal and person with travel history to malaria endemic zone in africa as part of service to un peacekeeping missions. patients with history of high-grade fever clinically diagnosed as a case of malaria were included after taking informed medical journal of shree birendra hospital 11 consent. thorough evaluation was done including obtaining a detailed history, physical examination and laboratory investigations (as in performa) of all enrolled patients. demographic variables included age, sex, marital status and occupation of the patients. history of travel to endemic area, presence or absence of malaria prophylaxis, presence or absence of jaundice, past history of blood transfusion, past malaria and treatment history was taken with emphasize to radical curative use in indicated cases. a detailed clinical examination was done with emphasis on temperature pattern its relation with pulse, bp, respiration, pallor / icterus (jaundice), abdominal examination for any tenderness and presence of hepatomegaly/ splenomegaly. anthropometiric measurements including height, weights were taken and bmi was calculated. all the samples were collected by the residents/ technicians in sterile vials containing edta as anticoagulant and processed immediately in parasitology laboratory, department of microbiology/ pathology, birendra army hospital. routine and specifi c laboratory tests were carried out within 1 to 2 hrs of collection of sample using standard laboratory protocol. few drop of blood was taken out from the fi nger pulp after wiping it with spirit swab by using sterile disposable surgical blade and samples were kept in two separate vials and two glass slides. thin blood fi lm was prepared for species identifi cation. * cbc comprising tc, dc, hemoglobin, haematocrit, platelets, and esr was done. * few drops of blood (2-3drops) were kept in two separate glass-slide for carrying out the microscopic examination of blood smears for about 3minute each[ (a) thin smear &(b) thick smear]. immunochromatological test using optimal assay –kit. optimal test is designed to detect infections with both p falciparum/ p vivax. manufacturer’s instructions were followed strictly in both tests. only a single drop (about 30ul) of the fresh whole blood was used for this test. methodology was as follows: 1. one drop of the buffer solution was added to the conjugated well and similarly four drops use was added to the second test well. 2. one drop (about 10ul) of blood obtained by fi nger prick was added to the conjugate well with the help of capillary tube provided in the kit and mixed gently. 3. the dipstick was then placed in conjugate well with its wick at the top for 10 minute. 4. after 10 min, the test strip was transferred to the second well which contained the clearing buffer and kept for about 5 min. 5. then, the dipstick was removed from the well and the interpretation was made after observing the result. 6. in the optimal assay, the reaction is visualized in the form of pink bands across the strip. there are 3 reaction zones in the optimal dipstick. ◙ a mono-specifi c antibody that recognizes only p falciparum is coated in the bottom reaction line. ◙ a second pan specifi c antibody is immediately above this zone. this monoclonal antibody that recognizes the pldh informs of p vivax. ◙ a third reaction zone is coated at the top of the dipstick where there is an antibody that captures the excess colloid conjugate and serves as a positive control for assay. the reaction bands are seen as pink-mauve line in the test strip. the interpretation of the assay test strip results is as follows: negative (one control band at the top) positive for p vivax (one control band plus one test band) positive for p falciparum (one control band plus two test band). observations & results all the specimens were examined within 2-6 hours of collections. giemsa stained slides were reported negative only after examination of 200-300 fi elds systematically. positive blood fi lms were recorded as parasites (rings/ trophozoites / schizonts) per 100 white blood cells. [microscopic demonstration of any morphological stages of malaria parasite was considered as the sole criteria (gold standard) for laboratory medical journal of shree birendra hospital12 diagnosis of malaria.]all the samples were examined by using both techniques for the laboratory diagnosis of malaria using standard protocols. results were noted as m. p.positive(+)stage. speciesrings/ schizont / trophozoite / gamete of p.vivax / falciparum. out of 50 patients 48 were positive for optimal test while 2 were negative and out of that 12 were p. falciparum and 36 were p.vivax and 1 each negative for both species. discussion the discovery of malaria parasites by laveran in 1880 added milestone in the history of malaria. malaria is traditionally been diagnosed by examining giemsa stained blood fi lms, which is considered as the ‘gold-standard’ method around the world and also in nepal. in our study we carried out both pbs and rdts for their comparision. this study showed that the malaria detected by optimal have sensitivity 96% and specifi city of 100% amongst 50 cases of malaria the optimal is able to detect 48 positive cases. the 2 blood samples (the positive) were not detected by the optimal test as positive as these patients had taken anti-malarial chemotherapy which might have already killed the parasites and only dead parasites might have been appeared in the slides. the reason would be that optimal assay had not detected them as it is well known that optimal assay captures the pldh antigen which was secreted only by live organisms. the sensitivity of the optimal for detection of p vivax was 97.3% and for detection of p falciparum was 92.3%. the blood fi lm could only detect and indicated that 70%(35 of 50) of the patients of which 77.14%(27 of 35) were positive for p vivax and 22.9%(8 of 35) were positive for p falciparum. our data was very much compatible with the results from honduras i.e. sensitivity of 94 % and specifi city of 100 % for opti mal assay2,3. another study conducted in university of munich, germany in 1998, similar results were obtained for opti mal assay, with a sensitivity of 88.7% & a specifi city of 91.9%. similar study was carried out by prakash ghimire (2004) in three holoendemic districts in far western regional vdcs of kanchanpur, southern nepal (jhalari, rampur-bisalpur & krishnapur). the result obtained was sensitivity of 85% and specifi city 100%.,ppv 100% & npv of 89.28%4. in another study carried out by sherchand jb (2001) in the endemic districts of nepal the result obtained was having the sensitivity of 97% and specifi city of 98% for optimal assay5. grobusch mp, et al carried out a study with interesting result that detection of false-positive rapid tests was high for malaria in patients with presence of rheumatoid factor6. it is also true that pcr test for malaria has high yield in cases where mixed inection is suspected because rdts cannot differentiate species in case of mixed infection. snounou g., et al. studied identifi cation of the four human malaria parasite species in fi eld samples by the polymerase chain reaction and detection of a high prevalence of mixed infections7. in conclusion, rdts have introduced a new dimension to the diagnosis and treatment of malaria. they now permit, among other things, on-the-spot confi rmatory diagnosis of malaria at the periphery of the health care system, by health workers with minimal training. the optimal test has thus special signifi cance in a country like nepal where most of rural centers are unable to diagnose malaria due to the lack of microscopes even slides for microscopy, stains and trained technicians. malaria endemic zones in nepal are usually in rural villages, which are at far distance from the highways. due to the poor economic condition, distant health centers, lack of transportation facility, patients cannot go to the health centers for treatment thus increasing mortality. in these group of patients follow up is also very diffi cult. therefore prompt diagnosis and treatment is a must for the rural malaria patients. it can be accomplished by the use of optimal test. the test is extremely simple and rapid to perform, making it easy to teach the technique/methodology to inexperienced or even untrained persons. besides the fi nancial savings from unnecessary treatments, the use of optimal test is of value in the early investigations and management of malarial endemics. the rational use of rdts as a complement to microscopy might give substantial health benefi ts through earlier treatment and a consequent reduction in morbidity and mortality, by targeting expensive drugs and drug combinations to high risk populations in multidrug resistant areas and through a more rational use of drugs that might effectively reduce drug pressure and possibly delay the progress of drug resistance. the optimal test is of great value in diagnosis of severe and complicated falciparum malaria when microscopy testing might delay institution of treatment promptly. in addition, presence of pldh in blood indicates presence of viable malaria parasites; the test can be used to evaluate the effectiveness of antimalarial chemotherapy. it is thus a simple way to monitor response to the drug therapy and in the detection of drug resistance malarial strains because pldh refl ects the presence of viable malaria parasites in the blood. pldh levels follow closely parasitism. nevertheless, rdts are unlikely to be widely adopted until their detection capacities have been improved, their potential benefi ts have been confi rmed, and their cost has come closer to what most national malaria programme can afford. medical journal of shree birendra hospital 13 to address these issues, and ensure the optimal use of rdts as a key tool in malaria control, it requires a co-ordinated effort among users, control programmes, manufacturers and international agencies. acknowledgements we are especially thankful to ward staff and laboratory technologists of shree birendra hospital, chhauni who worked with us on this study. references 1. nicholas j. white, joel g breman, malaria, harrison’s principles of internal medicine vol i, 16th edition, mc graw hill 2005 p1218-1233. 2. makler m t, palmer c j and ager a.l.;a review of practical techniques for diagnosis of malaria. ann. trop.med & parasitol.1998, 92(4),419-433. 3. quintana m., r piper, h.l. boling, mmarker, c sherman, e gill, f fernandez,s marten: malaria diagnosis in honduran population with coindemic p. falciparum and p. vivax. am.j.trop.med. hyg.1998,59(6)868-871. 4. ghimire prakash, puspa raj pande,deepak joshi yogan khatri, keshab parajuli.evaluation of rapid immunochromatographic test for diagnosis of malaria in nepal. scientifi c world, hmg nepal2004;2(2):40-44. 5. sherchand jb, rapid immunochromatographic optimal assay for detection of p vivax and p falciparum malaria from two districts of nepal, nepalese journal of medical laboratory sciences, 2001;1:21-25. 6. grobusch mp, et al. false-positive rapid tests for malaria in patients with rheumatoid factor. lancet, 1999, 353:297. 7. snounou g, et al. identifi cation of the four human malaria parasite species in fi eld samples by the polymerase chain reaction and detection of a high prevalence of mixed infections. molecular and biochemical parasitology,1993, 58:283–292. mjsbh vol12 issue1 final.indd m j s b h j a n u a r y j u n e 2 0 1 3 | vo l 1 2 | i s s u e 1 m e d i c a l j o u r n a l o f s h r e e b i r e n d r a h o s p i t a l 37 original article ceftriaxone, ofl oxacin or both in the treatment of enteric fever. rishi khatri1, rajeeb kumar deo1, binod karki1, arun sharma1. 1department of medicine, shree birendra hospital. introduction enteric fever is characterized by systemic illness with fever and abdominal pain1.the incidence of enteric fever has declined greatly with the provision of clean water and good sewage systems in europe and the usa since the early 20th century2 but the disease remains a serious publichealth problem in developing countries3.enteric fever is common diagnosis in day to day practice in kathmandu which can be attributed to poor personal hygiene, poor sanitation, and poor quality of water supply. the treatment of enteric fever at the outset may look straightforward with various classes of effective antibiotics available for use but the emerging resistance is a big problem. the problem may be choice of too many and choosing appropriate antibiotic can be a challenge at times. treatment of enteric fever has been complicated by the development and rapid dissemination of typhoidal organisms resistant to ampicillin, trimethoprim-sulfamethoxazole, and chloramphenicol. in recent years, development of resistance to fl uoroquinolones as well as some extent to cephalosporins has resulted in more challenges4-5. abstract introduction: enteric fever is a common diagnosis in febrile patients admitting to the hospital of nepal. ! e treatment of enteric fever, though looks straightforward, in recent times has been complicated by emerging resistance to various antibiotics including " uoroquinolones and cephalosporins. methods: ! is was a randomized clinical study done at shree birendra hospital from january 2011 to december 2011.patients with with high grade fever ,headache, relative bradycardia, abdominal pain, diarrhoea or constipation with normal to low leukocyte count were clinically diagnosed as enteric fever and were randomized to either o" oxacin or ce# riaxone group, both well accepted $ rst line treatment for enteric fever and observed for at least $ ve days before the addition of the second drug that is ce# riaxone in o" oxacin group and o" oxacin in ce# riaxonegroup and the response to the drug was noted in terms of defervescence of fever. results: total 50 patients were enrolled, 25 in each treatment group. a# er $ ve days, six patients in ce# riaxone group needed addition of o" oxacin and two patients in o" oxacin group needed ce# riaxone. ! e average fever defervescence time in ce# riaxone group was 3.88 days and in o" oxacin group was 3.04 days. all patients were afebrile by 9 days of antibiotics. conclusions: fever defervescence time with o" oxacin was lesser than ce# riaxone group and need of supplementary antibiotic is lesser in o" oxacine group. so, o" oxacin can be recommended as 1st line drug for enteric fever. keywords: ce# riaxone; enteric fever; fever defervescence; o" oxacin ....................................................................................... correspondence: col. dr. rishi khatri department of medicine, shree birendra hospital, kathmandu nepal email: khatririshi@ymail.com m e d i c a l j o u r n a l o f s h r e e b i r e n d r a h o s p i t a l38 m j s b h j a n u a r y j u n e 2 0 1 3 | vo l 1 2 | i s s u e 1 in this setting, it is really challenging to decide which antibiotics to initiate and how long to wait before adding the second drug for the treatment. in our study, we have tried to fi nd the effi cacy of ofl oxacin and ceftriaxone alone or in combination for the treatment of enteric fever. methods the randomized clinical study was conducted at shree birendra hospital for a period of one year from january 2011 to july 2011, which comprised of fi fty consecutive patients admitted with clinical diagnosis of enteric fever as suggested by high grade fever, headache, relative bradycardia, abdominal pain, diarrhoea orconstipation with normal to low leukocyte count. blood culture was sent from each patient. all patients above 15 years old with the abovementioned clinical features were included in the study and any patient already taking antibiotics from outside setting was excluded. the permission was taken from the hospital administration and consent obtained from the patients. they were randomly divided in two groups to receive either intravenous ceftriaxone 2 g per day or intravenous ofl oxacin 400 mgper day, which are both, approved fi rst line therapy for enteric fever. patients were observed for at least fi ve days for the fever defervescence before adding on the second antibiotic (intravenousofl oxacin in patients receiving ceftriaxone and intravenous ceftriaxone in a patients receiving ofl oxacin). once the patient became afebrile for about 48 hours they were switched to oral ofl oxacin 800 mg per day or oral cefi xime 800 mg per day from their respective iv preparations. all patients were planned for total of 14 days of therapy. the patients were discharged after 14 days and asked to follow up after one week in medical opd.the data were tabulated and analysed using chi-sqaire and t test as indicated using spss 17.1 software. results there were 25 patients in ceftriaxone group and 25 patients in ofl oxacin group.the baseline characteristics in both the treatment arm were comparable in the study (table 1).the mean age of the patient in the ofl oxacin group was 28.92 and that of the ceftriaxone grop was 31.36 which was not statistically signifi cant (p=0.45).the distribution of sex (male), duration of fever (days), and symptoms like headache, abdominal pain, diarrhoea, constipation, cough and blood culture positivity were not different in both the group indicating that both the groups were comparable (figure 1). the fever duration at the time of presentation to hospital for patients in ceftriaxone group and ofl oxacin group was 8.6 days and 6.04 days respectively. six patients in ceftriaxone group needed addition of ofl oxacin after fi ve days and two patients in ofl oxacin group needed addition of ceftriaxone after fi ve days (table 2). the average fever defervescence time in ceftriaxone group was 3.88 days and in ofl oxacin group was 3.04 days.all patients were afebrile by 9 days of antibiotics. average duration of hospital stay for patients on ceftriaxone group was 6.64 days and on ofl oxacin group was 5.28 days. there were no complications and all patients were discharged from the hospital in stable condition. discussion enteric fever also known as enteric feveris a systemic illness characterized by high grade fever and abdominal symptoms and it makes a major portion of hospital admission diagnosis for febrile patients in our hospital. though enteric feveris usually treated with a single antibacterial drug, the optimal choice of drug and duration of therapy is uncertain and the selection of antibiotics depend upon local resistance patterns, patient age, whether oral medications are feasible, the clinical setting, and available resources6-8. the current recommendation for the treatment is with either fl uoroquinolone such as ciprofl oxacin or ofl axacin or with third generationcephalosporins such as ceftraxone9. the emergence of multi drug resistance (mdr) strains have caused numerous outbreaks in the indian subcontinent, southeast asia, mexico, the arabian gulf, and africa4,10. there are concerns with the resistance even with ofl oxacin and ceftriaxone4-5. in this study, we tried to see the response of enteric fever in terms of fever defervescene with ofl oxacin, cefriaxone or both. the common presenting symptoms of enteric fever which are fever, abdominal pain, headache, cough, diarrhea and constipation were consistent with other previous studies. in a study conducted m j s b h j a n u a r y j u n e 2 0 1 3 | vo l 1 2 | i s s u e 1 m e d i c a l j o u r n a l o f s h r e e b i r e n d r a h o s p i t a l 39 by david et al11 in ciwec clinic of nepal and by sharma et al12 in dhulikhel have shown the similar clinical features of typhoid fever. in view of poor result from the blood culture, which was only 5 % of total cases, we had to depend mostly on the clinical features of typhoid fever. the low yield of culture may be due to inappropriate use of antibiotics by the primary care health worker before the patient presents to the hospital and the delay in incubating the media after the blood withdrawal. figure 1. comparison of clinical features in the patients. table 1: baseline characteristics of the two treatment groups variables ceftriaxone group (n=25) ofl oxacin group (n=25) p value mean age 28.92 31.36 0.45 sex (male) 24(96%) 21(84%) 0.34 fever duration at presentation (days) 8.6 6.04 0.70 headache 14(56%) 15(60%) 1.00 abdominal pain 12(48%) 9(36%) 0.56 diarrhoea 20(80%) 17(68%) 0.52 constipation 1(4%) 3(12%) 0.62 cough 2(8%) 2(8%) 1.00 blood culture positivity 2(8%) 3(12%) 1.00 m e d i c a l j o u r n a l o f s h r e e b i r e n d r a h o s p i t a l40 m j s b h j a n u a r y j u n e 2 0 1 3 | vo l 1 2 | i s s u e 1 the average fever defervescence time in ceftriaxone group was 3.88 days and in ofl oxacin group was 3.04 days which was also consistent with the similar studies of enteric fever done in kathmandu12. in our study, six of the patients receiving ceftriaxone and two of those receiving ofl oxacin needed the addition of the second drug which was ofl oxacin in ceftriaxone group and vice versa. the study done by sharma et al12 in dhulikhel hospital had shown 100% sensitivity to the ceftriaxone however the present fi nding of our study showed different result. smith et al had shown in his study when comparing the treatment with oral ofl oxacin with intravenous ceftriaxone in vietnamese patients, that short-course treatment with oral ofl oxacin was signifi cantly better than that withceftriaxone13. the low number of sample size and the lack of correlation whether the non responder were having resistant to the treatment drug in vitro also have been the limitation of our study. however it does provide a new area of research for the emerging resistance pattern of the salmonella species in our part of the world. it also raises the concern whether multi drug therapy may be better than monotherapy in order to avoid treatment failure or drug resistance. conclusion fever defervescence time with ofl oxacin was lesser than ceftriaxone group and need of supplementary antibiotic is lesser in ofl oxacine group. so, ofl oxacin can be recommended as 1st line drug for enteric fever. further large randomised trials are needed to substantiate the fi ndings. references 1. parry cm, hien tt, dougan g, et al. typhoid fever. n engl j med 2002; 347:1770. 2. osler w. the principles and practice of medicine: designed for the use of practitioners and students of medicine. 8th edn. new york:d appleton, 1912: 1–46. 3. crump ja, luby sp, mintz ed. the global burden of typhoid fever.bull world health organ 2004; 82: 346–53. 4. rowe b, ward lr, threlfall ej. multidrug-resistant salmonella typhi:a worldwide epidemic. clin infect dis 1997; 24 (suppl 1): s106–09. 5. saha sk, talukder sy, islam m, saha s. a highly ceftriaxone resistant salmonella typhiin bangladesh. pediatr infect dis j 1999;18: 387. 6. wain, j, hoa, nt, chinh, nt. quinolone-resistant salmonella typhi in viet nam: molecular basis of resistance and clinical response to treatment. clin infect dis 1997; 25:1404. 7. limson, bm. short course quinolone therapy of enteric feverin developing countries. drugs 1995; 49 s2:136. 8. thaver, d, zaidi, a, critchley, j, et al. fluoroquinolones for treating typhoid and paraenteric fever(enteric fever). cochrane database syst rev 2005; :cd004530. 9. longo dl, kasper dl, jameson lj, fauci as, hauser ls, loscalzo j. harrison’s principles of internal medicine. 18th ed. new york:mcgrawhill; 2012:1274-81. 10. rastegarlari a, validi n, ghaffarzadeh k, shamshiri ar. in vitro activity of cefi xime versus ceftizoxime against salmonella typhi. patholbiol (paris) 1997; 45:415. 11. david r. shlim,eli schwartz,molly eaton.clinical importance of salmonella paratyphi a infection to enteric fever in nepal.journal of travel medicine.1995;2(3):165-68 12. sharma n, koju r, karmacharya b, tamang md, makaju r, nepali n, shrestha p, adhikari d.typhoid fever in dhulikhel hospital, nepal.kathmandu univ med j (kumj). 2004 jul-sep;2(3):188-92. 13. smith md,duongnm,hoantt,wainj,hahd,diep ts et al. comparison of ofl oxacin and ceftriaxone for shortcoursetreatment of enteric fever. antimiocrobs agents chemother.1994; 38(8):1716-20 table 2. cross tabulation between treatment group and addition of second drug treatment group second drug added total no yes 25 ceftriaxone 19 6 25 ofl oxacin 23 2 50 total 42 8 mjsbh journal.indd medical journal of shree birendra hospital 15 abstract introducti on: teenage childbearing is linked to a host of negati ve social, economic and medical consequences for both mother and child. maternal mortality among girls under 18 years is two to fi ve ti mes higher than that of women in their 20s. this study was conducted to determine the relati onship between maternal age on fetal weight. method: it was a prospecti ve, hospital based study, carried out in 491 primi gravidas with fullterm singleton pregnancy. the study populati on was divided into two groups, women who were 19 and less than 19 years of age and women who were more than 19 years of age. fetal weight as the outcome variable was compared between these groups. results: the age of the mother ranged from 16 to 37 years. 24.8% women in the study populati on were <19 years of age. although the diff erence was not clinically signifi cant (p=0.51), 1/3rd of the mothers who were <19 had low birth weight. conclusion: the relati on of low birth weight and young maternal age could not be proven in this study. key words: age, fetal weight, maternal age. effect of maternal age on fetal weight sadikchya singh rana 1 1dept. of obs and gynae. shree birendra hospital introduction teenage pregnancy and childbearing have become pressing social concerns in the world. research has shown that teenage childbearing is linked with negati ve social, economic and medical consequences for both mother and child. there is a great deal of debate, however, whether these consequences are due to maternal age per se, or whether they are caused by the adverse economic and social circumstances of teenagers who become mothers. the world health organizati on (who) stressed that acceptable progress to reduce maternal and perinatal mortality will not be realized unti l the governments make a full commitment to lower maternal deaths. about 529 000 women in the world die each year from pregnancyrelated causes-and almost half of these deaths occur in the western pacifi c and south-east asia regions. maternal mortality among girls under 18 years is two to fi ve ti mes higher than that of women in their 20s. in the south-east asian region, the child-bearing rate among adolescents aged 15 to 19 years ranges from 146 live births per 1000 women in bangladesh to 26 per 1000 in the republic of korea. there are studies from third world countries menti oning the relati on between lbw and the maternal age. although, we have high incidence of adolescent mother, in our country no such research have been done. this study was conducted to fi nd correlati on between maternal age and lbw. correspondence: dr. sadhikchya singa rana department of obst gyanacoloy, shree birendra hospital. e-mail: drssrana@gmail.com cell no.: 9851078400 original arti clejuly-december 2011/vol.10/issue2 16 medical journal of shree birendra hospital method this was a hospital based prospecti ve comparati ve study done at paropakar maternity and women’s hospital thapathali, kathmandu, nepal. this study was conduced from 1st poush to 30th chaitra 2063 [16th december 2006 to 12th april 2007]. the study populati on were all the primi gravidas who were admitt ed with full term pregnancy. women who were 19 years and below were considered young primi. there were total of 7627 obstetric admissions in the study period out of which there were 2693 primi gravidas. five hundred pregnant women were enrolled for the study as per inclusion and exclusion criteria. all the primi pati ents admitt ed in the hospital with term and singleton pregnancy were included in the study. multi gravidae, pati ents with anaemia, twin or multi ple pregnancies, sti llbirths and pati ents not willing to parti cipate in the study were excluded. permission of the hospital was taken before the study began. questi onnaire was fi lled at the admission room which included informati on regarding identi fi cati on, age, residence, occupati on, educati on, socio-economic status, any previous diseases. a full obstetric history including at menarche, menstrual cycles, last menstrual period, durati on of marriage, gravida, para, number of antenatal visits (if they have done), iron intake was asked. the pati ent was examined generally and systemically. general examinati on included general conditi on, pallor, oedema, jaundice, pulse rate, blood pressure, height, weight, respiratory system, cardiovascular system followed by detail obstetric examinati on. the study populati on was divided into two groups, women more than 19 and less than 19 years of age. then the pati ent was followed either in the labour room, operati on theatre or ward. the weight of the baby was taken and recorded. low birth weight was considered if birth weight was below 2500gm. the collected informati on was entered daily in the master chart. spss version 10 was used for calculati ons. stati sti cal analysis was done using chi-square test and students t-test as applicable. results although fi ve hundred cases were initi ally enrolled in the study, only four hundred ninety one of them were fi nally analysed as six cases refused to take part in the study, two had sti ll birth and one had undiagnosed twin pregnancy. majority of the mothers in the study populati on were between 19-24 years of age. very few mothers were between 35-40 years of age. a total of 122 (24.8%) pati ents were below the age of 19 years (table 1). almost 1/3rd of the mothers below the age of 19 had low birth weight. but the diff erence in fetal weight was not stati sti cally signifi cant (p value= 0.51) among the mothers who were more or less than 19 years of age (table 2). discussion over half of the world’s populati on is below 25 years of age and more than 80% of the world’s youth live in developing countries. in the mid-1990s, the global teenage populati on was esti mated at 513 million. in this study the youngest mother was 16 years of age and the eldest mother was 37 years of age. a total of 122 (24.8%) women in the study populati on were <19 years of age (table 1). almost 1/3rd of the mothers below the age of 19 had low birth weight. but the diff erence in fetal weight was not stati sti cally signifi cant (p value =0.51) among the mothers who were more or less than 19 years of age (table 2). similar to this study reichman ne et al1 reported the youngest (younger than 15) and oldest (aged 40 and older) mothers were only at higher risk to deliver a low-birthweight baby; older teenagers were not at any signifi cantly increased risk to deliver a low-birth-weight baby than women aged 25-29. the seemingly poorer birth outcomes of teenage mothers appeared to result largely from their adverse socioeconomic circumstances, not from young maternal age. but hirve ss2 reported the unadjusted relati ve risks for lbw were signifi cantly higher for maternal age less than 20 years (rr = 1.27). leppert pc et al3 also reported aft er comparing three birth outcomes, gestati onal age, birth weight, and type of delivery, among adolescent (13-19) and those over 20 years of age, that younger mothers were more likely than older ones to have babies 38 weeks gestati on and weighing 2500 g. he concluded that, even with similar table 1.maternal age distribution age no. of pati ents percentage <19 122 24.8 19-24 293 59.7 25-29 61 12.4 30–34 12 2.4 35-40 3 0.6 total 491 100 table 2.fetal weight in relation to maternal age age low birth weight(<2.5kg) normal birth weight(>2.5kg) <19 32 90 >19 86 283 total 118 373 medical journal of shree birendra hospital 17 comprehensive care, adolescent mothers in this study were at greater risk of adverse outcomes than older mothers. briggs mm et al4 also reported adolescents (<19years of age) had signifi cantly more low birth weight infants (<2500 g) than adults (>20 years old) (p=0.008). anemia is signifi cant risk factor for poor obstetric outcomes and is potenti ally modifi able. similar analysis was done by machedo cj5 in a populati on based study on the impact of maternal age at fi rst birth on low birth weight, preterm birth and low apgar scores at one minute and at fi ve minutes among live births delivered to primiparous on 73,820 birth records from the 1998 birth cohort maternal ages below 20 and above 30 years were signifi cantly associated with the risks of low birth weight and preterm birth, but no associati on was found between maternal ages and apgar score. but this result seems to be inconsistent, low birth weight, preterm birth and low apgar scores measure diff erent dimensions of newborn well-being, and the associati on of each measure with maternal age is expected to diverge. conclusion although in this study, the eff ect of young maternal age on low birth weight could not be proven stati sti cally we could see the high incidence of low birth weight in younger age group. our study has several limitati ons including the sample size and considering only few variables. a detailed study with large sample size and correlati on of other variables will be more appropriate. eventhough the birth weight is less in young age group the diff erence is stati sti cally not signifi cant in our study. references 1. reichman ne, pagnini dl. maternal age and birth outcomes. fam. planning perspect. 1997; 29(6):268-72. 2. hirve ss, ganatra br., determinants of low birth weight: a community based prospecti ve cohort study. indian pediatrics j. 1994;31(10):1221-5. 3. leppert pc, pregnancy outcome among adolescent and older women receiving comprehensive prenatal care. j of adolescent health care. 1986;7(2);112-7. 4. briggs mm, hopman wm, comparing pregnancy in adolescents and adults: obstetric outcomes and prevalence of anemia. j obstet gynaecol can. 2007;29(7):546-55. 5. machedo cj. impact of maternal age on birth outcomes: a populati on based study of primiparous brazilian women. cambridge journals. 2005;10:1017. 6. rees jm, lederman sa, kiely jl. birth weight associated with lowest neonatal mortality: infants of adolescent and adult mothers. j of pediatrics. 1996;98(6):61-8. 7. strobino dm, margaret e, kim yj, nanda j. mechanisms for maternal age diff erences in birth weight. american journal of epidemiology. 1998; 142(5):504-14. 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 mjsbh 13-1-2014.indd � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � ! 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ê ë ì ý ì í û ù é ï ì é ê í á å ú ó ú õ â ë × ï × î ù î ê ü ê é ý ù ö � ì ï ü × á í � ã � ì à í û × û ì ý ã ö × þ × � ü é ì ã û ù í ê ì ý í â ó ä ô ó ë õ ù éý ì í û ù é ï ì é ê í ë ì × ý ï é ý ù ö ê ë ì ü ý é ý ü ì é ï í × é ï ý ì ø × ê ü è ì í × é ïô ó ú õ é ý ù ö ù ê ë ì ý í ù î ý ú ì í á í × î ø ì ú â óÿ � � � ô ö � ì ý ú ì û ê ü ù é ý ì þ × ý ï ü é þ í ð ö û ê ù ö í ù é í �� � � � � � � � � ò � � ô ó � � ô ó � ô � � � ñ ôù ù î þ ë � å à ì ì þ í ì ç ì å ó ä÷ ì è ì ý å æ å æ ó ô� ø ù ù ï ð í û î ê î ö ä ò ä ò ó å û û ì ê ü ê ì ø ù í í å ç å ç ó æø à ì × ê ü é þ ç ä ä ó ñù ë ì í ê û × ü é ä ç ä ç ó ñ� ì × þ é ì í í å ñ å ñ ó ä� ê � ù í í ä ú ä ú ó ä� ù é û ê þ é ù à ä å ä å ó ìê è ì ý × ø ø × à × ý ì é ì í í × î ù î ê í ð ö û ê ù ö í ù é í î î ì ý ú î ø ù í ü íà × í ø ù à ü é í ê î ï ð í î î ì ú ê í ó í ë ù î þ ë ê ë ì ð ë × ï ë ì × ý ï× î ù î ê í � ã ä å ó ì õ ù é ê ë ì ö à ì ý ì é ù ê × à × ý ì × î ù î ê × é ðí ð ö û ê ù ö í ù é í � ó ì å ó ä õ ê ë ü é þ ê ë × ê ú ù î þ ë ö ù ý ì ê 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s v u n \ n p o r z v m x r q p g f v m n f u n \ o n r r � m n f ß ` o np g y o s g \ t � � b p w s v r y r o l p n \ r n s o h r x m r [ r \ s v u s s v rm n w r q s m p n q p g x \ h r l y r [ r n s r \ h t q p [ r y m n f s v r ] p g s vu n \ n p o r z v m x r q p g f v m n f ` o n s v r o u ] r o s g \ t ] u i p y m s tp w y r o l p n \ r n s o ^ j � ` k b c l r y q r m [ r \ s v u s ] p o s l r p l x r m ns v r q p ] ] g n m s t w r r x u o v u ] r \ u w s r y s v r t u y r m n w r q s r \z m s v k l ` o n p g y o s g \ t a j ` k b o u m \ s v u s q p ] ] g n m s t z m x xs y r u s s v r ] \ m w w r y r n s x t `e x s v p g f v ] p o s p w s v r ] z r y r u z u y r u h p g s q p g f vw p y k z r r n o u o u o t ] l s p ] p w k l h g s [ r y t w r z v u \n n p z x r \ f r p w p s v r y o t ] l s p ] o x m n r w r [ r y m z r m f v s x p o o mx p o o p w u l l r s m s r u o u q p õ o t ] l s p ] p w k l m o p s v r y r w p y ro ø � o v p g x \ h r \ p n r y r f u y \ m n f n n p z 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h f [ ; a 9 < n ? f g l f < @ = c e f > a c ? < h 8 h y b \ zd 9 g 7 c b d 9 8 b b c 9 < g f t a 8 f 9 a ] e 8 > c h y p j u z d 9 g v f > a f v = 8 < 9d e < c = v > < e 8 g f > 8 9 8 = 8 d = f g p j u = f h = 8 9 l d 9 g a < c 9 h f ? ? 8 9 l d b < 9 lb \ v d = 8 f 9 = h d = = f 9 g 8 9 l 7 f d ? = 7 @ d a 8 ? 8 = 8 f h 8 9 p d > d > = < n 9 z x d h = f > 9x = 7 8 < v 8 d ; d f ] < c b d 9 g y f l f h h f \ [ 6 o c e ? 8 a p f d ? = 7 ; r s i f qi f m i r u ; http://dx.doi.org/10.1186/1471-2458-13-124 ;} 5 a 7 d ? 8 ? d z n 7 b d g x z a 7 d 9 ~ z o f > n 8 9 l ; n h = c g ] < @ ` 9 < n ? f g l fd 9 g d n d > f 9 f h h > f l d > g 8 9 l v c ? b < 9 d > ] = c e f > a c ? < h 8 h 8 9 v d = 8 f 9 = hc 9 g f > = > f d = b f 9 = @ < > = c e f > a c ? < h 8 h 8 9 d > c > d ? d > f d < @ n ? 8 l d > 7 h� o ; j 9 g 8 d 9 : < c > 9 d ? < @ 6 < b b c 9 8 = ] p f d ? = 7 ; r s i i q r f y r z m g f c p ;� 5 ^ < e = ; < @ l f v d ? ; a 9 < n ? f g l f n = = 8 = c g f d 9 g o > d a = 8 a f h d = c 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[ 8 9 8 h = > ] < @p f d ? = 7 d 9 g o < v c ? d = 8 < 9 l d = 8 < 9 d ? b c e f > a c ? < h 8 h 6 f 9 = > f r s s g ; 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at www.nepjol.info port 443 mjsbh vol11 issue2.indd m j s b h j u l y d e c e m b e r 2 0 1 2 | vo l 1 1 | i s s u e 2 m e d i c a l j o u r n a l o f s h r e e b i r e n d r a h o s p i t a l 36 original article introduction community-acquired pneumonia (cap) is de! ned as an acute infection of the pulmonary parenchyma in a patient who has acquired the infection in the community1. it is caused by a number of infectious agents, including viruses, bacteria and fungi. " e most common bacteria in causing pneumonia in children are streptococcus pneumoniae followed by haemophilus in# uenzae type b (hib)2,3. cap is the most common cause of childhood deaths in the developing countries4. in the developed countries the burden of the disease is in order of 10-15 cases/1000 children per year and a hospital admission rate of 1-4/1000 per year5. use of antibiotics is one of the main strategies used to overcome children's morbidity and mortality in such circumstances6. world health organization (who) has recommended penicillin g to children hospitalized with severe cap in developing countries7,8. " e rational for such a choice is, to treat streptococcus pneumonia, which is the most common cause of bacterial cap who are appropriately treated could be seen clinically within 24 to 48 hours9. penicillin resistant strains of streptococcus pneumonie is emerging worldwide10,11. intermediate or high-level resistance to penicillin has become a signi! cant problem. children, particularly those living in child care facilities and those receiving frequent courses of antibiotics, appear to be important carriers of resistant strains12. " us the objective of this study was to observe the clinical response of the children hospitalized with communityacquired pneumonia to the treatment with crystalline penicillin and to see the clinical features of community– acquired pneumonia in hospitalized children. methods crystalline penicillin for community acquired pneumonia: does it still work? nirjala aryal1, arun kumar neopane1, moon � apa1, umesh kumar singh1, keshav agrawal1. 1 department of paediatrics, shree birendra hospital, chhauni, kathmandu, nepal. abstract introduction: pneumonia is the most common cause of mortality and morbidity in children in underdeveloped countries. " e common bacterial agents are streptococcus pneumonia followed by haemophilus in# uenzae type b. " e only measure to treat bacterial pneumonia is the correct use of antibiotics along with oxygen in moderate to severe cases. " e objectives of this study were to see the clinical features of community-acquired pneumonia and to observe the response to treatment with crystalline penicillin in hospitalized children. methods: " is study was a prospective study. " e children aged between two months to 59 months with pneumonia were treated with intravenous crystalline penicillin. response was observed by normalization of respiratory rate and absence of lower chest indrawing. results: out of 88 children treated, 79(89.8%) showed improvement in 48 hours. in children who had tachypnoea, 62.9% showed normalization in respiratory rate in the ! rst 24 hours and 37.1 percent in 48 hours of treatment. similarly, among children with lower chest indrawing; 61.1% showed improvement in 24 hours and the remaining in 48 hours. in 24 hours of treatment 17.7% of children became afebrile and 46.8% in 48hours of treatment. conclusion: " e most common clinical features like cough, fever, tachypnoea and lower chest indrawing can be used to diagnose cap where chest xray is not possible. " e response to treatment with crystalline penicillin is very good and, thus, can be used as the ! rst line drug in the treatment of children with cap. keywords: community acquired pneumonia, crystalline penicillin, tachypnoea, hypoxia. .......................................................................................... correspondence: maj. dr. nirjala aryal department of paediatrics, shree birendra hospital. kathmandu, nepal email: nirjalaaryal@gmail.com phone: m j s b h j u l y d e c e m b e r 2 0 1 2 | vo l 1 1 | i s s u e 2 m e d i c a l j o u r n a l o f s h r e e b i r e n d r a h o s p i t a l37 � is was a prospective study conducted from 30th january 2011 to 1st january 2012. a� er obtaining informed consent from the parents or caretakers, children aged between two months to 59 months with fever (axillary temperature ≥ 380c), fast breathing (de� ned as respiratory rate ≥ 50/min in 2-11 months and ≥ 40/min in 12-59 month aged child) and/or with di� culty in breathing (de� ned by bilateral lower chest wall indrawing) 10 and children with chest x-ray � ndings suggestive of pneumonia were included in this study. among the enrolled children the respiratory rate and chest indrawing were observed when the children were calm and quiet. besides, oxygen saturation (spo 2 ) was monitored using pulse oximeter with a � nger probe. � e respiratory rate was counted twice if it was equal or above the reference range for each age group. � e second count was recorded as the rr for the child. � e rr count was done by experienced paediatrician. hypoxemia was de� ned as oxygen saturation less than 90% in room air10. pneumonia was con� rmed if a pulmonary in� ltrate or pleural e� usion was described by a quali� ed radiologist. fever was treated with paracetamol as and when required and hypoxemia if present was treated with oxygen via nasal cannula. � ose children that quali� ed the above criteria were hospitalized and treated with intravenous crystalline penicillin (cp) @200,000 iu/kg/day in four divided doses a� er the skin sensitivity test. axillary temperature, respiratory rate, chest indrawing and oxygen saturation of the enrolled children were recorded 6 hourly. � e response was measured by normalization of respiratory rate and absence of chest indrawing at 24 hours and 48 hours of treatment. if no improvement were seen in 48 hours of intravenous cp, the child were treated with other antibiotics as per the hospital protocol. improvement in signs and symptoms were considered “improved” only at 24 hour and 48 hours of initiation of treatment to allow adequate time for action of antibiotics. children with underlying debilitating or chronic pulmonary illnesses and heart disease, children already taking oral antibiotics at the time of enrollment, those who are known allergic to penicillin group of drugs, patients requiring referrals to other centers for various reasons and children without evidence of pneumonia on chest x-ray were excluded from this study. results a total of 200 children were screened and 88 children who met the inclusion criteria were enrolled in the study. among the enrolled patients 55.68% were males. � e mean age of children was 33.26 in the age group of 2-59 months. � ere were 14(15.9%) children within the age group 2-12 months and 74(84.1%) children aged more than 12-59 months. table1. showing improvement in signs and symptoms a! er treatment with cp. signs and symptoms improvement a! er 24 hrs improvement a! er 48 hrs tachypnea 33(53.2%) 24(38.7%) lower chest indrawing and tachypnea 15 (57.7%) 7(26.9%) fever 14(17.7%) 37(46.8%) decrease in cough as reported by mother 5(6%) 18(21%) hypoxia 3(100%) out of 88 children treated with cp, 79(89.8%) responded well. in 62(70%) children who presented with tachypnoea 53.2% had normalization of respiratory rate in the � rst 24 hours of intravenous cp and 38.7% of the children had normalization of respiratory rate within 48 hours of treatment. similarly out of 26(29.5%) children who had lower chest indrawing and tachypnoea at the time of enrollment 57.7% of the children showed disappearance of lower chest indrawing and normalization of respiratory rate in � rst 24hours and 26.9% children in 48hours of treatment. none of the enrolled children had lower chest indrawing in isolation without tachypnoea. figure 1. treatment outcome of patients. m j s b h j u l y d e c e m b e r 2 0 1 2 | vo l 1 1 | i s s u e 2 m e d i c a l j o u r n a l o f s h r e e b i r e n d r a h o s p i t a l38 all of the three (3.34%) children presenting with hypoxia at the time of enrollment maintained their sp02 above 90% at room air in the � rst 24 hours of treatment with intravenous cp. among children who presented with fever, 17.7% became afebrile in 24 hours and 46.8% became afebrile in 48 hours of treatment and a� er that there was no need of paracetamol in them. out of 83(94%) children presenting with cough, the mother reported decrease in cough only in 6% of children in 24 hours and 21.7% in 48 hours of treatment. all the enrolled case recovered completely. out of 9 cases who didn’t respond to cp , two developed pleural e� usion, one empyema thoracic and six remained tachypnoeic with chest indrawing even a� er 48 hours of cp. discussion ! e estimated incidences of pneumonia in india, pakistan and bangladesh are 44 million, 7 million and 6 million repectively2. ! e demographic and health survey done in nepal in 2011 showed that 5% of the children less than � ve years of age had symptoms of acute respiratory illness (ari), 19% had fever and 14% had diarrhea 2 weeks preceding the survey. ari and severe diarrhoea causing dehydration are the major causes of childhood mortality in nepal3. but the published data of death due to pneumonia in children less than � ve years of age is lacking. in our study the main presenting clinical feature of pneumonia was cough (94%) followed by fever, tachypnoea and tachypnoea with lower chest indrawing. ! e least common feature was hypoxia. ! is is supported by a similar study done in himachal pradesh, india where the most common presenting complaints were fever and cough followed by rapid or di" culty in breathing.13 similarly a study done in children >1 year of age with the � rst episode of wheezing found that the combination of tachypnea, tachycardia, fever, and localized � ndings (rales or wheezing) both before and a� er bronchodilator therapy could identify 95% of patients with pneumonia.14 another study done in 154 hospitalized children aged more than two months with cap showed that the most common presenting complaints of pneumonia were cough (99.2%), fever (97.2%) and di" culty in breathing (56.5%). ! e � ndings were tachypnea (75.2%), fever (49.7%) and crackles (33.8%).15 all these show that fever, cough and tachypnoea can be used as the diagnostic tool for pneumonia where chest x-ray is not always possible especially in rural and under equipped health settings. since most of the causative agents of childhood pneumonia cannot be detected, antibiotic treatment is most o� en empiric, especially in underdeveloped countries. various antibiotics are being used in the treatment protocol of cap worldwide16 and so also in nepal. in our study the data showed that cp successfully treated the great majority (89.8%) of the children aged between 2 to 59 months with radiographically con� rmed cap. ! ese results are also similar to the result shown in the retrospective cohort study done in hospitalized children with cap in brazil where penicillin g successfully treated 82% (126/154) of the study group and the improvement was markedly seen on the � rst day of treatment itself.15 another study done in finland showed that out of 153 children hospitalized for uncomplicated cap, 66% were treated with penicillin g and they also showed a rapid and uneventful recovery.17 penicillin g is still considered a drug of choice in hospitalized children with cap even in many european countries with low penicillin resistance of pneumococci.18,19,20 penicillin g is no longer recommended in the united states as the � rstfigure 2. clinical features at presentation. of pneumonia. none of the children presented with cyanosis and dehydration. m j s b h j u l y d e c e m b e r 2 0 1 2 | vo l 1 1 | i s s u e 2 m e d i c a l j o u r n a l o f s h r e e b i r e n d r a h o s p i t a l39 choice drug because of limited supply and the increasing resistance of pneumococci to penicillin21, whereas in western countries like finland, 95% of pneumococcal strains still remained sensitive to penicillin. 22since a majority of children with cap responded signi� cantly well to cp in our study, it could still be considered a drug of choice in hospitalized children with cap in low income and resource poor countries like nepal. since the aim of the study was to see the response to treatment with antibiotics (cp) in diagnosed cases of pneumonia, the onset of symptoms of ari, days of hospital admission, nutritional status and other confounding variables were not included in this study. � is was a descriptive study in which a cohort of children was followed up. � erefore, further statistical analysis was not considered of additional value. � e relatively small sample size was also one of the limitations of this study. conclusions crystalline penicillin is a very good drug for the treatment of cap and can still be used as the � rst drug in the treatment of children with cap. � e most common clinical features like cough, fever, tachypnoea and lower chest indrawing can still be used in the diagnosis of cap where chest x ray facilities are absent. � is study however had certain limitations like; absence of bacteriological diagnosis and a relatively small sample size. acknowledgement � e authors would like to thank all the sta! s of the department of paediatrics at shree birendra hospital we are also very grateful to the consultant doctors of the department of radiology without whom the study would not have been been completed. references 1. � eodore c.sectish, charles g. prober. pneumonia. in: kliegman, behrman, st. geme, schor, stanton, editors. nelson text book of pediatrics. 19th ed. philadelphia: saunder elsevier; 2012: p.1474-9. 2. world health organization. pneumonia: � e forgotten killer of children. � e united nations children’s fund /world health organization; sept 2006. 3. ministry of health and population, new era, icf micro, usaid. nepal demographic and health survey 2011. katmandu: ministry of health and population, government of nepal; 2011. 4. mulholland k. childhood pneumonia mortality–a permanent global emergency. lancet 2007;370:285–9. 5. farha t, � omson ah. � e burden of pneumonia in children in the developed world. paediatr respir rev 2005;6:76–82. 6. sazawal s, black re. e� ect of pneumonia case management on mortality in neonates, infants, and preschool children: a meta-analysis of community-based trials. lancet infect dis 2003;3:547–56. 7. world health organization. a manual for doctors and other senior health workers. programme for the control of ari. geneva: who; 1990. ari in children: case management in small hospitals in developing countries. 8. addo-yobo e, chisaka n, hassan m, hibberd p, lozano jm, jeena p, et al. a randomized multicentre equivalency study of oral amoxicillin versus injectable penicillin in children aged 3 to 59 months with severe pneumonia. lancet 2004;364:1141–8. 9. sandora tj, harper mb. pneumonia in hospitalized children. pediatr clin north am 2005; 52:1059. 10. � ornsberry c, ogilvie pt, holley hp jr, sahm df. survey of susceptibilities of streptococcus pneumoniae, haemophilus in� uenzae, and moraxella catarrhalis isolates to 26 antimicrobial agents: a prospective u.s. study. antimicrob agents chemother 1999; 43:2612. 11. raymond j, le � omas i, moulin f, et al. sequential colonization by streptococcus pneumoniae of healthy children living in an orphanage. j infect dis 2000;181:1983. 12. sisson ba, buck g, franco sm, et al. penicillin minimum inhibitory concentration dri� in identical sequential streptococcus pneumoniae isolates from colonized healthy infants. clin infect dis 2000;30:191. 13. bhavneet b, sahul b, vandna v. role of acute illness observation scale (aios) in managing severe childhood pneumonia. indian j pediatr 2007;74:27. 14. gershel jc, goldman hs, stein re, et al. � e usefulness of chest radiographs in � rst asthma attacks. n engl j med.1983;309(6):336–39. 15. simbalista r, araújo m, nascimento‐carvalho, c.outcome of children hospitalized with community‐acquired pneumonia treated with aqueous penicillin g. clinics (sao paulo). 2011;66(1):95–100. 16. feyzullah c, abdulkadir g, gunsel k. comparison of two antibiotic regimens in the empirical treatment of severe childhood pneumonia. indian j pediatr 2004;71(11):969-72. 17. juvén t, mertsola j, waris m, leinonen m, ruuskanen o. clinical response to antibiotic therapy for community‐acquired pneumonia. eur j pediatr 2004;163:140–4. 18. hedlund j, ortqvist a. management of patients with communityacquired pneumonia treated in hospital in sweden. scand j infect dis 2002;34:887–89 19. moroney jf, fiore ae, harrison lh, patterson je, farley mm, jorgensen jh et al. clinical outcomes of bacteremic pneumococcal pneumonia in the era of antibiotic resistance. clin infect dis 2001;33:797–805 20. ruuskanen o, mertsola j. childhood community acquired pneumonia. semin respir infect 1999;14:163–72 21. nelson jd. community-acquired pneumonia in children: guidelines for treatment. pediatr infect dis j 2000;19:251–53 22. pihlajamaki m, kotilainen p, kaurila t, klaukka t, palva e, huovinen p. macrolide-resistant streptococcus pneumonia and use of antimicrobial agents. clin infect dis 2001;33:483–88 medical_journal_year2.pdf    47        rajbhandary gl dr gambhir lal rajbhandary, prof. of ctvs (nams), shree birendra hospital address for correspondence: gambhirlrb@hotmail.com introduction like in many agriculture farming countries cystic echinococcal disease is endemic in nepal also1,2. incidence of liver & pulmonary hydatid cysts are common among adult population in nepal, but there are few literature published on surgical experience with pulmonary hydatid cyst in pediatric age group in nepal3. material during last 14 years since 1994 to 2008, 18 cases of pulmonary hydatid cyst were operated at cardio-thoracic surgery unit of birendra hospital. there were 14 male & 4 female. their age range from 7 years to 70 years. there were 2 patients between 7 years to 14 years. recently there were more presentation of hydatid cyst in young age group. case no 1 (operated 2008 ) pediatric case no 1 a 14 years old boy presented with rt sided chest pain, cough & fever one month, x-ray chest showed huge round radio opaque shadow over rt lung. ct scan of chest reveled cystic homogenous opacity rt lung lung cyst on rt. lower lobe size – 12cm x 10cm pt had pre-operative, tab. albendazole 400 mg bd for 4 weeks 4,5 .operation:rt thoracotomy & enucleation of hydatid cyst from rt lower lobe 6,7 .the bronchi at opening were closed with proline suture . the cavity is closed with vicryl suture post operation period was smooth. patient had unilocator hydatid cyst & on echinococcal pathology. case no 2. operated 2008 ad pediatric case no. 2 a 7 years old boy presented with cough, fever, hemoptysis – 2 months on x-ray chest there were two large rounds opacities over rt lung one upper lobe & one is rt lower lobe lung. ct scan of chest revealed cyst size – 10 cm x 8 cm on rt lung lower lobe . cyst size – 8cm x 6cm on rt lung upper lobe. on usg abdomen there was no hepatic cyst. blood agglutinate test for ecchinococcus was negative. ptatient was operated after 4 weeks of albendazole 400 mg daily. during surgery there was large unilocator cyst over rt lower lobe lung cyst of rt. lobe was enucleated, cavity closed multiple layers. another lung cyst on rt upper lobe was also enucleated & cavity obliterated, pt had smooth post overactive recovery. fig 1,2,3,4 shows the patient during and post operation. fig. 1 fig. 2 fig. 3 48 fig. 4 discussion cystic hydatid cyst of lung & liver are common in adult age group in nepal. there were not many cases presented with hydatid cyst in pediatric age group in nepal. recently we have noticed increase in pulmonary hydatid cyst in young age group in nepal. most of the cyst in our country present as unilocator cysts but size were large 7,8 . both the pediatric pulmonary hydatid cysts fall in who group 1 larger than 2 cm. & active9 . all the patients had smooth post operative recovery & there was no reporting of recurrence in 14 years of follow up10 . vats surgery was not used due to large size of pulmonary cyst & to avoid rupture & recurrence11 . conclusion pulmonary hydatid cyst is still common in nepal. now we see more in younger age group. prognosis of surgery in younger age group is good. in our study most of the pulmonary hydatid cysts were large but unilocator. references 1 schantz pm : epidemiology of cystic echinococosis global distribution & pattern of transmission, proceeding of national seminar on echinococosis, kathmandu, nepal 1996 2 joshi ab, joshi dd, schantz pm etal, epidemiological assessment of echinococosis in nepal proceedings of national seminar on echinococosis kathmandu, nepal 1996 3 robert w. tohan, echinococcosis e-medicine. jan 22, 2009 4 harton, chemotherapy of echinococcus infection in man with albendazole, pharmacopia martin dale 1993 5 rajbhandary g.l., hydatid cysts complete resolution following albendazole j.nep. med. assoc. 1995.33,131-132 6 gizzberg e. pulmonary hydatid cyst. robs smith’s operative surgery thoracic surgery jackson jw, cooper dkc, butter worth, london 1986, 194 203 7 rajbhandary g.l. surgical experience with hydatid cysts of lung & liver. j.society of surgeons of nepal 1998 – vol 1, 13 15 8 ayten a. yten kayi cangir srugical treatment of pulmonary hydatid cysts in children journal of pead. surgery. 2001, vol 36 issue 6 page (917 – 920) . 9 who informal working group on echinococosis 2003. 3 grouping of echinocococus cyst. 10 keramidas dc, passalides ag, soutis m. hydatidosis management in children: depend on anatomical location for treatment international association of hydatology. news letter of hydatidosis 1997 is. 15 11 wum, jhag lw 2 hutt, qian z-x surgical treatment of thoracic hydatidosis review of 1230 cases. chinese medical journal 2005: 118, 1665. 62 prostate cancer metastasizing to the orbit; praveena s, et al. mjsbh vol 21 issue 2 jul-dec 2022 case report rare occurrence of prostate cancer metastasizing to the orbit: a case report department of urology, nu hospitals, bengaluru, karnataka, india. praveena s, vinay k, karunakar reddy chalimidi, t krishna prasad prostate cancer is the second most common cancer among men.1 the metastasis from prostate cancer occurs most frequently to bone.2 the metastasis to orbit from carcinoma prostate is rarely reported in the medical literature.3 we present a case of 74 years old male with prostate cancer. he was on abiraterone therapy and presented with orbital metastasis two years following the initial diagnosis. he was evaluated with ct scan and treated with radiotherapy. case report a 74 years old gentleman presented to us with lower urinary tract symptoms, who had undergone trans urethral resection of prostrate (turp) elsewhere years back and histopathology reported as benign prostatic hyperplasia. the clinical examination revealed hard nodular prostate with serum total psa of 22 ng / dl. we performed trans rectal ultrasound (trus) guided prostatic biopsy which reported adenocarcinoma prostate with gleason score of 7 (3 + 4). the bone scan reported axial skeletal metastases with no visceral metastases. he was started on docetaxel chemotherapy and androgen deprivation therapy (adt). after two cycles of chemotherapy, he was switched to abiraterone therapy, as he could not tolerate chemotherapy. post abiraterone therapy, his serum psa was 3.1 ng / dl with serum testosterone under castrate level at three months follow up. however, he was lost to follow up for two years and he presented suddenly with left orbital swelling and excess lacrimation (figure 1). he had reduced the dosage of abiraterone by himself and was non-compliant. case report introduction prostate cancer metastasizing to the orbit; praveena s, et al. prostate cancer is second most common cancer with frequent metastasis occurring to bone. we report a unique case of soft tissue and bony orbital metastasis from carcinoma prostate. the patient presented with orbital metastasis after defaulting to the advised treatment. he responded well to radiation therapy and the lesion regressed completely. our patient was diagnosed to have an oligo-metastatic carcinoma of the prostate. he was non-compliant with treatment and presented to us with proptosis, which was later diagnosed to be an orbital metastasis from prostate cancer. it responded well to the external beam chemotherapy. orbital metastasis is a rare but known complication of carcinoma prostate. one must consider the diagnosis of orbital metastasis from carcinoma prostate in an elderly male presenting with proptosis. abstractcorresponding author praveena s, department of urology, nu hospitals, bengaluru, karnataka, india. email: praveenas82@gmail.com online access keywords prostate cancer; orbital metastasis © the author(s) 2023. this work is licensed under a creative commons attribution 4.0 international license. (cc by-nc) doi: 10.3126/mjsbh.v21i2.42879 received date: 03 feb, 2022 accepted date: 17 dec, 2022 https://creativecommons.org/licenses/by/4.0/ 63 prostate cancer metastasizing to the orbit; praveena s, et al. civil med j | vol 01 | issue 01 | jan, 2023 case report mjsbh vol 21 issue 2 jul-dec 2022 figure 1: clinical photographs depicting the proptosis (figure a anterior view and figure b lateral view); axial section of ct brain depicting the soft tissue and lytic bony lesion in the left orbit (figure c white arrow). his serum psa at that point was 22.4 ng / dl with castration levels of serum testosterone. the ct orbit revealed soft tissue space occupying lesion in the left orbit with no bony destruction diagnosed to be metastasis from carcinoma prostate. he was referred to radiation oncologist for further management. he received palliative rt to orbit (30 gy in 10 fractions) following which lesion regressed completely. discussion the most common primary malignancy in the orbit is choroidal melanoma and the most common secondary malignancy in the orbit is metastasis form breast cancer.4 on the other hand, the most common sites of metastasis of prostate cancer are bone (84%), distant lymph nodes (10.6%), liver (10.2%) and thorax (9.1%).5-7 the pelvis and spine are frequent localizations for bone metastases, but orbital and calvarial spread is extremely rare.3 a review of the literature revealed that metastasis from prostate cancer accounts for about 3.6 to 4% of all cases of orbital secondaries.8 two third of these patients were diagnosed cases of prostate cancer, while one‑third of them were diagnosed based on orbital metastasis, trauma, elevated intracranial pressure, brainstem lesions, and vasculopathies.9 here, we describe a rare cause of sixth cranial nerve palsy. the prostate carcinoma metastasis is considered to spread in the brain, calvarium and orbit by two pathways.10 first, it spreads directly through paravertebral batson’s venous plexus. second, it spreads initially to the areas such as lung and bone where prostate cancer frequently metastasizes and then it spreads by secondary seeding. majority of reported cases had primary ocular presentation (50%), compared to patients presenting with ocular symptoms later to a primarily diagnosed carcinoma prostate (27%). we also found that left orbit was more commonly involved (48%) than right orbit (33%). bilateral orbital involvement was seen in 4% cases, in remaining cases we could not find the laterality of involvement in the available literature. in about 39.5% of cases, there was at least one extra orbital skeletal metastasis documented; most common one being axial skeleton specifically spinal metastasis. we could not assert the importance of serum psa value, gleason’s score of the tumour as they were not well documented in the available literature and due to the fact that significant number of cases belonged to prepsa era. we found that 62.5% patients received hormone based treatments. few patients received radiation therapy, surgery and multimodal therapy. the majority of patient’s ocular symptoms responded to the treatment given, but the survival was poor (< 12 months in majority of the cases). in our case, the patient had already been found to have other skeletal metastasis at initial diagnosis. he was intolerant to chemotherapy hence was initiated on treatment with abiraterone. initially, it brought down the psa level. later on, he was lost to follow-up and lost compliance to the treatment. poor compliance to advised treatment resulted in progression of disease and elevated serum psa during follow-up. prompt diagnosis and early referral to radiotherapy resulted in complete resolution. conclusions though the orbital metastasis from prostate cancer is rare, a possibility of the same need to be kept in mind in the evaluation orbital swelling in elderly males and also in carcinoma prostate cases with biochemical recurrence. ba c 64 prostate cancer metastasizing to the orbit; praveena s, et al. mjsbh vol 21 issue 2 jul-dec 2022 case report references 1. worldwide cancer data. world cancer research fund. available at: https://www.wcrf.org/dietandcancer/cancertrends/worldwide-cancer-data 2. patrikidou a, loriot y, eymard jc. who dies from prostate cancer? prostate cancer prostatic dis. 2014;17:348–52. doi: 10.1038/pcan.2014.35. 3. valenzuela aa, archibald cw, fleming b. orbital metastasis: clinical features, management and outcome. orbit amst neth. 2009;28:153–9. doi: 10.1080/01676830902897470. 4. tailor td, gupta d, dalley rw, keene cd, anzai y. orbital neoplasms in adults: clinical, radiologic, and pathologic review. radio graphics. 2013;33:1739–58. doi: 10.1148/rg.336135502. 5. gandaglia g, abdollah f, schiffmann j. distribution of metastatic sites in patients with prostate cancer: a population-based analysis. the prostate. 2014;74:210–6. doi: 10.1002/pros.22742. 6. disibio g, french sw. metastatic patterns of cancers: results from a large autopsy study. arch pathol lab med. 2008;132:931–9. doi: 10.1043/1543-2165(2008)132[931:mpocrf]2.0.co;2. 7. szot w, kostkiewicz m, zając j, owoc a, bojar i. prostate cancer in patients from rural and suburban areas--psa value, gleason score and presence of metastases in bone scan. ann agric environ med aaem. 2014;21:888–92. doi: 10.5604/12321966.1129953. 8. saadi a, kerkeni w, bouzouita a. bilateral orbital metastasis of prostatic adenocarcinoma. urology. 2016;94:e3–4. doi: 10.1016/j.urology.2016.05.005. 9. özbek z, özkara e, arik d, ant ma. calvarial-orbital metastasis of prostate carcinoma which was diagnosed with sixth cranial nerve palsy. asian j neurosurg. 2017;12:769–71. doi: 10.4103/1793-5482.180933. 10. ransom dt, dinapoli rp, richardson rl. cranial nerve lesions due to base of the skull metastases in prostate carcinoma. cancer. 1990;65:586–9. doi: 10.1002/1097-0142(19900201)65:3<586:: aidcncr2820650333>3.0.co;2-p. medical_journal_year2.pdf   44  khatri r1, manandhar r2, pradhan n3, manandhar b4, rawal s5 1dr ratna khatri, 2dr rita manandhar, 3dr neelam pradhan,4dr bekeha manandhar, 5dr sunuti rawal, obstetrician and gynecologist, department of obstertics and gynaecology, tuth, kathmandu nepal abstract we report a case of chrioangima of placenta resulting to hydropsfetalis. a 24 yrs old primigravida with polyhydramnios and large placental chorioangioma at 24 wks of gestation expelled a nonimmune hydropic male baby weighing 900gms. the baby expired after 5 minutes of expulsion. keywords: placental chorioangioma, hydropsfetalis, polyhydraamnios address for correspondence: shirish.khatri@yahoo.com introduction placental chorioangioma is the most common benign tumor of placenta. the incidence being 1% of pregnancies. the relationship of vascularised chorioangiomas to adverse pregnancy outcome is well recognized. 50% of all cases will lead to maternal and fetal complications. ultrasonography and doppler ultrasonography are useful in establishing the prenatal diagnosis and the prognosis. case report a 24 yrs old primigravida, resident of kathmandu was admitted in the female surgical ward on 11 chaitra 062 for observation with the diagnosis of 27 +3 weeks of gestation with chorioangioma by usg. she had 2 antenatal visit,1st at 18 wks, 2nd at 26+5 weeks of gestation. at tuth. she attained menarche at 14 yrs. and had her lmp was on18.06.062 and edd calculated to be on 25.03.063. no family history suggestive of chorioangioma. she was non smoker, non alcoholic. in her last ante-natal visit, at 26 weeks of gestation on examination perabdominally she was found to have uterus of 30 weeks size, it was tense in consistency with foetal parts not palpable and fhs was present. since uterine height was more than the period of gestation urgent usg was advised keeping in mind she might have polyhydramnios, abruptio placentae, multiple pregnancy. usg revealed single live foetus of 24 week gestation with adequate liquor. and a separate placental mass measuring 8.8 x 9 cm size was also noted, giving the impression of chorioangioma of placenta. so she was advised admission for observation. next day she went into premature labour and expelled an alive male baby was cyanosed, had generalized oedema, and ascitis. there was no gross congenital anomaly. the liver and spleen were not palpable. grossly umbilical cord was 23cm placenta measured 13x 14 x 5 cm size and was friable. there were two separate pieces of smooth brown coloured mass measuring 9x10x3 cm & 10 x 60 x 2 cm size, which was lobulated on the outer surface.  45 on microscopic examination section from umbilical cord showed 2 arteries & 1 vein. placental section showed multiple chorionic villi lined by trophoblasts with increased vascularity in the mesenchymal cone. the separate tumour mass composed mainly of small blood capillaries along with her intranatal and post natal period was uneventful and she was discharged on 3rd post natal day. discussion chorioangima is the most frequent non trophoblastic tumour of the placenta with a incidence ranging from 0.01 1.3% of pregnancies. this term is used to describe abnormal proliferation of vessels arising from chorionic tissue (1). it is the most common benign tumour of the placenta (2). small placental chorioangiomas are found in 1% of large chorioangiomas larger than 5 cm are much less common with an estimated incidence of 1 in 2000-3500 births, but are associated with high perinatal mortality of 40% (3). it is usually single but occasionally multiple. this case also had two placental chorioangiomas with size measuring more than 5 cms. hpoxia and genetic factors are predisposing factors (4). the majority are small not visible on external surface are asymptomatic. most commonly protrudes from the foetal surface of the placenta near the insertion of cord. the size more than 5 cm is associated with complications (5). there are multiple risk factors for chorioangioma. it is divided into moderate and high risks. moderate risk factors include age of the patient >35 years, increased bp during second trimester, new paternity and dietetic factor: famine, anorexia. environmental factors like high altitude, smoking, controlled diabetes mellitus, genetic factor. bmi more than 25, primiparous, past family to premature placental release, cocaine, tobacco or caffeine use, molar pregnancy, uncontrolled diabetes mellitus, scleroderma, chronic hypertension, antiphospholipid syndrome, past history of deep vein thromosis, thrombophilia, past history of placental vascular pathology, iufd, abruptio placentae, iugr, repeated foetal loss, hyperhomocystinaemia are the high risk factors for chorioangioma of placenta (6). in this case clinically and by history she was not suggestive of any of the risk factors mentioned above except she was primigravida. maternal complications includes polyhydroamnios, precipitate labour, preeclampsia, maternal thrombocytopenia, maternal coagulopathy, hypertonic uterus, prom, haemorrhageboth aph &pph (6). this case had polyhydramnios, pre term premature rupture of membrane and precipitate labour. foetal complication includes: abortion due to hypoxia, iugr, and iud because the considerable proportion foetal blood passes through the tumour rather than the functional placental tissue. so foetus is supplied by deoxygenated blood and nutrient poor state. there can be foetal cardiomegaly due to peripheral av shunts leading to increased foetal cardiac output. the cause of neonatal oedema can be cardia failure or hypoalbuminaemia – because of trasudation of protein from the surface vessels of the tumour or from chorionic foetomaternal bleeding from haemangioma. neonatal thrombocytopaenia is due to injury within the tumour vessels. dic may occur due to release of thromboplastic substance from the haemangioma. neonatal anaemia is due to sequestration of foetal erythrocytes within the tumour, or massive foetomaternal bleed from the haemangioma or microangiopathic haemolytic anaemia induced by injury ultrasonogram, maternal serum afpincreased prenatally , colour doppler imagingto differentiate placental chorioangima from other placental lesions. but clear foetal waveforms in its periphery can be demonstrated (7). 3d power doppler angiography clearly shows highly vascularized placental mass including its feeding vessels& drainage at the foetal surface of the tumour (5). this case was diagnosed ultrasonographically the most effective way of diagnosing chorioangioma 46 is doppler ultrasonography but we could not apply it in this case, it was planned but same night she went into preterm labour. various modalities of treatment of chorioangioma of placenta have been reported in different case reports. 1. treating the cause is by occluding the vascular supply like a. foetoscopic devascularization by ablating the feeding vessels (8). b. microcoil embolization by ultrasound guided laser therapy which leads to tissue coagulation causing complete cessation of tumor blood c. intravascular injection of absolute alcohol in the feeding vessels of large tumour – this may be one of the best choices due to its high (10). d. ligation of tumor vessels. 2. treating the foetal complications produced by chorioangioma prenatally by intrauterine transfusion. it is necessary if foetal anaemia is diagnosed by cordocentesis in early pregnancy. there is risk of repeated transfusion, pre-term labour and iron overload, so some form of embolization or tumour devascularization is necessary(8). 3. symptomatic treatment like amniodrainage: pocket 12 cm and excessive maternal symptoms. prognosis is poor for large tumor. it largely depends on foetal haemodynamic tolerance with large placental chorioangioma. 50% lead to maternal & foetal complication (11). references 1. sepulveda w, alcade jl, schnapp c, bravo m. perinatal outcome after prenatal diagnosis of placental chorioangioma. jacog 2003;102:1028-33. 2. napolitano r, maruotti gm, mazzarelli ll, quaglia f, tessitore g, pecorare m et al. prenatal diagnosis of placental chorioangioma: our experience. minerva ginecol. 2005; 57(6): 649-54. 3. lau tk, leung ty, yu sch, to kf, leung tn. prenatal treatment of chorioangioma by microcoil embolization. a case reort. bjog 2003;110:7073. 4. noack f, sotlar k, thorns c, smreek j, diedrich k, feller ac et al. vegf-kit protein and chorioangioma? placenta 2003; 24(7):758-66. 5. hata t, inubashiri e, kanenishi k, akiyama m, tanaka h, yaagihara t. three dimensional power doppler angiographic features of placental chorioangioma. j ultrasound med 2004; 23:1517-20. 6. foidart jm, seak-san s, emonts p, schaaps jp. vascular placental pathology in high-risk groups: 154(5): 332-9. 7. maymon r, hermann g, reish a, strauss s, sherman d, heyman e. chorioangioma and its severe infantile sequelae: case report. prenat diagn 2003;15(12); 976-80. 8. witters i, van damme m, racemakers p, van assche f, fryns jp. benign multiple diffuse neonatal haemangimatsis after a pregnancy complicated by polyhydramnios and a placental chorioangioma. european journal of obstetrics& gynaecology and reproductive biology 2003; 106:83-85. 9. bhide a, perfumo f, sairam s, carvelho j, thilaganathan b. ultrasound guided interstitial laser therapy for the treatment o placental chorioangioma. obstet gynecol 2003;102: 118991. 10. wanpirak c. tongsong t, sirichotiyakul s, chanprapaph p. alcoholization: the choice of intrautrine treatment for chorioangioma. j obstet gynaecol res. 2002;28 (2):71-5. 11. wehrens xh, offermans jp, snijders m, peeters ll. foetal cardiovascular response to large placental chorioangiomas. j perinat med. 2004; 32(2): 107-12. 59civil med j | vol 01 | issue 01 | jan, 2023 case report mjsbh vol 21 issue 2 jul-dec 2022 true facial artery aneurysm; jha m, et al. endovascular management of a rare case of a true facial artery aneurysm: a case report 1base hospital, srinagar, india. 2command hospital, kolkata, india 3army hospital research & referral, new delhi, india. manvendu jha1, girija nandan tripathy2, anand vembu3 true aneurysms involving the extracranial head and neck vessels are rare and most often involve the superficial temporal and facial artery.1,2 majority of extracranial lesions are classified as false aneurysms and are sequelae of trauma. facial artery involvement in true aneurysms is rarer with only eight cases reported in literature so far.2,3,59 in this article, we describe a rare case of true aneurysm of the facial artery which was managed at our centre by endovascular approach. case report a 78 years old female, non-smoker, known case of coronary artery disease (cad), chronic obstructive pulmonary disease (copd) and hypertension presented with history of neck swelling on left side of five months duration. there was no history of trauma or any surgical procedure in head and neck region. there was no history of any sudden increase or decrease in size of the swelling. it was associated with occasional pain which was distressing to the patient. local examination revealed a 4 x 4 cm, pulsatile swelling in the left submandibular region which was non tender, globular with smooth surface. no palpable thrill or bruit was present. intra oral examination was normal. the colour doppler showed a 3.5 cm x 3 cm aneurysm of left facial artery with turbulent flow and absent yin yang sign. there was no wall calcification. left facial artery could not be traced completely. further evaluation by ct angiography revealed a 30 mm x 27 mm x 38 mm (ap x tr x cc) saccular outpouching from the facial branch of left external carotid artery. contrast was seen within, with thrombus in the peripheral rim of the aneurysmal sac. there was no venous filling. posteriorly, it was compressing the left internal jugular vein with maintained flow within (fig 1 & 2). echocardiogram of case report introduction true facial artery aneurysm; jha m, et al. true aneurysms of the facial artery are rare and their management protocol is not defined. there are only eight cases reported in the literature. here we report a case of true aneurysm of the facial artery in a 78 years old female. she presented with swelling left side of the neck who underwent further imaging including ct angiography which revealed an aneurysm of left facial artery. she was successfully treated with coiling. abstractcorresponding author manvendu jha, base hospital, srinagar, india. email: jhamanvendu@rediffmail.com online access keywords facial artery, endovascular, true aneurysm © the author(s) 2023. this work is licensed under a creative commons attribution 4.0 international license. (cc by-nc) doi: 10.3126/mjsbh.v21i2.40676 received date: 06 nov, 2021 accepted date: 09 jan, 2023 https://creativecommons.org/licenses/by/4.0/ 60 mjsbh vol 21 issue 2 jul-dec 2022 case report true facial artery aneurysm; jha m, et al. patient showed left ventricular ejection fraction of 40% with hypokinesia of inferolateral wall and without valvular regurgitation or clot. due to high risk for general anaesthesia, hybrid management was not possible and thus patient was planned for endovascular intervention under local anaesthesia. the right common femoral artery access was used, which was punctured under ultrasound guidance. a 6 f sheath was introduced over guidewire. the left common carotid artery was cannulated using 0.035 terumo wire and vertebral catheter and wire was parked in left external carotid artery. the sheath was exchanged with 7 f shuttle sheath over a stiff wire and angiogram was done in different planes to define the aneurysm. coiling of the aneurysm was done using two 35 x 15 x 20 and one 35 x 8 x 15 ptfe coil (fig 3a). the completion angiography showed decreased flow in the aneurysmal sac with partial thrombosis (fig 3b). there was no bruit after the procedure. there were no access site complications. she was discharged on second post-operative day. the patient was followed up every two weeks. she reported symptomatic improvement with decrease in pain and size of the swelling. the serial color doppler examination showed complete thrombosis of the aneurysm sac at three months. at one year follow up, the patient was asymptomatic with complete obliteration of aneurysm sac and clinical disappearance of the swelling. figure 1. ct angiography with coronal reconstruction depicting a saccular aneurysm arising from the facial branch of left external carotid artery figure 2. 3d reconstructed image demonstrating the aneurysm figure 3 (a) figure 3 (b) figure 3 (a) coiling of the aneurysm cavity with two 35 x 15 x 20 and one 35 x 8 x 15 coil (b) fig 6: completion angiogram with diagnostic catheter in the facial artery showing partial opacification of the aneurysm with coils in situ with patency of the collateral discussion aneurysms arising from facial artery usually present as a soft, compressible and pulsatile mass in the anterior triangle of neck. only eight cases have been documented in the literature so far, out of which only two patients underwent endovascular intervention. the mean size of these aneurysms ranged from 1 to 5 cm, the mean 61civil med j | vol 01 | issue 01 | jan, 2023 case report mjsbh vol 21 issue 2 jul-dec 2022 true facial artery aneurysm; jha m, et al. age of patients was 70 years and only eight cases had history of cardiovascular disease. the male: female ratio was 5:3 indicating almost equal incidence among both the sexes.2,3,5-9 in our case, we had a similar demographic profile but our patient had coronary artery disease, hypertension and pulmonary involvement. doppler ultrasonography is considered a useful tool due to its non-invasive nature and as facial artery is superficial in its anatomic course, its detection becomes relatively easier.2,3 it can also rule out wall calcifications, pseudoaneurysms and av fistulae. however, we resorted to ct angiogram as an evaluation tool to define the exact anatomy of the facial artery as we had initially planned for a hybrid approach and as we could not trace the facial artery completely by doppler. the treatment of aneurysms involves various documented procedures including ligation, surgical excision, embolization and hybrid approach. the surgical excision has been advocated with risk of potential injuries to the facial nerve during dissection. five out of the eight reported cases were managed by surgical excision alone, however no report of any injury to the facial nerve has been documented. collin et al6 reported spontaneous resolution of a 3 cm size facial artery aneurysm in a 78 years old man, who presented with swelling in left cheek. no further details were available to the reason for conservative management. no other documented case has been managed conservatively. kiernan et al7 reported excision of the aneurysm using facial nerve monitoring with excellent results. the endovascular intervention has remained limited to management of false aneurysms. setacci f et al8 first reported coil embolization in a patient with a large true aneurysm of the facial artery which was close to the parotid gland, to avoid potential facial nerve injury during surgical dissection. nakagawa et al9 reported the first hybrid approach in a 79 years old woman with a huge true aneurysm of the right facial artery. they treated the patient using endovascular internal trapping using coils followed by surgical excision after eight days. our case is only the second case in literature for pure endovascular management of a true facial artery aneurysm. the decision to intervene was made as the patient was symptomatic. she was planned for surgical excision / hybrid approach, however her preoperative assessment deemed her high risk for general anaesthesia in view of her cardiac and respiratory status. thus, an endovascular approach under local anaesthesia was performed with good result. conclusions true aneurysms of facial artery are very rare. clinical examination along with colour doppler usually clinches the diagnosis but ct angiography is a better diagnostic and evaluation tool as it can delineate the exact anatomy. endovascular approach either in isolation or associated with hybrid approach holds promise due to its minimal invasive nature, however more cases need to be done to have a defined role. references 1. buckspan rj, rees rs. aneurysm of the superficial temporal artery presenting as a parotid mass. plast reconstr surg 1986;78: 515-17. doi: 10.1097/00006534-198610000-00015. 2. do carmo gc, augusto lc, galindo fg, marcondes pf. true atherosclerotic aneurysm of the facial artery. int j oral maxillofac surg. 2006; 35:566–568. doi: 10.1016/j.ijom.2005.10.002 3. zhao yp, ariji y, gotoh m, kurita k, natsume n, ma xc, et al. color doppler sonography of the facial artery in anterior face. oral surg oral med oral pathol oral radiol endod. 2002;93:195-201. doi: 10.1067/moe.2002.120054. 4. hampel ah, villanueva mj, encina ms. true aneurysm of the facial artery. report of a clinical case. med oral. 2001;6: 148–150. doi: 10.1016/j.avsg.2011.10.023 5. hoshi e, owaki s, ogawa f, fukui j, ogawa t, shimizu t. true aneurysm of the facial artery.  auris nasus larynx.  2010; 37:539–660. doi: 10.1016/j.anl.2010.01.007. epub 2010 feb 26. 6. collin j, french k, davies r, hughes c. aneurysm of the facial artery.  br j oral maxillofac surg.  2015; 53: e86. doi: 10.1016/j.jvscit.2017.09.001 7. kiernan ac, kinsella j, tierney s. excision of true facial artery aneurysm using facial nerve monitoring. j vasc surg cases innov tech. 2008;4: 126-7. doi: 10.1016/j.jvscit.2017.09.001 8. setacci f, sirignano p, de donato g, palasciano g, setacci c. embolization of a true huge facial artery aneurysm. j cardiovasc surg (torino). 2008;49: 703-4. pmid:18670392 9. nakagawa k, yasuda t, kobayashi n, urabe k. huge true aneurysm of the facial artery treated with internal trapping and surgical excision. j surg case rep. 2020;9: 1-3. doi: 10.1093/jscr/rjaa375 http://dx.doi.org/10.1016/j.jvscit.2017.09.001 https://dx.doi.org/10.1093%2fjscr%2frjaa375 46 mjsbh vol 21 issue 2 jul-dec 2022 original article variation of hba1c with hemoglobin levels; bhattarai am, et al. glycated hemoglobin (hba1c) is the hemoglobin that is irreversibly glycated at one or both n-terminal valines of the beta chain.1 it is formed by slow and irreversible, nonenzymatic addition of a sugar residue to the hemoglobin.2 the main objective of our study is to find the influence of hemoglobin in estimation of hba1c by hplc and immunochromatography methods. the erythrocytes are freely permeable to glucose and the rate of production of hba1c is directly proportional to the ambient glucose concentration, the mean concentration of glucose in the blood and the lifespan of erythrocytes which is about 120 days.3 the hba1c concentration gives an integrated value for glucose with wide diurnal variations over the preceding 2–3 months.4 many factors are implicated in the rate of ketoamine formations which are physiological like temperature, ph, lifetime of proteins, substrate concentrations as well as the reactivity of amino groups.5 when the changes in introduction variation of hba1c with hemoglobin level: a comparative study between high performance liquid chromatography and immunochromatography analyzer introduction: the measurement of glycated hemoglobin (hba1c) is an established procedure in evaluating long-term glycemic control in diabetic patients. there are many factors like temperature, ph, lifespan of protein, substrate concentrations and hemoglobin levels that influence hba1c estimation by any methods. the aim of the study is to estimate hba1c by high performance liquid chromatography (hplc) and immunochromatography analyzer and find the influence of hemoglobin in hba1c by both the methods. methods: this was a descriptive, cross-sectional study carried out in the department of biochemistry of shree birendra hospital, chhauni, kathmandu over a period of two months from may 2021 to june 2021. we selected patients with type 2 diabetes mellitus. hba1c was measured in edta blood samples by bio-rad d10 (hplc method) and nycocard (immunochromatography method) whereas hemoglobin was estimated using horiba penta xlr fully automated hematology analyzer. results: in our study of 100 known cases with type 2 diabetes mellitus, the mean hemoglobin level was 14 ± 2.09 g/dl. the mean hba1c value obtained by nycocard and hplc analyzer were 7 ± 1.95 % and 7.39 ± 2.21% respectively. we found that there was a strong correlation of hba1c values with hemoglobin levels in hplc method p = 0.001, r = 0.6. however, we found no such correlation by nycocard method p = 0.6, r = 0.08. conclusion: there was a positive correlation of hemoglobin with hba1c values obtained by hplc method however no such variation was seen with immunochromatography method. this suggests that estimating hba1c by hplc methods may show decreased hba1c with decreased hemoglobin levels and increased hba1c with increased hemoglobin levels. abstract 1department of biochemistry, nepalese army institute of health sciences, bhandarkhal, syanobharyang, kathmandu, nepal 2department of microbiology, manipal college of medical sciences, pokhara, nepal arabinda mohan bhattarai1, sulochana parajuli2, salina pradhananga1 corresponding author arabinda mohan bhattarai, assistant professor, department of biochemistry, nepalese army institute of health sciences (naihs), kathmandu, nepal. email: arabinda.bhattarai@gmail.com online access keywords anemia; glycated hemoglobin; hemoglobin variants © the author(s) 2023. this work is licensed under a creative commons attribution 4.0 international license. (cc by-nc) doi: 10.3126/mjsbh.v21i2.41823 received date: 27 dec, 2021 accepted date: 01 dec, 2022 https://creativecommons.org/licenses/by/4.0/ 47civil med j | vol 01 | issue 01 | jan, 2023 original article mjsbh vol 21 issue 2 jul-dec 2022 variation of hba1c with hemoglobin levels; bhattarai am, et al. hba1c occurs by 1%, it may lead to changes of 1.4 1.9 mmol / l in average blood glucose concentration.6 the medical factors like dyslipidemia, malignancy, pregnancy, liver cirrhosis and hematological factors like hemolytic anemia, iron deficiency anemia, presence of carbamylated hemoglobin in uremia, etc. may affect hba1c levels.7 methods this was a descriptive, cross-sectional study done in the department of biochemistry of shree birendra hospital, chhauni, kathmandu, nepal. this is a tertiary care referral hospital run by nepali army for the army personnel and their families. the study was initiated after taking approval from institutional research committee (irc/387) of nepalese army institute of health sciences. the patients of both sexes with type 2 diabetes mellitus were included in the study. after obtaining the informed consent, blood samples of patients were collected in edta tubes. known cases of type 2 diabetes were included in the study while cases with secondary diabetes like thyrotoxicosis, cushing’s, exogenous steroid use and cases with hematological disorders like thalassemia and hemolytic anemia were excluded from the study. we measured hba1c levels using both hplc (bio-rad d10) analyzer and immunochromatographic (nycocard) analyzer. hemoglobin was estimated in the horiba penta xlr fully automated hematology analyzer. the sample size was calculated with a 95% confidence level and 10% error of margin taking the expected prevalence of type 2 diabetes in nepal as 9.2%. 8 the formula used is n = z2*p(1-p)/(e)2, where z is level of confidence, p is expected prevalence and e is precision (5%). the statistical level of significance (p) is < 0.05. microsoft excel 2010 was used to analyze the data. linear regressive analysis with correlation coefficient was used to compare hba1c with hemoglobin levels and a p-value <0.05 was considered statistically significant. results total 100 patients with type 2 diabetes mellitus were included in the study. the mean hemoglobin level was found to be 14 ± 2.09 g/dl. the mean hba1c values obtained from nycocard and hplc analyzer were 7 ± 1.95 % and 7.39 ± 2.21% respectively (table 1). there was a strong correlation of hba1c values with hemoglobin levels in hplc methods p=0.001, r=0.6, however, there was no such correlation in nycocard method p=0.6, r=0.08 (figure1and 2). fig. 1 linear regressive analysis of hemoglobin with hba1c measured by nycocard analyzer fig. 2 linear regressive analysis of hemoglobin with hba1c measured by bio-rad d10 analyzer table 1. hba1c results obtained by hplc and nycocard analyzer h e m o g l o b i n levels (g / dl) %hba1c (mean ± sd) p value r value nycocard 2.09 ± 14 1.95 ± 7.7 0.6 0.08 hplc biorad d10 2.09 ± 14 2.21 ± 7.39 0.001 0.6 discussion in our study, we found a strong correlation of hemoglobin levels with hba1c results obtained from the hplc method (p = 0.001, r = 0.6), however, there was no such correlation in nycocard method. iron deficiency anemia is a major public health problem in developing countries like nepal. therefore, the estimation of hba1c by nycocard method has the least interference from hb levels. the estimation of hba1c by hplc method is positively influenced by hemoglobin levels which must be taken into consideration in cases of iron deficiency anemia. any condition that shortens erythrocyte survival or decreases 48 mjsbh vol 21 issue 2 jul-dec 2022 original article variation of hba1c with hemoglobin levels; bhattarai am, et al. mean erythrocyte age (e.g., recovery from acute blood loss, hemolytic anemia) will falsely lower hba1c results regardless of the assay method used.9 the concentration of glycated hemoglobin has been reported to be increased in anemic patients because of increased production of malondialdehye and fructosamine which can be reversed by iron treatment.9 hba1c as a marker of long-term glycemic control must be interpreted with caution, especially in patients with anemia, increased red cell turnover, and transfusion requirements. a study done by roberts et al10 who compared hba1c results from blood samples collected in individuals with hemoglobinopathies, found differences in results in samples with hemoglobin-c trait. similarly, study done by diabetes control and complications trial research group (dcct) have found that the hplc method can misidentify hemoglobin variants that have lost positive charges and carbamylated hemoglobin-s as hba1c.11 a retrospective study done by rekha et al12 in nepal has shown that sickle cell anemia is predominant in tharu ethnic group residing in western nepal and β-thalassemia is predominant among other ethnic groups of nepal. in a study done by marchand et al in dang district of nepal there was a high prevalence (9.3%) of sickle cell disease13. we conclude from our study that estimation of hba1c by hplc may be influenced by hemoglobin variants, but other methods such as nycocard may help to measure the hba1c levels accurately but do not allow the identification of hemoglobin variants.14 the limitation of our study are small sample size and based on participants from a single center. it would be desirable to conduct larger, multi centric study to find out the exact influence of hemoglobin and its variants in hba1c estimation. conclusions the hba1c estimation with hplc method may show decrease in hba1c by positively correlating with decreased hemoglobin levels. however, alternative self-monitoring of blood glucose levels, glycated serum albumin and serum fructosamine must be considered in such cases to find the exact hba1c values. references 1. nasir nm, thevarajah m, yean cy. hemoglobin variants detected by hemoglobin a1c (hba1c) analysis and the effects on hba1c measurements. int j diabetes dev ctries. 2010;30(2):86-90. doi: 10.4103/0973-3930.62598. 2. behan kj, storey nm, lee hk. reporting variant hemoglobins discovered during hemoglobin a1c analysis common practices in clinical laboratories. clin chim acta. 2009; 406(1-2):124-8. doi:10.1016/j.cca.2009.06.012. 3. john wg. glycated haemoglobin analysis. ann clin biochem. 1997;34 ( pt 1):17-31. doi: 10.1177/000456329703400105. 4. sacks db. hemoglobin variants and hemoglobin a1c analysis: problem solved? clin chem. 2003;49(8):1245-7. doi: 10.1373/49.8.1245. 5. shapiro r, mcmanus mj, zalut c, bunn hf. sites of nonenzymatic glycosylation of human hemoglobin a. j biol chem. 1980;255(7):3120-7. doi:10.1016/0026-0495(79)90050-7 6. gillery p, hue g, bordas-fonfrede m, chapelle jp, drouin p, levy-marchal c, et al. hemoglobin a1c determination and hemoglobinopathies: problems and strategies. ann biol clin (paris). 2000;58(4):425-9. pmid: 10932042. 7. shrestha n, mishra sr, ghimire s, gyawali b, mehata s. burden of diabetes and prediabetes in nepal: a systematic review and meta-analysis. diabetes therapy. 2020 jul 25:1-2. doi: 10.1007/s13300-020-00884-0. 8. sundaram rc, selvaraj n, vijayan g, bobby z, hamide a, rattina dasse n. increased plasma malondialdehyde and fructosamine in iron deficiency anemia: effect of treatment. biomed pharmacother. 2007 dec;61(10):682-5. doi: 10.3748/wjg.v13.i5.796 9. goldstein de, little rr, lorenz ra, malone ji, nathan d, peterson cm: american diabetes association technical review on tests of glycemia. diabetes care 1995; 18:896909. doi: 10.2337/diacare.27.7.1761 10. roberts wl, frank el, moulton l, papadea c, noffsinger jk, ou cn. effects of nine hemoglobin variants on five glycohemoglobin methods. clin chem. 2000;46(4):569-72. pmid: 10759485. 11. diabetes control and complications trial research group; nathan dm, genuth s, lachin j, cleary p, et al. the effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. n engl j med. 1993;329(14):977-86. doi: 10.1056/nejm199309303291401. 12. shrestha rm, pandit r, yadav uk, das r, yadav bk, upreti hc. distribution of hemoglobinopathy in nepalese population. j nepal health res counc. 2020;18(1):52-8. doi: https://doi.org/10.33314/jnhrc.v18i1.2303. 13. marchand m, gill c, malhotra ak, bell c, busto e, mckeown md, et al. the assessment and sustainable management of sickle cell disease in the indigenous tharu population of nepal. hemoglobin. 2017;41(4-6):278-82. doi:10.1080/03630269.2017.1414058. 14. jung cl, kwon kj, hong ks, sung ya, lee st, ki cs, et al. hemoglobin yamagata: hemoglobin variant detected by hba1c test. korean j lab med. 2009;29(6):53640. doi:10.3343/kjlm.2009.29.6.536. medical journal of birendra hospital.indd case report january-june, 2010/vol 9/issue 1 medical journal of shree birendra hospital28 sub mucous cleft palate and its diagnosis and management pradhan b1 1bhawani pradhan, speech pathology & audiologist, shree birendra hospital, chhauni abstract four different age groups of cases came to hospital with the complaint of severely nasalized speech and since childhood. parents had already consulted to the physician in one of the valley hospital who referred the patient for speech therapy without a clinical diagnosed as sub mucous cleft (smc). speech pathologist has to confirm of sub mucous cleft palate with the help of the plastic surgeon. sub mucous cleft palate is a significant cause of severs speech and language disorder. aim of the paper is to make the clinician and laymen aware of the sub mucous cleft palate which is less commonly diagnosed partly due to ignorance and misdiagnosis. sub mucous cleft is the cleft of muscle and bony portion of palate it has got triad characters:bifid uvular, thin bluish line in the margin raphe (septum palludine) & hyper nasality. and we could feel palpable sign and speech and language disorder. it may have also lots of related problems like mental retarted, hearing loss, behavior problems etc. sub mucous cleft, is diagnosed and management by team approach like plastic surgeon, e.n.t. surgeon, dental surgeon, sp & lag pathologist and audiologist etc. speech therapy is the one of the essential area for their better quality of life after surgery. address for correspondence: pradhanbh@yahoo.com introduction sub mucous cleft palate is characterized by triad characters:bifi d uvular, thin bluish line in the margin raphe (septum palludine) & hyper nasality and also speech and language1. s.m.c is generally confused & ignored by clinician & parents until they prominently shown their speech & language problem. some of them need to have surgery & speech therapy and some them need only speech therapy. they can be diagnosed & managed by team approach speech therapy is one of most essential area for their better quality of life after surgery. clinical feature of smc anatomically they must have got bifi d uvular, thin bluish line in mid line soft palate, also seen bony notch in hard palate, attenuation of mid line raphe1. and we could also see in function abnormalities like palpable sigh in hard palate, nasalized speech & audible nasal air emission too. most important is speech & language disorder. case report four different age group of cases(w-7/m, x-8y/f, y-10y/m & z-13y/f) came with the complaint of speech & language defect since childhood. some of them also complaining about car discharge & diminished hearing. some of then having positive family history some of them not. they were found that hard palate shown to be normal but soft palate shown to be normal but soft palate shown thin bluish line in middle & bifi d uvula. their voice & respiration was normal but resonance was hyper & defect of articulation. all of them consulted to different hospital for about their speech problems. all the physician directly refer medical journal of shree birendra hospital 29 to speech therapy without diagnosis. lastly they were conform diagnosis by plastic surgeon. after that they went under surgery. then speech therapy was taken. this shows markedly improvement by taking speech therapy. discussion calnan (1954) has given triad sign of sub muscous cleft palate that is bony notch in hard palate, thin bluish line in mid line of soft palate and bifi d uvula which is easy to recognized about the sub mucous cleft palate1. pennbeker (1984) has done 25 years of research about language ability of cleft palate which was found that language ability of this child tend to reduced due to hearing loss, lacks of exposure in outer environments and introverts nature and frequent visited in hospitals etc2. trost-cord manes (1990)found that cleft palate children tend to have velopharyngeal incompetence (v.p.i.) which leads to inability to sustain intra oral air pressure which can't balance between oral & nasal air fl ow during speech3. and also affects for feeding due to diffi cult to produce negative pressure during feeding. mc william (1993) found that cleft palate children tend to have low language ability due to tensor palatine muscles defect which leads to otitis media and hearing loss, because of hearing loss children tend to have low language ability4. related disorder feeding problems: this problems are very common in infant stage of sub mucous cleft children. (w.b.jones) among them are choking, excessive are intake requiring several burping, inability to create suffi cient suction to pull milk from nipple, nasal reguargiation and slowness to complete feeding (arvedson 1992)5, (all 4 cases found that nasal regurgitation) e.n.t and hearing problems: because of otitis media occurs more frequently in individual with sub mucous cleft need consistent e.n.t. check up6. hearing loss is frequently common for these cases so audio logical consultation is also critical. (2 cases found that otitis media & mild hearing loss and 2 cases found that normal ear condition) dental and orthodontic: complication related to cleft cases is also common so it required careful coordination between orthodontic and surgical management of lip, palate and alveolar ridge5. (all cases found that dental problems) psychological problems: it may occur among children, teems and adult with sub mucous cleft as they face the same challgenge in life as anyone else, plus some challenge unique to their condition, there were some people who adopt well to their condition they will survive as normal life with other hand who developed low self esteem and dissatisfaction with their communication defects7. (2 younger cases shown to be normal psychological condition and social adjustment but rest two adolescent shown to be little bit shy and introvert nature & didn't want to interact with other peer group.) speech and language problems sub mucous cleft children are prone to have speech and language inadequacy and severe problems delay speech. language acquired is quite common for these children for 3-4 years. some children we fi nds language deviant, however their language is normal still their speech characters are very effective7. they tend to have hoarseness of voice due to excessive pressure in larynx. faulty placement of articulators is very common so they will have severe misarticulation duet to faulty learning & compensation articulation. and most common & remarkably fi nd hyper resonance speech which their speech heard as nasalized speech. (all of them found to be nasalized speech and severe articulation defect.) speech & language disorder velopharyngeal dysfunction: includes hyper nasal resonance and nasal distortion of pressure consonant caused by inability to sustain and control of intra oral air pressure the result in inadequate balance of oral and nasal air pressure during speaking. velopharyngeral dysfunctions of these children are main caused by structure defect 8. phonationresonance a lack of coordination in the timing of respiratory, larynges, articulators and velopharyngeral system may give perception of hyper nasality and slow the speaking rate in speakers with velopharyngeral incompetence8. other symptom that may develop either from inadequacy control of air pressure due to velopharyngeral dysfunction or from compensatory strategies, include in pitch range use of a soft aspirate voice, monotonous pitch and strangled and hoarseness of bvoice and extremely loud and effortful phonation. (all of them have hyper resonance and hoarseness of voice) medical journal of shree birendra hospital30 articulation problems either due to structural defect or faulty learning if they are repairing al late age they tend to have articulation disorder. substitution of articulation and glottal stop, distortion and omission are very common for these cases9 (all of them have severe matriculation like glottal stop, substation of sound etc.) language disorder although not as common as speech disorder delay early language development is possible, children with sub mucous cleft. generally present normal receptive language development severe factor hover may cause with sub mucous cleft shows poor expression7 (all of them have normal language level). diagnosis the team approach to evaluating and treating cleft palate is most important. there is interdisciplinary and transdisciplinery is more common, in this team includes surgeon, pediatrician, dietician, dentist, psychiatrics & psychologist, speech and language pathologist & audiologist and parents, school teachers, social workers etc10. all team members are equally responsible for evaluating and treatment for cleft palate and sub mucous children11. speech and language pathologist: is responsible for monitoring and screening all areas of speech and language in clients with cleft lip/palate and sub mucous cleft. ealuating procedure may be classifi ed as screening to determine the need for in depth evaluation, diagnosis evaluation and programming evaluation to identify therapy objectives, effective therapy procedure and the probable prognosis and program assessment to determine effectiveness of treatment, speech and language pathologist may be the recognize the possible syndromes12. other client and family plays vital roles in the team decision making process and including the family as team members. parents and client education about cleft palate is an important components of the treatment process. treatment all team members are responsible for their treatment and management. they does their treatments respectably to their areas. speech and language pathologist provides treatment for language delay development, resonance problems, articulation disorder and compensatory articulation like glottal stop and hoarseness of voice1. children with sub mucous cleft are at high risk for developing speech and language disorder or delay. therefore preventing the development of language delay or compensatory articulation error such as glottal stop are high priorities during the preschool year. parents and other primary care givers is primary provider of language stimulation for children with sub mucous cleft1. clinician provides information and suggestion about language stimulation activities. if language delay of disorder found formal language therapy is identifi ed, then parents and clinician should work as team. family education about strategies for stimulation and languages development is an important aspect of comprehensive treatment for child with sub mucous cleft. the parents, members of the health care team and school personnel's should cooperate is effort to build the child self esteem and self confi dent13, because behaviors is an important variables in peer acceptance, they should set the behavior expectation for the child with sub mucous cleft as for any other child. conclusion sub mucous cleft(s.m.c) palate is seems to be less common may be due to improper diagnosis or over looked by physicians with or without speech problems. but s.m.c is the signifi cant cause for speech & language problem & most of them tend to have hyper resounance s.m.c. is manage by team approach like surgeon, pediatrician, audiologist & speech & language pathologist and speech therapy is one of the essentials for their better quality of life after surgery. references 1. croft c.b. shprintzen, r.j. daniller. a. and lewin, m.l. the occults sub mucous cleft palate and muscular uvular, cleft palate journal vol 15, no 2150-154 (1997). 2. mc. willeams, b.j. cleft palate, in shameer, g. and w, gg.e.)eds) communication disorders p.p.330369). columbus, oh: charles e. mersell, 1982 b. 3. pennbecker m. language abilities of individuals with cleft palate: implication for intervention, paper presented at the annual meeting of the texas speech language hearing association, hauston, txfebruary 1989. medical journal of shree birendra hospital 31 4. seltor r.l. hahn e. & morris h.l. diagnosis & therapy. in spriestesback, d.c. and sherman, d(eds) cleft palate & communication. pp 225-268, new york, academic press 1968. 5. arvedson, j.c. infant oral – motor function and feeding. in brodsky, hall, l. and ritter schmida. d.h.(eds), cranio facial anomalies, an interdisciplinary approach, pp. 188-195, louis c.v. morby. 6. van dr and hardin. m.d speech therapy for the child with cleft lip & palate, in bordach, j. and morris h.l.(eds) multidisciplinary management of cleft lip & palate pp 799-806. philadelphia w.b. saunders company 1990. 7. bevis r.c. orthodontic diagnosis and treatment procedures, in moller, k.t and star c.d.(eds) cleft palate interdisciplinary issues and treatment pp 121-144. austin tx pro-ed 1993. 8. bluesstones c.d and klein, j.o.otitis media in infant and children, philadelphia, p.p: ww.b.saunders company 1988. 9. borley, e.c. technique, for articulatory disorders spring fi eld, ii: charle c. tomes, 1981. 10. broen, p.p. doyle, s.s. and bacon, c.k. the velopharyngeally inadequate child phonologic, change with intervention, cleft palate – caniofacial journal, vol 30, no 5:500-507 ( 1993). 11. bzoch k.c (eds) communication disorder, rrlated to cleft lip and palate boston's college hill 1981. 12. golding – kushner, k.j. treatment and resonance disorders associated with cleft palate and v.p.i in shprintzen, r.j. and bardah. j(eds) cleft palate speech amangement. a multidisciplinary approach p.p 327-351, st lousis c.v. morby, 1995. 13. trost – cardamane, j.e. the development of speech: assessing cleft palate misarticulations. in kernahan, d.a. and rosenstein, cleft lip and palate: a system of management, pp. 227-235, baltimore: williams and wilkins, 1990b. medical journal of birendra hospital.indd case reportjanuary-june, 2010/vol 9/issue 1 medical journal of shree birendra hospital 19 anaesthetic management of a case of pheochromocytoma panta s1, rai s2, kc nb3 1sunita panta, anaesthesiologist, 2shashi rai, consultanat anaesthesiologist, 3nagendra bahadur kc, consultant anaesthesiologist, shree birendra hospital, chhauni abstract pheochromocytoma is rare, accounting for less than 0.1 % of hypertensive population. in this report, we describe a 40-year-old male a diagnosed case of pheochromocytoma who underwent adrenalectomy under general anaesthesia with epidural analgesia. the patient was adequately prepared with alpha adrenergic blockers. intraoperative course was stormy but was managed with antihypertensives, inotropes and intravenous fluid. the patient was electively ventilated overnight and had an uncomplicated recovery. pheochromocytoma is a rare medical condition and an anaesthesiologist comes across it only a few times in his or her practice. therefore there is a limited exposure in management. furthermore hemodynamic instability encountered intra and postoperatively itself is a challenge. hence management of a case of pheochromocytoma demands a meticulous preoperative preparation, advanced monitoring devices and good interdepartment coordination preferably in a tertiary medical center for a favourable outcome. key words: haemodynamic instability, inotropes, pheochromocytoma, sodium nitroprusside. address for correspondence: sunitapanta@gmail.com case history a 40 year old male weighing 65 kg was diagnosed 2 months back as a case of pheochromocytoma. he presented with headache, sweating and palpitation along with hypertension. he was on treatment for 1year with tablet prazosin 7.5 mg. twice daily, tablet aquazide 25 mg once daily and tablet amlodipine at once daily. he was now posted for laparotomy and excision of the tumor. on examination, he was alert, afebrile and cooperative. pulse rate was 63/minute, regular and good volume. blood pressure recording over right upper limb was 150/90 mm hg in supine and 140/80 mm hg in standing position. systemic examination and airway assessment revealed no abnormality. investigations revealed a hb-12 gm %, fbs122mg/dl. electrocardiogram showed left ventricular hypertrophy. echocardiogram revealed concentric left ventricular hypertrophy with ejection fraction of 60%. mri showed lt adrenal mass. renal ct angiogram revealed lt adrenal mass and lt renal artery stenosis. suspecting pheochromocytoma specifi c tests were carried out which were positive only in the second time. 24 hour urinary catecholamines 625 mcg/day (normal 0275) vma-26.53mg% (normal<13.6) and metanephrines 1.83 mg/day ( normal <1.0). anaesthetic management pre operative preparation with alpha blocker prazosin, amlodipine and aquazide ensured adequate control of hemodynamic status. patient was given tablet diazepam 10 mg on the previous night and on morning of the surgery and was kept fasting overnight. adequate blood was arranged. medical journal of shree birendra hospital20 in the operation theater pulse oximeter, ecg and nibp were connected for monitoring. 16g intravenous cannula was inserted over right forearm and 20g cannula over left radial artery for invasive monitoring. the patient was then positioned in sitting position and 18g epidural catheter inserted in t9t10 space. for confi rmation of epidural cannulation 2% plain xylocaine was injected and adrenaline was avoided. for analgesia 50 mcg of fentanyl in 10 cc normal saline was injected through the epidural catheter. foley’s urinary catheter was inserted after induction. this was followed by cannulation of right subclavian vein for cvp monitoring, fl uid and drug administration. after pre oxygenation, the patient was induced with midazolam 2 mg, xylocard 40 mg, fentanyl 150 mcg and propofol 140 mg. he was intubated with 7.5 mm cuffed oral endotracheal tube with rocuronium 50 mg iv. the blood pressure shot up to 180/100 mm hg which was managed by esmolol 30 mg in divided doses. anesthesia was maintained with oxygen, vecuronium, fentanyl, midazolam, isofl urane, titrated doses of sodium nitroprusside and epidural bupivacaine in regular intervals. during intra operative handling of tumor there was a sudden surge of blood pressure with tachycardia which was managed by stepping up the dose of snp, i.v boluses of xylocard and increasing the depth of anesthesia. after ligation of the tumor there was severe refractory hypotension, which was managed initially by colloids and incremental doses of norepinephrine. a very high dose of norepinephrine infusion was required to combat the hypotension. after the surgery the patient was put on elective ventilation on cmv mode overnight in the post operative ward. norepinephrine was gradually tapered. fluctuation in blood glucose levels were managed with insulin and dextrose. analgesia was maintained via epidural catheter with top up doses of bupivacaine. patient was extubated next morning. the further course was uneventful. patient was discharged home days later. the biopsy report confi rmed the diagnosis of pheochromocytoma. discussion in 1886, fränkel made the fi rst description of a patient with pheochromocytoma however the term was fi rst coined by ludwig pick, a pathologist, in 1912. in 1926, roux (in switzerland) and mayo (in u.s.a.) were the fi rst surgeons to remove pheochromocytomas. a phaeochromocytoma (pcc) or pheochromocytoma, is a neuroendocrine tumor of the medulla of the adrenal glands (originating in the chromaffi n cells), or extra-adrenal chromaffi n tissue that failed to involute after birth and secretes excessive amounts of catecholamines. extra-adrenal pheochromocytomas (paragangliomas) are closely related, though less common, tumors that originate in the ganglia of the sympathetic nervous system and are named based upon the primary anatomical site of origin. incidence pheochromocytoma is seen in between 2-8 in 1,000,000 with approximately 1000 cases diagnosed in united states yearly. it mostly occurs in young or middle age adults, though presents earlier in hereditary cases. these tumors can form a pattern with other endocrine gland cancers which is labeled multiple endocrine neoplasia (men). pheochromocytoma may occur in patients with men 2 and men 3 (men 2b). in adults, approximately 80% of pheochromocytomas are unilateral and solitary, 10% are bilateral, and 10% are extra-adrenal. the tumors are made up of large, polyhedral, pleomorphic chromaffi n cells. fewer that 10% of these are malignant. local invasion of surrounding tissues or distant metastases indicate malignancy. clinical features the signs and symptoms of a pheochromocytoma are those of sympathetic nervous system hyperactivity including: skin sensations, fl ank pain, hypertension, photograph of adrenal mass and kidney medical journal of shree birendra hospital 21 palpitations, anxiety diaphoresis, headaches and hyperglycaemia. a pheochromocytoma can also cause resistant hypertension. the most common presentation is paroxysms of headache, diaphoresis and palpitations. patients experiencing symptoms associated with pheochromocytoma should be aware that it is rare. however, it often goes undiagnosed until autopsy therefore patients might wisely choose to take steps to provide a physician with important clues, such as recording whether blood pressure changes signifi cantly during episodes of apparent anxiety. diagnosis the diagnosis can be established by measuring catecholamines and metanephrines in plasma or through a 24-hour urine collection. care should be taken to rule out other causes of adrenergic excess like hypoglycemia, stress, exercise, and drugs affecting the catecholamines (methyldopa, dopamine agonists, or ganglion blocking antihypertensives). various foodstuffs (e.g. vanilla ice cream) can also affect the levels of urinary metanephrine and vma (vanillylmandelic acid). imaging by computed tomography or a t2 weighted mri of the head, neck, and chest, and abdomen can help localize the tumor. tumors can also be located using iodine-123 meta-iodobenzylguanidine (i123 mibg) imaging. diff erential diagnosis the differential diagnosis of pheochromocytoma includes: anxiety disorders, paragangliomas essential hypertension, renovascular hypertension and carcinoid syndrome. treatment surgical resection of the tumor is the treatment of fi rst choice, either by open laparotomy or else laparoscopy. given the complexity of perioperative management, and the potential for catastrophic intra and postoperative complications, such surgery should be performed only at centers experienced in the management of this disorder. in addition to the surgical expertise that such centers can provide, they will also have the necessary endocrine and anesthesia resources. preoperative preparation either surgical option requires prior treatment with the non-specifi c and irreversible alpha adrenoceptor blocker (phenoxybenzamine). doing so permits the surgery to proceed while minimizing the likelihood of severe intraoperative hypertension. some authorities would recommend that a combined alpha/beta blocker such as labetalol also be given in order to slow the heart rate. regardless, a "pure" beta blocker such as atenolol must never be used in the presence of a pheochromocytoma due to the risk of such treatment leading to unopposed alpha agonism and, thus, severe and potentially refractory hypertension. the patient with pheochromocytoma is invariably volume depleted. in other words, the chronically elevated adrenergic state characteristic of an untreated pheochromocytoma leads to near-total inhibition of reninangiotensin activity, resulting in excessive fl uid loss in the urine and thus reduced blood volume. hence, once the pheochromocytoma has been resected, thereby removing the major source of circulating catecholamines, a situation arises where there is both very low sympathetic activity and volume depletion. this can result in profound hypotension. therefore, it is usually advised to "salt load" pheochromocytoma patients before their surgery. this may consist of simple interventions such as consumption of high salt food pre-operatively, direct salt replacement or through the administration of intravenous saline solution. the anaesthetic management of a patient with pheochromocytoma requires consideration in following points: • preoperative preparation with adrenergic blocking agents. • use of an anaesthetic agent which is not associated with release of endogenous catecholamines and does not sensitize the myocardium to high levels of circulating catecholamines. • adequate fl uid and blood administration, including preoperative transfusion if necessary. • careful monitoring during surgery, including direct arterial pressure, central venous pressure, electrocardiogram, urinary output, and blood gas determinations. • ready availability of all pharmacological agents appropriate for the control of hypertension, hypotension, and cardiac arrhythmias. to help assess the adequacy of preoperative management of pheochromocytoma, the following roizen criteria1 should be met in order to reduce perioperative morbidity and mortality: • no in-hospital blood pressure >160/90 mm hg for 24 hours prior to surgery. medical journal of shree birendra hospital22 • no orthostatic hypotension with blood pressure <80/45 mm hg. • no st or t wave changes for 1 week prior to surgery. • no more than 5 premature ventricular contractions per minute. in our case report, the patient was adequately prepared with prazosin and amtas and aquazide and he met all the parameters of roizen criteria. he was premedicated with diazepam before the surgery. there are reports suggesting the dangers of using drugs like morphine and atracurium which potentially release histamine because of the risk of provoking catecholamine release from chromaffi n granules2. choice of anaesthesia the combination of adequate regional anesthesia with general anesthesia provides satisfactory conditions for the initial surgical incision and exposure of the tumor. we chose to insert the epidural catheter also under local anesthesia before induction. test dose was given only with 2% plain lignocaine. adrenaline was avoided even in test dose for epidural catheter. a segmental blockade was achieved at mid to low thoracic level. monitoring peripheral venous, arterial and central venous catheters were placed under local anesthesia and hemodynamic monitoring was established together with ecg and pulse oximeter. however invasive arterial blood pressure monitoring was not possible due to machinery error. extensive monitoring is required for such surgeries to monitor both the hypertensive crises and the post ligation hypotensive episodes. manipulation of the tumor, however gently performed, usually causes a brisk hemodynamic response. drugs to combat haemodynamic alteration intraoperatively, intravenous phentolamine, nitroglycerin and sodium nitroprusside are most often used to control blood pressure swings. hull claimed that phentolamine is less satisfactory because tachycardia is an invariable problem3. we decided to use snp to manage the intraoperative hypertension as there was ample evidence that snp has been successfully used4,5,6. the most widely quoted alternative to snp is phentolamine, a competitive 1and weak 2-adrenoceptor antagonist, which can be given intravenously as an infusion or as incremental doses of 1–2 mg. just prior to venous ligation of the tumor, anticipating hypotension, low dose dopamine was started along with volume loading and tapering of snp. postoperative care the main postoperative complication of surgery for pheochromocytoma is persistent arterial hypotension which may be refractory to intravascular volume replacement and adrenoceptor agonists. our patient responded to dopamine infusion which was later tapered and fi nally weaned off after 2days. our patient also developed hypoglycemia during the post operative period and had to be given dextrose infusions. this hypoglycemia is due to the excessive rebound secretion of insulin after the removal of catecholamine secreting pheochromocytoma7,8. conclusion pheochromocytoma constitutes only a small fraction of hypertensive patients. many of these cases remain undiagnosed. an anaesthesiologist may encounter these cases only a few times in practice. therefore even though many of us are aware of the management aspect academically handling such a situation may be very diffi cult. preoperative preparation of the patients is of utmost importance. the management of patients with pheochromocytoma remains a challenge for the anesthesiologist despite the advent of new drugs and techniques. our role in the successful outcome of such surgeries begins from adequate pre operative preparation, extensive intra operative monitoring and careful follow up during post operative period. prognosis is usually good if the tumor is detected early to avoid major complications related to catecholamine excess. references 1. roizen mf, horrigan rw, koike m, eger, ie. a prospective randomized trial of four anesthetic techniques for resection of pheochromocytoma. anesthesiology. 1982; 57: a 43. 2. c. prys-roberts. phaeochromocytoma—recent progress in its management. br j anaesth 2000; vol. 85, no. 1: 44-57. 3. hull cj. phaeochromocytoma: diagnosis, pre-operative preparation, and anaesthetic management. br j anaesth 1986; 58: 1453–68. medical journal of shree birendra hospital 23 4. brown br jr. anaesthesia for phaeochromocytoma. international practice of anaesthesia. oxford: butterworth heinemann, 1996; 1/83/1–7. 5. munro j, hurlbert bj, hill ge. calcium channel blockade and uncontrolled blood pressure during phaeochromocytoma surgery. can j anaesth 1995; 42: 228–30. 6. tjeuw m, fong j. anaesthetic management of a patient with a single ventricle and pheochromocytoma. anaesth intens care 1990; 18: 567–9. 7. g. e. wilkins, n. schmidt, and w. a. doll. hypoglycemia following excision of pheochromocytoma. can med assoc j. 1977 february 19; 116(4): 367–368. 8. masako a, takaya k, yukio i, takao o, yoshihide f. hypoglycemia induced by excessive rebound secretion of insulin after removal of pheochromocytoma. world j. surg. 1990; 14: 317324. 31civil med j | vol 01 | issue 01 | jan, 2023 original article mjsbh vol 21 issue 2 jul-dec 2022 experience of patients with services in hospitals; khatri p, et al. perceived experience of old adult patients with services provided in the tertiary level hospitals in kathmandu: a cross-sectional study 1 manmohan cardiothoracic transplant center, kathmandu, nepal 2 associate professor, maharajgunj nursing campus, institute of medicine, maharajgunj, kathmandu, nepal 3 research officer, research department, institute of medicine, maharajgunj, kathmandu, nepal pratima khatri,1 muna sharma,2 shreejana singh3 the old adult is an emerging issue, not only globally but also in developing countries like nepal. globally the proportion of old adults is growing at a faster rate than the general population,1 it was estimated by unfpa in 2012 that the ratio of one old adult in five persons will be projected by 2050.2 similarly, in the southeast asian region (sear), old adult people above 60 years was 9.8% in 2017, and it is estimated to be increased by 13.7% and 20.3% by 2030 and 2050 respectively. likewise, nepal government identifies the old adults above the age of 60 years.3 as per nepal 2011 census, old age people above the age of 60 years were 8.1% of the 26,494,504 total population.4,5 the old adult population grew steadily at the rate of 3.8 % per year which was three times higher than the annual population growth rate of 1.4% in our country.1 the old adult age is a period where people have multiple chronic health problems due to compromised physical, physiological, and economic functions.6 therefore, they need to be supported especially in the aspect of health and wellbeing. old people have multiple health issues during their increasing old age. due to rapid decline in fertility, adult population globally tend to be increasing original article introduction introduction: most old adults are vulnerable to multiple non-communicable diseases and need extensive care, treatment and support for a good quality of life. the main objective of this study was to identify the old adult patient’s perceived experience with the care provided in the tertiary level hospitals under the institute of medicine, tribhuvan university, kathmandu, nepal. methods: the cross-sectional study was conducted among 404 old adult patients admitted with non-communicable diseases in two tertiary levels university hospitals in kathmandu, nepal. an interview schedule was conducted with hospitalized old adult patients to collect data using a consecutive sampling technique. results: most participants [208 (51.5%)] were from the age group of 60 to 69 years with a mean age (± sd) of 71.1 (± 9.7) years. one-fourth [103 (25.5%)] of them were financially independent. two hundred thirty-three (57.7%) were admitted with a single diagnosis. two hundred forty (59.4%) participants bore their hospital expenses with out-of-pocket payment, and 40.6% were covered by a third party payment. the majority of them (86.1%) had the experience of finding approachable health personnel in the hospital whereas 82.7% felt that the cost of treatment was higher than expected. 80.4% perceived that access to the hospital service (e.g. getting the outpatient tickets) was user-friendly. however, only 10.9% experienced follow-up visits user friendly. conclusions: the hospitals where this research was done have a relatively high standard of care for old adult patients. old adult-friendly health policy, physical environments of the hospital, and advocacy for them should further be considered in the tertiary level hospitals for the benefit of old adult patients. abstractcorresponding author pratima khatri, manmohan cardiothoracic transplant center, kathmandu, nepal email: pratimakhatri45@gmail.com online access keywords hospital services, old adult patients, perceived experiences, tertiary hospital experience of patients with services in hospitals; khatri p, et al. © the author(s) 2023. this work is licensed under a creative commons attribution 4.0 international license. (cc by-nc) doi: 10.3126/mjsbh.v21i2.49066 received date: 26 oct, 2022 accepted date: 14 mar, 2023 https://creativecommons.org/licenses/by/4.0/ 32 mjsbh vol 21 issue 2 jul-dec 2022 original article experience of patients with services in hospitals; khatri p, et al. and governments all over the world are striving to take care of this population. there has been a significant and remarkable improvement in morbidity and mortality of old age people due to availability of modern health services, a governmental scheme for their senior citizens, improving quality of life, and a large migration of economically active population in the third world countries.  further, wang et al has stated that the impact of ncds has been creating attention in countries where a severely increasing aging population, especially in low and middleincome countries (lmics).7 ncds have even become a barrier to their continued economic development and progress.7,8 ultimately, the mechanism of ncds is linked to the influence of socio-economic factors, the transition of disease burden, and old adult people’s health and wellbeing. these chronic diseases have been affecting the individual not only physically but also affecting their psychological, social, economic, and spiritual health and well-being which directly influences the quality of life of old adult people.9 regarding the hospital services for old adult patients with ncds, it is quite challenging, especially in resource limited countries. in such regions, their status seems more stressful because there is typically no old adult-friendly accommodation such as quiet rooms, lower beds, extra pillows, indirect lighting, and toilet facilities.10 however, hospital systems in developed countries are creating special geriatric emergency departments, wards, and trained geriatric health care providers.11 according to the government policy of nepal, 10% of hospital beds should be allocated for old adult patients in tertiary hospitals. recently, in 2021, nepal government approved a 50% discount has been given to treatment costs of old adult people from certain tertiary level hospitals throughout the country in all seven provinces.12 there are no specialized geriatric health care providers, an old adult-friendly emergency department, wards, and old adult-specific hospitals are available in nepal. however, advocacy for old adult-friendly hospitals and trained human resources has been done by very few local organizations and countable people at the private level. however, the research regarding the services for the old people’s health problems and their perception has not been adequately done in our region. hence, this study was conceived to study the perceived experience of old nepali population in their health services in a tertiary level care teaching hospital in kathmandu, nepal. methods  a cross-sectional study among 404 old adult patients admitted with ncd’s in two tertiary care levels university hospitals were included in the study. the population of this study was the old adult patients (≥ 60 years) admitted to manmohan cardiothoracic vascular and transplant center and tribhuvan university teaching hospital, maharajgunj, kathmandu, nepal with a diagnosis of ncds including cardiovascular and respiratory, gynecological, cancer, musculoskeletal, gastrointestinal, neurological, renal, and endocrine diseases etc. the sample size was calculated by using the crochan infinite standard formula with a precision of error allowing 0.05 with a prevalence of 50% and a non-response rate of 5% (20). an interview schedule was conducted with hospitalized old adult patients to collect data in kathmandu, nepal, using a consecutive sampling technique. while collecting data ten old adult patients discontinued the interview schedule. results  most of the participants [208 (51.5%)] were from the age group of 60 to 69 years with mean age (± sd) of 71.1 (± 9.7) years. one hundred three (25.5%) old adult patients admitted to the hospital were financially independent. table 1old adult patients’ disease related characteristics n = 404 variables number percentage *diseases cardiovascular problems 233 57.7 respiratory problems 97 24.0 gynecological problems 71 17.6 musculoskeletal problems 51 12.6 gastrointestinal problems 44 10.9 cancer 23 5.7 neurological problems 21 5.2 renal problems 20 5.0 endocrine problems 13 3.2 number of morbid conditions only one disease two diseases three or more disease 233 102 69 57.7 25.2 17.1 payment methods for treatment out of pocket payment third party payment 240 164 59.4 40.6 (third party payment (n = 164 health insurance rheumatic heart diseases fund ((rhdf senior citizen fund for heart dis (eases (scfhd 130 18 16 79.3 10.9 9.8 *multiple response item most of the old adult patients (57.7%) had cardiovascular 33civil med j | vol 01 | issue 01 | jan, 2023 original article mjsbh vol 21 issue 2 jul-dec 2022 experience of patients with services in hospitals; khatri p, et al. diseases followed by respiratory (24.0%), and gynecological problems (17.6%), musculoskeletal (12.6%), gastrointestinal problems (10.9%), cancer (5.7%), neurological problems (5.2%), renal problems (5.0%), and endocrine problems (3.2%). two hundred thirty-three old adult patients (57.7%) were admitted with a single non-communicable disease with no comorbid condition and 42.3% had two or more comorbid conditions. two hundred fourty (59.4%) old adult patients paid their treatment expenses of the hospital with out-ofpocket payment, 40.6% of old adult patient’s treatment expenses was covered by third party payment such as health insurance (79.3%), rheumatic heart diseases fund (10.9%), and senior citizen assistance fund (9.8%) as depicted in table 1. table 2 old adult patients’ perceived experiences with health services n = 404 *variables number percentage approachable health personal in hospital 348 86.1 costly treatment 334 82.7 easily access to opd ticket 325 80.4 impossible to access treatment from hospital coming alone by old .adult 317 78.5 easily available doctors 304 75.2 received early treatment when reached to hospital 286 70.8 feeling irritate while in staying on queue 271 67.1 easily access to bed for admission 232 57.4 no need to stay on queue for old adult patients 126 31.2 easy treatment modality 67 16.6 accessible regular checkup 44 10.9 *multiple response question the majority of old adult patients (86.1%) experienced approachable health personnel in the hospital. similarly, 82.7% felt that the health care cost for their diseases as expensive, 80.4% had felt that there was easy access to tickets for the hospital service. however, only 31.2% of old adult patients experience no need to stay in the queue for services, 16.6% experienced easy treatment modalities, and 10.9% experienced accessible followup health services delivered through hospitals shown in table 2. discussion the findings of this study have been based on the information collected from old adult patients, who were admitted to the tertiary level hospitals with diagnosed various ncds. this study explored the perceived experiences of old adult patients, which revealed their perception of the hospitals’ services during their hospitalization. the findings revealed the majority of old adult patients with non-communicable diseases admitted to hospitals were due to cardiovascular problems, followed by the respiratory problem. global, as well as the national scenario of leading ncds, were cardiovascular and respiratory.13 ncds were high prevalence among old adult patients in other studies too.1,14 hence, the government should focus more on ncd’s. especially, cardiovascular and respiratory diseases, for making the adult population healthier and reduce the burden of ncds in the old age. this study highlighted that most the old adult patients perceived experiences of approachable health personnel (nurses and doctors) in hospitals. this is an encouraging finding for health care personnels. old adult patients were satisfied with nurses’ and doctors’ behavior in the hospital, which is similar to the finding of a qualitative study done by karki et al.14 similarly, a previous systematic review and an experimental study revealed that the old adult patients are vulnerable to complex health problems and they need frequent support and care to meet their basic needs during hospitalization from health personnel.14,15 although this finding is quite optimisitic, as our research has been conducted in two central hospitals, the findings could not be generalized to the entire population. another study by who in 2007 and legare et al in 2014 suggested that polite behavior of health professionals could be helpful to reduce health problems and psychological support.16 this fact has to be borne in mind by all the health personnels while providing services in their daily routine. the important negative experiences which the general population express were the long queues for the service provision, difficult accessibility of hospital followup services, expensive treatment costs, and difficult treatment modalities.10,11 a previous study by who also expressed these findings in the past. this study has also found similar experience from the study population. in view of limited resource and budgetary constraints, governments in the resource limited countries should be focusing more on managing the health care services in more economical, feasible, accessible, affordable and simpler manners. although this is easier said than done, various factors come into play while providing health care services to the old population, especially in the resource limited countries. this study is relatively new research in this field which has been conducted in two tertiary care hospitals in the capital of our country. this research would be of valuable 34 mjsbh vol 21 issue 2 jul-dec 2022 original article experience of patients with services in hospitals; khatri p, et al. input to people involved in the health care of the old age population in the resource limited set ups. as our study sample size is small, the findings of our study may not be possible to generalize to the entire nation. hence, there should be further larger, multi centric research in this field to get the clearer picture. conclusions majority of the old patients suffered from ncds, especially cardiovascular and respiratory diseases. their perception of services being provided in the tertiary care hospitals were overall satisfactory. governments should focus on minimizing the ncds in their population and they should focus more on provision of safe, easy, effective, and affordable health care system with old adult patient friendly specialized human resources within limited budgetary constraints. references 1. bhandari k. social security system of elderly population in nepal. nuta journal. 2019;6(1-2):18-24. doi: 10.3126/nutaj. v6i1-2.23223. issn: 2616 017x 2. unfpa and helpage international. ageing in the twentyfirst century: a celebration and a challenge. unfpa and help age international. 2012. available from: https://www. helpage.org/global-agewatch/reports/ageing-in-the-21stcentury-a-celebration-and-a-challenge/ 3. senior citizens act, 2063 (2006) – nepal law commission [internet ]. lawcommission.gov.np. 2022 [cited 22 september 2022]. available from: https://lawcommission. gov.np/en/?cat=575 4. central bureau of statistics [cbs]. nepal government. 2014. [internet ]. available from: https://opendatanepal. com/organization/central-bureau-of-statistics 5. adhikari r, upadhaya n, paudel s, pokhrel r, bhandari n, cole l, et al. psychosocial and mental health problems of older people in postearthquake nepal. j aging health 2017;30(6):945-964. doi: 10.1177/0898264317702056 6. ruthsatz m, candeias v. non-communicable disease prevention, nutrition and aging.   acta biomed. 2020 may 11;91(2):379-388. doi: 10.23750/abm.v91i2.9721. pmid: 32420978; pmcid: pmc7569619. 7. wang y, wang j. modelling and prediction of global noncommunicable diseases. bmc public health. 2020;20(1). doi: https://doi.org/10.1186/s12889-020-08890-4 8. world health organization [who]. (2018). noncommunicable diseases. available from: https://www. who.int/news-room/fact-sheets/detail/noncommunicablediseases on 12 february, 2021 9. bigna j, noubiap j. the rising burden of non-communicable diseases in sub-saharan africa. lancet glob. health. 2019;7(10):e1295-e1296. doi: 10.1016/s2214-109x(19)30370-5 10. who.int. 2022. non communicable diseases [internet ]. [cited 22 september 2022]. available from: https://www. who.int/news-room/fact-sheets/detail/noncommunicablediseases 11. who. (2020). ageing and health in the south-east asia region. available from: https://www.who.int/southeastasia/ health-topics/ageing#:~:text=the%20population%20 i n % 2 0 w h o % 2 0 s o u t h , 2 0 3 0 % 2 0 a n d % 2 0 b y % 2 0 2050%2c%20respectively. on 18th january, 2021. 12. the rising nepal. national newspaper. 50% discount for senior citizen. 14th march 2021. available from: https:// risingnepaldaily.com/nation/50discount-for-seniorcitizens. on 21 march 2021 13. who (2015). global age-friendly cities: a guide. world health organization; 2007. available from: http://www. who.int /ageing/publications/global_age_friendly_cities_ guide_english.pdf. on 20th september, 2020. 14. karki s, bhatta dn, aryal ur. older people perspectives on an old adult-friendly hospital environment: an exploratory study. risk manag. healthc. policy. 2015; 8:81–89. doi: https://doi.org/10.2147/risk manag health policy. s83008. 15. hickman l, newton p, halcomb e, chang e, davidson p. best practice interventions to improve the management of older people in acute care settings: a literature review. j adv nurs. . 2007;60(2):113-126. doi: 10.1111/j.1365-2648.2007.04417. 16. légaré f, stacey d, brière n, robitaille h, lord m, desroches s, et al. an interprofessional approach to shared decision making: an exploratory case study with family caregivers of one ip home care team. bmc geriatrics. 2014;14(1). doi: 10.1186/1471-2318-14-83 17. who. (2020). proposed working definition of an older person in africa for the mds project. retrieved from http:// www.who.int/healthinfo/survey/ageingdefnolder/en/ on february 7, 2020 https://www.helpage.org/global-agewatch/reports/ageing-in-the-21st-century-a-celebration-and-a-challenge/ https://www.helpage.org/global-agewatch/reports/ageing-in-the-21st-century-a-celebration-and-a-challenge/ https://www.helpage.org/global-agewatch/reports/ageing-in-the-21st-century-a-celebration-and-a-challenge/ https://lawcommission.gov.np/en/?cat=575 https://lawcommission.gov.np/en/?cat=575 https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases https://risingnepaldaily.com/nation/50-discount-for-senior-citizens.%20on%2021%20march%202021 https://risingnepaldaily.com/nation/50-discount-for-senior-citizens.%20on%2021%20march%202021 https://risingnepaldaily.com/nation/50-discount-for-senior-citizens.%20on%2021%20march%202021 https://doi.org/10.2147/rmhp.s83008 https://doi.org/10.2147/rmhp.s83008 1civil med j | vol 01 | issue 01 | jan, 2023 original article mjsbh vol 21 issue 2 jul-dec 2022 outcomes of paediatric pyeloplasty; praveena s, et al. a retrospective study to analyze the outcomes of paediatric pyeloplasty in poorly functioning kidneys department of urology, nu hospitals, bengaluru, karnataka, india nayan timbadiya j, praveena s, prasanna matippa original article introduction outcomes of paediatric pyeloplasty; praveena s, et al. introduction: pyeloplasty has success rate of up to 98%. we believe that paediatric pyeloplasty even in poorly functioning kidney, will result in maximum salvage of renal function. the aim of our study was to evaluate the outcome of pyeloplasty in poorly functioning kidneys with pujo in the paediatric population. methods: the children with pujo with a gfr < 30 ml / min or < 30% differential function on dtpa, who underwent pyeloplasty in nu hospitals, bengaluru over a period of 11 years 2 months, were included in our retrospective study. anteroposterior diameters (apd) and parenchymal thickness (pt) were assessed at three months. after one year of surgery, they underwent dtpa. outcomes analyzed were febrile uti, the need for secondary procedures, structural and functional outcomes in operated kidneys till one year of follow-up. results: a total of 30 patients with a mean age of four years ± 4 sd (standard deviation) with poor function on dtpa renogram (< 30%) were included in the study. 10 patients (33.33%) had a differential renal function (drf) of 15% or less. pre operative mean pt was 4.7mm, mean apd was 38.5 mm, mean drf was 19.3% and mean gfr was 17.7 ml / min. pt was increased to 6.4mm (± 2.4sd) and apd reduced to a 16.7 mm (± 10 sd) at the end of three months (p < 0.001). increment in drf percentage was 33.2 (± 9.4 sd) and gfr was 33.9 (± 12.5 sd) at the end of one year (p < 0.001). 13.3% of the patients had uti, none of the study subjects required re-intervention within one year. conclusions: the pyeloplasty for pediatric pujo significantly improved the functional outcomes even in poorly functioning kidney, hence we recommend the pyeloplasty for selected pediatric cases of poorly functioning kidney with pujo. abstractcorresponding author praveena s department of urology, nu hospitals, bengaluru, karnataka, india. email: praveenas82@gmail.com online access keywords dtpa renogram, pujo, pyeloplasty pelviureteric junction obstruction (pujo) is the most common form of urological obstruction in children.1 it is reported to occur in 1:500 to 1:1250 live births.2 boys are more commonly affected than girls (65% : 35%). in 60% of cases, left side predilection is seen. the bilateral involvement is seen in 10%. the response to urine flow impairment is renal atrophy due to programmed cell death called apoptosis. it may lead to significant and long standing histological and functional damage to the renal parenchyma.3 the indication for pyeloplasty versus nephrectomy is mainly based on the results of repeated renal ultrasonography (us) and dtpa renogram with % drf, gfr and drainage pattern. nephrectomy is usually recommended if drf is less than 10%. however, recent studies with long-term follow-up indicate that even with an initial drf of less than 10%, a significant improvement of drf may be seen when pyeloplasty is performed so that nephrectomy may not be justified.4 the management of poorly functioning kidneys with ureteropelvic junction obstruction (upjo) is controversial, with some recommending direct nephrectomy and others direct pyeloplasty, and others temporary diversion. the aim of the study was to determine outcomes of pyeloplasty in poorly functioning kidneys. methods the paediatric patients (defined by indian academy © the author(s) 2023. this work is licensed under a creative commons attribution 4.0 international license. (cc by-nc) doi: 10.3126/mjsbh.v21i2.46686 received date: 13 jul, 2022 accepted date: 24 jan, 2023 https://creativecommons.org/licenses/by/4.0/ 2 mjsbh vol 21 issue 2 jul-dec 2022 original article outcomes of paediatric pyeloplasty; praveena s, et al. of paediatrics age group of 18 or less) who had poor renal function and underwent pyeloplasty at our hospital were included in the study.5 it was a bidirectional cohort study. the subjects of retrospective chohort were operated between may 2008 and april 2018, and that of prospective arm were between may 2018 and june 2019. the poor renal function was defined for the purpose of the study as gfr less than 30 ml / min or drf less than 30%. the patients under the age of 18 years with pelvi-ureteric junction block undergoing pyeloplasty with affected kidney gfr of less than 30 ml / min or a differential renal function of less than 30% were included in the study. the children with pyonephrosis, renal failure, solitary kidney, who had already undergone one attempt of pyeloplasty, whose parents / guardians refused to participate in the study or who lost to follow up were excluded from the study. the demographic parameters, the mode of presentation, clinical and laboratory parameters, pre-operative renal parameters including parenchymal thickness, renal ap diameters were recorded by ultrasound of abdomen. the gfr, split renal function and drainage (o’reilly curves) were recorded by dtpa renogram. anderson hynes pyeloplasty and stenting was performed for all the patients via an open or laparoscopic approach, depending upon surgeon’s preference. as per our hospital protocol, follow up ultrasound was done at three months to assess renal pelvis ap diameters and maximum renal parenchymal thickness. the renal size was measured for all the patients’ pre and post operatively but not included as an outcome parameter in our study. ultrasound abdomen was done even at one year as well but ultrasound parameters were looked at three months only as per protocol. after one year of surgery, all patients underwent dtpa renogram at radio diagnostic centre to measure split renal function of the operated kidney and gfr and drainage pattern. dtpa renogram was decided as it was available and to maintain similar standard pre and post operatively. the total injected dose was determined by subtracting the post count from the pre count. the region of interest (roi) was manually drawn on the frame of the kidney, and a semi lunar background was placed around the lower, outer renal margin. after the patient’s weight and height were entered into an online computer, the gfr was automatically calculated by commercially available software according to the gate’s algorithm. though it’s not a standardized method of gfr calculation and also various pitfalls with dtpa renogram, we have calculated gfr based on dtpa as per protocol. the drainage patterns were also recorded by using o’reilly curves. the incidence of febrile urinary tract infection and the need for secondary procedures till the end of one year were noted. at the end of one year, the data was analyzed to evaluate structural and functional outcomes in the form of apd, parenchymal thickness and gfr, drf in the operated kidney respectively. all characteristics were summarized descriptively. for continuous variables, the summary statistics of mean ± sd (standard deviation) were used. chi square test, paired t-test, bivariate correlation analysis was used to analyze and interpret the data in appropriate settings using spss statistical analysis software (version 23.0). the p-value of < 0.05 was considered to be statistically significant. results out of 30 patients, 14 were aged between one to five years, seven were between six to ten years and so on (table 1). the mean age for pyeloplasty was four years ± 4 sd. there was no difference in age at presentation and age at the pyeloplasty because all children had undergone pyeloplasty shortly after the first consultation. the majority of the participants were males (80%). table 1: patient characteristics characteristic number of subjects (in % of total subjects) age < 1 year 6 (20) 1 5 years 14 (46.7) 6 10 years 7 (23.3) 10 years 3 (10) sex male 24 (80) female 6 (20) the range of stenting days were from 14 22 days (mean = 16.7). the mean decrease of apd diameter postoperatively was 16.7 mm with sd of 10.0. (p value = < 0.001). the mean increased parenchymal thickness was up to 6.4 mm with sd of 2.4. (p value = < 0.001). postoperatively, the mean increment in gfr was 33.9 ml / min with sd of 12.5 (p value = < 0.001). the mean increase in the %drf postoperatively was from 19.3% to 33.2% with sd of 9.4. (table 2, figures1 and 2) table 2 : determinants of outcome parameter pre operative post operative p value mean apd in mm 38.5 16.7 < 0.001 mean parenchymal thickness in mm 4.7 6.4 < 0.001 gfr ml/min 17.7 33.9 < 0.001 of drf ipsilater% al kidney 19.3 33.2 < 0.001 3civil med j | vol 01 | issue 01 | jan, 2023 original article mjsbh vol 21 issue 2 jul-dec 2022 outcomes of paediatric pyeloplasty; praveena s, et al. post operatively, the %drf was increased more than 20 in 20% of the patients, between 10 and 20 in 50% patients, between five to ten in 20% and less than five in 6.7% patients. one child showed worsening of drf from 29.5% to 15% (figure 1). pre operatively, all the patients had type-2 curve whereas post operatively all patients had type-3a pattern, one patient showed type3b pattern in dtpa (figure 2). figure 1: distribution of change in drf compared to preoperative values figure 2 : pattern of o’reilly drainage (pre / post operative) discussion pujo is defined as an obstruction to the flow of urine from the renal pelvis to the proximal ureter. as a result of back pressure within the renal pelvis, progressive renal damage and deterioration sets in. the widespread use of ultrasonography and the advent of modern imaging techniques have resulted in earlier diagnosis of pujo. the condition is more frequently encountered in males and on the left side, as noted in the present study. the renal function reserve is the difference between pre-operative and postoperative gfr measurements at one year. this reserve is preserved in children with hydronephrosis, which ultimately contributes to the improvement in renal function after surgery. the goals of management of pujo are to improve urine flow, to prevent further parenchymal damage and to alleviate symptoms. in the literature there are number of studies both in favor and against preservation of poorly functioning kidneys. the earlier trend was to perform nephrectomy for poorly functioning kidneys as the functional improvement with pyeloplasty was questionable.6 moreover the complications like recurrent uti episodes, hypertension, renal dysfunction and re-do surgeries has been reported in the literature for pyeloplasty in those poorly functioning kidneys.7 however, the trend has been changed over the time due to early detection and modified methods of pyeloplasty. the nephrectomies and subsequent complications related with solitary kidney can be avoided in these poorly functioning kidneys. also, early pyeloplasty may result in better structural and functional outcomes and maximum salvage of the poorly functioning kidneys.8 pyeloplasty is followed by an improvement in the renal dilatation, renal parenchymal thickness, gfr, %drf and excretion pattern in up to 98% of patients.9 the nephrectomy can be opted for poorly functioning kidney to prevent long term sequelae. in 1985, mcanena oj et al10 studied role of nephrectomies in poorly functioning kidneys. in 2012 datta b et al6 and daradka i et al 11 did nephrectomies for poorly functioning kidneys due to recurrent uti, persistent hypertension and symptomatic puj block. on the other side, pyeloplasty in poorly functioning kidney may be associated with immediate and long-term complications. the patient may need redo surgery for recurrent block. the recurrent pain, uti episodes, chronic hypertension and renal dysfunction were reported in the literature with pyeloplasty.7,12 lee he et al7 analyzed 55 patients who were followed up for at least 10 years and follow-up data available were analyzed. seven (12.7%) patients were diagnosed with hypertension, and 10 (18.2%) with proteinuria. the grade of hydronephrosis decreased, and the differential rf measured by mag-3 renal scan significantly increased at final analysis (p = < 0.001). presence of preoperative symptoms (p = 0.034), and serum creatinine elevation showed correlation with hypertension. the highest incidence of both hypertension and proteinuria was observed between 15 and 20 years postoperatively. vihma y et al13 studied the effect of pyeloplasty in 23 children and followed them with a post-operative renal scan. they observed that hydronephrotic kidneys that had reduced glomerular function preoperatively improved after pyeloplasty. in our series left kidney was affected with pujo in almost three fourth cases and this is similar to the findings of the literature in which 66% was more common on left side. males are commonly affected than females with a ratio of 4:1 according to our study and the literature showed a ratio of 2:1. wagner m et al4 studied long-term results of pyeloplasty 4 mjsbh vol 21 issue 2 jul-dec 2022 original article outcomes of paediatric pyeloplasty; praveena s, et al. in 32 patients (mean age 33 months) and divided them into three groups (i > 40%, ii 10 to 40%, iii < 10%). there was significant improvement of split function 12 months after pyeloplasty in children with < 10% split function. in our study, according to diuretic renogram, drf improved in 29 children (96.7%) and worsened in one postoperatively. the average drf was19.3% preoperatively and 33.2% post operatively at one year. the improvement was more pronounced in the group of kidneys with severely reduced preoperative glomerular function. our study showed mean gfr increased to 33.9 (± 12.5 sd) at the end of one year. menon p et al14 studied total 744 patients with upjo in the study period with 112 had drf ≤ 20%. ten with no function underwent nephrectomy. the study included 102 subjects (mean age 4.7 years) with drf 0 – 9% (n  =  40) and 10 – 20% (n  =  62). during the follow up period ranging from one to eight years, there was significant improvement in drainage in the remaining 96 patients. the mean drf and ivu function showed highly significant improvement (p = < .001) in those with clinical signs and symptoms (n = 85), compared to asymptomatic patients in preoperative 0 – 9% and 10 – 20% group. all patients had resolution of initial complaints. hypertension resolved in two patients with crossing vessels. no patient required re-do pyeloplasty or developed hypertension during follow up. kumar m et al15 studied 145 patients after pyeloplasty for structural changes in ultrasonography. there was reduced apd with increased parenchymal thickness in 96.55% patients. in our study, it was100% improvement as apd was reduced and parenchymal thickness was increased for all the children. more recently in 2019, gnech et al8 studied the role of nephrectomy vs pyeloplasty in such poorly functioning kidneys. the patients undergoing nephrectomy had significantly lower median pre-operative drf (p < 0.001) and were significantly more likely to undergo a minimally invasive approach than those undergoing pyeloplasty. no postoperative variable was statistically different between groups. after a mean follow-up of 63 months, no statistically significant difference was found in intraoperative, early, late, and overall complications between pyeloplasty and nephrectomy. pyeloplasty failed in 3% of cases. of the patients undergoing successful pyeloplasty, 36 had a pre-operative and a postoperative renogram, and functional recovery of more than 5% was observed in 13 (36%), whereas the drf remained unchanged in 16 (45%) patients. only postnatal diagnosis was associated with a significantly higher chance of functional recovery (p = 0.047). since the number of children in this group was small, it is too early to say that such kidneys may always be taken up for pyeloplasty. conclusions there was significant improvement in the mean apd, mean parenchymal thickness, gfr, %drf ipsilateral kidney post pyeloplasty of poorly functioning kidneys. the success of pyeloplasty is determined by the relief of symptoms, improved renal drainage, gfr and differential renal function in follow up diuretic renogram. hence, we would like to recommend pyeloplasty as a standard of care even in poorly functioning kidneys with pujo. however, nephrectomy is an option to prevent recurrent uti, hypertension and renal dysfunction in poorly functioning kidneys. references 1. aksu n, yavaşcan ő, kangın m, kara od, aydın y, erdoğan h, et al. postnatal management of infants with antenatally detected hydronephrosis. pediatr nephrol. 2005 sep 1;20(9):1253–9. doi: 10.1007/s00467-005-1989-3. 2. arger ph, coleman bg, mintz mc, snyder hp, camardese t, arenson rl, et al. routine fetal genitourinary tract screening. radiology. 1985;aug;156(2):485-9. doi: 10.1148/radiology.156.2.3892578. 3. murnaghan gf. the dynamics of the renal pelvis and ureter with reference to congenital hydronephrosis. br j urol. 1958;sep;30(3):321-9. doi : 10.1111/j.1464-410x.1958.tb03525.x 4. wagner m, mayr j, häcker fm. improvement of renal split function in hydronephrosis with less than 10% function. eur j pediatr surg. 2008 jun;18(03):156–9. doi: 10.1055/s-2008-1038445. 5. iap policy on age of children for pediatric care. indian pediatr. 1999;36:461–3. pmid: 10728035 6. datta b, moitra t, chaudhury dn, halder b. analysis of 88 nephrectomies in a rural tertiary care center of india. saudi j kidney transpl. 2012;23(2):409–13. pmid: 22382250 7. lee he, park k, choi h. an analysis of long-term occurrence of renal complications following pediatric pyeloplasty. j pediatr urol. 2014 dec;1;10(6):1083-8. doi: 10.1016/j.jpurol.2014.03.015 8. gnech m, berrettini a, lopes ri, moscardi p, esposito c, zucchetta p, et al. pyeloplasty vs. nephrectomy for ureteropelvic junction obstruction in poorly functioning kidneys (differential renal function <20%): a multicentric study. j pediatr urol. 2019;553(e1-553.e8). doi: 10.1016/j.jpurol.2019.05.032 9. salem yh, majd m, rushton hg, belman ab. outcome analysis of pediatric pyeloplasty as a function of patient age, presentation and differential renal function. j urol. 1995;(v;154(5):1889). doi : 10.1016/s0022-5347(01)66819-8 5civil med j | vol 01 | issue 01 | jan, 2023 original article mjsbh vol 21 issue 2 jul-dec 2022 outcomes of paediatric pyeloplasty; praveena s, et al. 10. mcanena oj, kelly dg. nephrectomy in childhood-a tenyear review. ir med j. 1985;78:121–5. 11. daradka i. indications for nephrectomy in children: a report on 119 cases. saudi j kidney transpl. 2012;23(6):1221–6. 12. o’reilly ph, brooman pj, mak s, jones m, pickup c, atkinson c, et al. the long-term results of anderson-hynes pyeloplasty. bju int. 2001;mar;87(4):287-9. doi: 10.1046/j.1464-410x.2001.00108.x. 13. vihma y, korppi-tommola t, parkkulainen kv. pelviureteric obstruction in children: the effect of pyeloplasty on 99mtc-dtpa uptake and wash out. zkinderchir. 1984;dec;39(06):358-63. doi: 10.1055/s-2008-1044245. 14. menon p, rao kl, bhattacharya a, mittal br. outcome analysis of pediatric pyeloplasty in units with less than 20% differential renal function. j pediatr urol. 2016;171(e1-7). doi: 10.1016/j.jpurol.2015.12.013 15. kumar m, singh sk, arora s, mittal v, patidar n, sureka sk, et al. follow-up imaging after pediatric pyeloplasty. indian j urol iju j urol soc india. 2016;jul;32(3):221. doi: 10.4103/0970-1591.185090 16 mjsbh vol 21 issue 2 jul-dec 2022 original article antenatal services utilization among the women; maharjan r, et al. level of autonomy and antenatal services utilization among the women of reproductive age group residing in an urban municipality of lalitpur 1 senior instructor, patan academy of health sciences (pahs), school of nursing and midwifery, lalitpur, nursing campus, sanepa, lalitpur, nepal. 2 associate professor, college of nursing, nepalese army institute of health sciences, bhandarkhal, sanobharyang, kathmandu, nepal. 3 professor, college of nursing, nepalese army institute of health sciences, bhandarkhal, sanobharyang, kathmandu, nepal. 4 lecturer, chakrabarti habi education academy, college of nursing sciences, madhyapur thimi, nepal. 5 lecturer, national academy of medical sciences, bir hospital nursing campus, mahabauddha, kathmandu, nepal. 6 research officer, research department, institute of medicine, tribhuvan university, maharajgunj, kathmandu, nepal. reena maharjan1, mamata bharati2, sarala shrestha3, bimala tandukar4, bimala parajuli 5,shreejana singh6 maternal mortality continues to be a major health problem in developing countries. in the 20 years’ time period from 1996 to 2016 the maternal mortality ratio (mmr) in nepal has decreased to about half from 539 to 239 maternal deaths per 100,000 live births.1 however, this ratio is among the highest in asian countries. in its sustainable development goals (sdgs) 3, nepal targets to reduce mmr to less than 70 per 100,000 live births by 2030 in original article introduction introduction: antenatal care is one of the pillars of a safe motherhood programme in improving maternal and child health. women’s autonomy is seen as an important factor in utilization of maternal health services. therefore, the objective of study was to find the level of autonomy and utilization of antenatal services among the women of reproductive age group. methods: a descriptive cross-sectional study design was used. a total of 151 women of reproductive age group having at least one child in the age group of less than one year were selected using non probability purposive sampling technique from four randomly selected wards of godawari municipality. a validated and pretested nepali version interview schedule was used to collect data from the respondents through door-to-door visit. descriptive statistics such as frequency, percentage, mean, standard deviation and inferential statistics i.e. fisher’s exact test was used to analyze data. results: the study findings revealed that the majority (58.3%) of respondents had a lower level of overall autonomy. the highest autonomy was seen in decision making and lowest in financial related issues. almost all (96%) of the respondents had fully utilized antenatal services. there was significant association between antenatal services utilization with women’s autonomy (p-value 0.041). education of women and their husbands (p-value 0.009 and 0.013 respectively) as well as easy access to health facilities and availability of private transportation (p-value 0.005 and 0.039 respectively) were significantly associated with utilization of antenatal services. conclusions: this study concludes that women’ autonomy tends to influence their antenatal services utilization. likewise, education of women as well as their husbands tends to facilitate utilization of antenatal services. the study also concludes that easy access to health facilities and availability of private vehicles facilitates utilization of antenatal services. abstractcorresponding author reena maharjan, patan academy of health sciences (pahs), school of nursing and midwifery, lalitpur nursing campus, sanepa, lalitpur, nepal email: reena6np@gmail.com online access keywords autonomy; antenatal service utilization; antenatal care utilization antenatal services utilization among the women; maharjan r, et al. © the author(s) 2023. this work is licensed under a creative commons attribution 4.0 international license. (cc by-nc) doi: 10.3126/mjsbh.v21i2.47439 received date: 11 aug, 2022 accepted date: 26 mar, 2023 https://creativecommons.org/licenses/by/4.0/ 17civil med j | vol 01 | issue 01 | jan, 2023 original article mjsbh vol 21 issue 2 jul-dec 2022 antenatal services utilization among the women; maharjan r, et al. line with the global target.2 worldwide only half of the women receive the recommended amount of care during pregnancy. eighty six percent of pregnant women receive antenatal care from skilled health personnel at least once.3 anc services offer pregnant women an entry point to the health care systems, appropriate screening intervention and treatment throughout pregnancy and encouraging women to seek a skilled birth attendant for their delivery.4 the anc guideline includes a significant new recommendation that pregnant women have eight contacts with the health system during each pregnancy.5 who (2016) in its recent anc guideline had included health system interventions to improve the utilization and quality of anc and women’s positive experience of pregnancy.6 approximately 830 women die every day from preventable causes related to pregnancy and childbirth. the goal of the national safe motherhood program is to reduce maternal neonatal morbidity and mortality and improve maternal and neonatal health through preventive and promotive activities and by addressing avoidable factors that cause death during pregnancy, childbirth and postpartum period.6 according to nepal demographic health survey 2016, 84% of women received anc in their most recent birth from a skill provider, 69% of women had at least four anc visits.7 the proportion of pregnant women coming to their first anc visit declined from 70% of expected life birth to 60% in 2018 / 19. the proportion of pregnant women attending at least four anc visits has also declined from 53% in 2017 / 18 to 50% in 2018 / 19 at the national level. however, there is sharp decline in the percentage of women who had four anc per the protocol for province 3 from 68% to 49%.8 various researches done in nigeria and bangladesh showed that there is a strong relationship between women decision making autonomy and anc services.9,10 limited women’s autonomy in maternal health care are the main underlying causes of poor utilization of maternal health care services and high maternal morbidity and mortality in developing countries.11 the cross sectional study done in kapilvastu showed that antenatal services utilization was higher among those women who had autonomy in household decision (32%) compared to those women who did not have autonomy 24.5%.12 the objective of the study was to find out the level of autonomy and antenatal services utilization among the women of reproductive age group (wrag) in a municipality of lalitpur, nepal.  methods a descriptive cross-sectional study design was used to identify the level of women autonomy and antenatal services utilization among wrag who have at least one child under the age of one year. the study was conducted at godawari municipality, lalitpur, nepal.13 it is divided into 14 wards committees. out of these 14 wards, four (ward no. 3, 6, 10 and 12) were selected randomly through the lottery method. non probability purposive sampling technique was used with the total sample size 151.14 the semi-structured interview schedule was developed by researchers through literature review. it consisted of three sections consisting questions related to socio demographic, obstetrics and services factors, women’s autonomy and antenatal service utiliztion. regarding women’s autonomy the validated tool was used.15 content validity of the instrument was ascertained. reliability test was done by using cronbach’s alpha tools and score was 0.735. data collection was initiated after getting ethical approval from institutional review committee (irc) of naihs and written permission from godawari municipality. informed written consent was obtained from each respondent before interviews. different descriptive and inferential statistics were used for analysis. data were taken from the primary source. results the mean age of women was 26.66 years (sd ± 4.96) from janajati ethnic group and joint family. almost all (91.4%) respondents and their husbands (96.7%) could read and write. the majority of respondents were home makers and majority (53.3%) had only one child and an accessible health facility was a government / semi government hospital that was 90%. almost all (92.7%) respondents were residing up to 30 minutes walking distance from the health facility. majority of respondents had access to public vehicles to visit the health facility for antenatal services. table 1. respondent’s score on different components of autonomy variables mean mean score percentage standard deviation autonomy in decision making 11.0199 55.09 2.09911 autonomy in mobility 6.2450 44.60 4.28636 autonomy in financial aspect 5.4901 31.21 4.11642 table 1 shows that the maximum autonomy was in decision making autonomy mean = 11.02 ± 2.1 followed by mobility autonomy mean 6.2 ± 4.3 while there was least autonomy in financial related issue with mean as 5.5 ± 4.1. 18 mjsbh vol 21 issue 2 jul-dec 2022 original article antenatal services utilization among the women; maharjan r, et al. table 2 overall autonomy level of autonomy number percentage low (< 24) 88 58.3 high (> 24) 63 41.7 total 151 100.0 table 3 level of antenatal services utilization among the respondents in their last pregnancy antenatal service utilization number percentage fully utilization (> 50%) 145 96.0 underutilization (< 50%) 6 4.0 total 151 100.0 table 4 association of level of antenatal services utilization with socio-demographic and services-related variables (n =151) variables level of utilization of antenatal services # p-value fully utilized under utilized no. (%) no. (%) educational status of the respondents can read and write 135 (97.8) 3 (2.2) 0.009* cannot read and write 10 (76.9) 3 (23.1) educational status of the respondents’ husbands can read and write 142 (97.3) 4 (2.7) 0.013* cannot read and write 3 (60.0) 2 (40.0) time required to reach health facility for antenatal services by walking up to 30 minutes 137 (97.9) 3 (2.1) 0.005* above 30minutes 8 (72.7) 3 (27.3) transportation facilities used private vehicle (two/four wheels) 64 (100.0) 0.039* public vehicle 81 (93.1) (6.9) 6 *p-value significant at <0.05; # fisher’s exact test table 4 shows that status of women and husband education of respondents were significantly associated with antenatal service utilization indicating that higher proportion of respondents who can read and write had fully used anc services that those who cannot read and write  (p-value = 0.009 of respondents’ education and p-value = 0.013 of respondents’ husband education). time required to reach health facilities for antenatal services by walking and transportation facilities were significantly associated with antenatal services utilization (p-value = 0.005 of distance to health facilities by walking), (p-value = 0.039 of transportation) respectively. there were no significant associations between antenatal services utilization with obstetric factors.  table 5 women’s autonomy and antenatal services utilization (n = 151) women’s overall autonomy level  utilization level p-value #fully utilized (%) .no under utilized no. (%) low 82 (93.2) 6 (6.8) 0.041 * high 63 (100) *p-value significant at <0.05, # fisher’s exact test table 5 reveals that there was significant association between antenatal services utilization and women’s autonomy (p-value 0.041). 19civil med j | vol 01 | issue 01 | jan, 2023 original article mjsbh vol 21 issue 2 jul-dec 2022 antenatal services utilization among the women; maharjan r, et al. discussion  the present study revealed that in relation to decision making autonomy 24.5% of respondents decided independently in daily household whereas only 0.7% decided independently in purchasing major goods. these findings are in agreement with a study done in bangladesh where 29% of women decided independently in making household purchases for daily needs and a small proportion of women (8.2%) had made decisions independently in making large household purchases.16. present study finding is in contrast with the finding of study done in philippines where 61% of women decided alone on purchase for daily household needs.17 in present study, 11.9% women made decision on children’s health care. but this finding is in contrast with finding of study in bale zone where 49.6% of women were autonomous to take their child to health facility.18 in this study only 14.6% of respondents did not need permission for going to a natal family. this finding is in contrast with a study in a north indian city where 58% of women could go to their natal home when they wished. 19 these differences among various researches may have been resulted due to different settings, sample sizes, social and cultural aspects. in this study regarding health checkup during recent pregnancy, almost all (98.7%) of respondents had attended antenatal visits. this finding is higher than the finding of study conducted in gorkha, nepal where 76% of respondent had attended antenatal visits.20 and this finding is higher than the finding of study done in hilly area of tamang community of nepal where 79% had attended anc visits.21 in this study almost all (94.0%) of respondents had four or more anc visits during their recent pregnancy. this finding is higher than the finding of study done in kapilvastu of nepal where 68.9% of respondents had attended four or more visits.12 these findings are also consistent with the finding of a study done in teaching hospital of kathmandu  where 83% of women had four antenatal visits.22 these findings are also consistent with the finding of study done north ethiopia shows that 84.8% have four or  more antenatal visits.23 in this study, 73.8% of respondents had received the first antenatal visit within four months of pregnancy. this finding is higher that the study done in kapilvastu, nepal where 47.6% of respondents did the first anc visit within four months of pregnancy.12 this study revealed that 93.1% respondent had received two td injections during their pregnancy and only 4% respondents had not received td injection. this finding is nearly consistent with the findings of the study done phc in jhapa, nepal where 74% respondents received two doses td injection and 6% respondents did not receive the td injection.24 this study revealed a significant association between antenatal services utilization and women’s autonomy (p-value = 0.041). this finding is similar to findings of the study done in bangladesh which also revealed a significant association between women autonomy and anc (p-value < 0.001).13 the study done in nigeria showed that overall autonomy was significantly associated with anc utilization (p-value < 0.000).25 this study revealed that the status of education (p-value = 0.009) and status of husband education (p-value = 0.013) were associated with utilization of the anc services.  this study result also illustrated that time required to reach health facilities for antenatal services by walking (p-value = 0.005) and transportation facilities (p-value = 0.039) were associated with utilization of the anc services.  the present study revealed that status of education of respondents and respondent’s husband were associated with anc utilization (p-value 0.009 of respondents) and (p-value 0.013 of respondent’s husband). these findings are similar to findings of the study done in mahottari district of nepal which revealed a significant association between anc with education of respondents and their husbands.26. another study findings were also similar to findings of the study done in amagie, west ghana revealed that education level also had significant association with anc (p-value = 0.005).27 the findings of this study might be helpful to plan and provide health education to husband and family members for raising autonomy of women for women’s health through proper and timely use of anc. it would be useful to health workers for planning effective intervention for the increment of utilization of antenatal services. conclusions based on the results of the study, it is concluded that the wrag tend to have low autonomy. maximum autonomy is seen in decision making followed by mobility, while there is least autonomy in financial related issues. women tend to utilize antenatal services properly and women’s autonomy, women’s education, their husband’s education, walking distance of health facilities and availability of private vehicles tends to influence the antenatal services utilization among the wrag. references 1. the current state of maternal health in nepal – maternal health task force [internet ]. [cited 2022 aug 7]. available from: https://www.mhtf.org/2017/12/29/the-current-stateof-maternal-health-in-nepal/ 2. government of nepal, national planning commission (2017). nepal’s sustainable development goals baseline report. kathmandu: author. retrieved from https://www. npc.gov.np/images/categor y/sdgs_baseline_repor t_ final_29_june-1  https://www.mhtf.org/2017/12/29/the-current-state-of-maternal-health-in-nepal/ https://www.mhtf.org/2017/12/29/the-current-state-of-maternal-health-in-nepal/ https://www.npc.gov.np/images/categor https://www.npc.gov.np/images/categor 20 mjsbh vol 21 issue 2 jul-dec 2022 original article antenatal services utilization among the women; maharjan r, et al. 3. antenatal care | unicef global development commons [internet ]. [cited 2022 aug 7]. available from: https://gdc. unicef.org/resource/antenatal-care 4. lincetto o, mothebesoane-anoh s, gomez p, munjanja s. opportunities for africa’s newborns. antenatal care. 2006: 55-62. 5. who recommendations on antenatal care for a positive pregnancy experience [internet ]. who.int. 2022 [cited 7 august 2022]. available from: https://www.who.int/ publications-detail-redirect/9789241549912 6. world health organization. who recommendations on antenatal care for a positive pregnancy experience. world health organization; 2016.  7. ministry of health, new era, international coach federation. 2017. nepal demographic and health survey 2016. kathmandu, nepal: ministry of health. 8. department of health services. (2018). annual report. kathmandu, nepal: ministry of health. retrieved from https://dohs.gov.np/annual-report-2074-75/ 9. obasohan pe, gana p, mustapha ma, umar ae, makada a, obasohan dn. decision making autonomy and maternal healthcare utilization among nigerian women. int j mch aids. 2019;8(1):11–8. doi: 10.21106/ijma.264 10. haque se, rahman m, mostofa mg, zahan ms. reproductive health care utilization among young mothers in bangladesh: does autonomy matter? women health issues. 2012;22(2):171-180. doi: 10.1016/j.whi.2011.08.004. epub 2011 oct 2. 11. dangal g, bhandari tr. women’s autonomy: new paradigm in maternal health care utilization. glob j health sci. 2014;3(5):1-2. 12. tulsi ram b. women’s autonomy and utilization of maternal health services in kapilvastu district, nepal (doctoral dissertation, sctimst). 13. household survey, godawari nagarpalika, (2075).  retrieved from http://godawarimunlalitpur.gov.np/ s i te s /g o d awa r i m u n l a l i t p u r.g ov. n p / f i le s /d o c u m e n t s / godawari%20final%20%202075.pdf 14. cochran wg. sampling techniques. 1977. (3rd). new york: john wiley & sons. https://gist.github.corn/ marcoscaceres/7137166 15. bhandari tr, kutty vr, ravindran ts. women’s autonomy and its correlates in western nepal: a demographic study. plos one. 2016 jan 22;11(1): e0147473. doi: https://doi.org/10.1371/journal.pone.0147473 16. chowdhury s. women’s autonomy and its influences on utilization of maternal and child health care facilities in bangladesh. diujbe. 2015 feb 15. 17. castro r, casique i, brindis c. empowerment and physical violence throughout women’s reproductive life in mexico. violence against women. 2008;14(6):655-677. doi: 10.1177/1077801208319102 18. nigatu d, gebremariam a, abera m, setegn t, deribe k. factors associated with women’s autonomy regarding maternal and child health care utilization in bale zone: a community based cross-sectional study. bmc women’s health. 2014 dec;14(1):1-9. doi: 10.1186/1472-6874-14-79. pmid: 24990689; pmcid: pmc4094397. 19. bloom ss, wypij d, gupta md. dimensions of women’s autonomy and the influence on maternal health care utilization in a north indian city. demography. 2001 feb;38(1):67-78. doi: 10.1353/dem.2001.0001. pmid: 11227846 20. awasthi ms, awasthi kr, thapa hs, saud b, pradhan s, khatry ra. utilization of antenatal care services in dalit communities in gorkha, nepal. j pregnancy. 2018 nov 1;2018:3467308. doi: 10.1155/2018/3467308. pmid: 30515327; pmcid: pmc6236651. 21. sanjel s, ghimire rh, pun k. antenatal care practices in tamang community of hilly area in centra nepal. kathmandu univ med j (kumj). 2011;9(2):57-61. doi: 10.3126/kumj.v9i2.6290. 22. thapa m, yadav s, bhujel k. utilization of antenatal care services in present pregnancy among the women attending in a teaching hospital for delivery. nepal j obstet and gynaecol. 2016;11(1):26-29 doi:10.3126/njog.v11i1.16295 23. mullat g, kassaw t, aychiluhim m. antenatal care service utilization and its associated factors among mothers who gave live birth in the past one year in womberma woreda, north west ethiopia [internet ]. [cited 2022 aug 7]. 24. obasohan pe, gana p, mustapha ma, umar ae, makada a, obasohan dn. decision making autonomy and maternal healthcare utilization among nigerian women. matern child health j. 2019;8(1):11. doi: 10.21106/ijma.264 25. chaurasiya s, pravana n, khanal v, giri d. factors affecting antenatal care utilization among the disadvantaged dalit population of nepal: a crosssectional study. open public health j 2019;12(1):155-163. doi: 10.2174/1874944501912010155,2019,12,155-16 26. nuamah gb, agyei-baffour p, mensah ka, boateng d, quansah dy, dobin d, et al. access and utilization of maternal healthcare in a rural district in the forest belt of ghana. bmc pregnancy childbirth. 2019 dec;19(1):1-1. doi: https://doi.org/10.1186/s12884-018-2159-5 https://gdc.unicef.org/resource/antenatal-care https://gdc.unicef.org/resource/antenatal-care https://dohs.gov.np/annual-report-2074-75/ http://godawarimunlalitpur.gov.np/sites/godawarimunlalitpur.gov.np/files/documents/godawari%20final%20%202075.pdf http://godawarimunlalitpur.gov.np/sites/godawarimunlalitpur.gov.np/files/documents/godawari%20final%20%202075.pdf http://godawarimunlalitpur.gov.np/sites/godawarimunlalitpur.gov.np/files/documents/godawari%20final%20%202075.pdf https://gist.github.corn/marcoscaceres/7137166 https://gist.github.corn/marcoscaceres/7137166 https://doi.org/10.1371/journal.pone.0147473 https://doi.org/10.21106/ijma.264 mjsbh vol 21 issue 2 jul-dec 2022 25 original articledrug information sources utilized by medical practitioners; prasad p, et al. pattern of drug information sources utilized by medical practitioners at a teaching hospital in nepal introduction: the development of pharmaceutical industry has been adding new knowledge about drugs continuously making it difficult to remember each piece of information. the physicians need to be supplemented with new information using various unbiased and reliable drug information (di) sources which will promote rationale use of medicines. this study aims to understand the commonly used sources of di by prescribers at our institute, their usefulness and the need for an independent drug information unit at the institute. methods: a cross-sectional descriptive study that included all prescribers presently working at this institute and actively involved in patient care was conducted. consenting participants were requested to fill in the self-administered questionnaire. data thus collected were entered using epidata version 3.1 and were analysed using spss version 18. results: filled-in questionnaires were obtained from 147 prescribers. almost all of the participants (95.80%) used textbooks and online medical sites (oms) as sources of di. among participants using oms for di, 80 (58.39%) classified them as sometimes biased. less than half (41.25%) agreed that they will absolutely be benefitted from having unbiased di services at the hospital. the participants most commonly (136, 92.50%) had queries related to dosage / administration on a daily basis. conclusions: most prescribers relied on textbooks and oms for di which in their opinion had some level of biasness associated with them. they also agreed on the need of independent di services in the institution to support prescription practices. abstract 1department of clinical pharmacology, maharajgunj medical campus, institute of medicine, maharajgunj, kathmandu, nepal 2department of pharmacology, lumbini medical college and teaching hospital, tansen, palpa, nepal. 3department of community medicine, kathmandu medical college and teaching hospital, sinamangal, kathmandu, nepal 4b. p. koirala institute of health sciences, dharan, nepal pravin prasad1, naresh karki2, kamal kandel2, shruti shah3, vitasta muskan4, rakesh ghimire1, anis mudvari1, pradip gyanwali1 corresponding author pravin prasad, assistant professor, department of clinical pharmacology, maharajgunj medical campus, institute of medicine, maharajgunj, kathmandu, nepal e-mail: prapsd@gmail.com online access the development of pharmaceutical industry has been enriching our knowledge about drugs continuously making it impractical to remember each piece of information.1 physicians require supplemental new information using various drug information (di) sources. di is a broader concept that incorporates all information on medicines provided by a professional with specific skills and functions in any (verbal, electronic or printed) form.2 di can be in response to a request from health care professionals, patients, organizations, committees and members of the public.3 based on the querier, it can be specific for either patient or academic or populationbased.4 it focuses on the transfer of knowledge related to drugs, in order to optimize therapeutics for a benefit of patients and of society.1 the availability of unbiased and reliable sources of di will help to enhance patient care.5 the available di sources are classified as primary, secondary and tertiary.1,3 the studies have reported that di sources can be at times incomplete and / or biased. having up-to-date knowledge of the relevant drugs for a clinician is a time-consuming task and the time spent for searching information is very small.6,7 hence it is essential to understand the pattern of utilization as well introduction keywords drug information; drug information service; rationale use of medicines © the author(s) 2023. this work is licensed under a creative commons attribution 4.0 international license. (cc by-nc) doi: 10.3126/mjsbh.v21i2.40323 received date: 21 oct, 2021 accepted date: 14 jan, 2023 original articledrug information sources utilized by medical practitioners; prasad p, et al. https://creativecommons.org/licenses/by/4.0/ mjsbh vol 21 issue 2 jul-dec 202226 original article drug information sources utilized by medical practitioners; prasad p, et al. as satisfaction from the sources of di used by prescribers. additionally, to address this problem, institutes can establish their own drug information service (dis), which will encompass the activities of specially trained individuals to provide accurate, unbiased, factual information, primarily in response to patient-oriented drug problems received from various members of the healthcare team.8 there has not been any research in this field in our region. the aim of this study was to understand the commonly used di sources by prescribers at our institute, their usefulness and the need for an independent drug information unit. methods a cross-sectional descriptive study was conducted at our institute from 1 november 2018 to 1 may 2019 after obtaining ethical approval from the institutional review committee. all prescribers (127 interns, 10 medical officers, 19 residents and 42 faculties) presently working at this institute and actively involved in patient care were included in the study. the list of prescribers was obtained from the institute’s administration. a written informed consent was obtained from the participants and they were requested to fill within three working days, failing which they were given additional three days time. the participants failing to submit the questionnaire sheet even after six days of receiving the study questionnaire sheet were labelled as non-responder and excluded from the study. the study questionnaire used consisted of three sections: the general information about the participant, the present practice of seeking di and the opinion about the necessity of an independent di unit at the institute. the general information of the participant including their initials, practice, designation and department were noted. for present practice, information about the sources of di utilized by the participant (yes or no), how likely they felt that the sources they utilize are biased (using a likert scale of 1-4, 1 being never biased and 4 being always biased), how frequently they had their queries answered by the sources utilized by them (using a likert scale of 1-5, 1 being never answered and 5 being answered at all instances) were included. the list of sources of di was provided in the questionnaire. the last section regarding their opinion about the necessity of an independent di unit at the institute had two questions: likeliness that they will be benefitted by an independent di unit at the institute (1-not at all, 5absolutely); types of queries faced by the participants during their day-today activities. the questionnaire sheet was validated by experts and pretested at the study site itself. the sources of di (references) were grouped into four categories. original articles, case reports, case series, etc. were categorised as primary references. similarly, review articles, meta-analyses, indexes, abstracts, reprints, etc. were categorised as secondary references. tertiary references include formulary manuals, standard treatment manuals, drug bulletins, textbooks, reference books and drug compendia.9 conferences, drug information services / centres, internet, advertisement to the public and pharmaceutical company sales representatives (sr) were categorised as others.10 all the data collected were entered using epidata version 3.1 and were analysed using spss version 18. results there were 198 prescribers currently working at our institute. three faculties were not available during the data collection period. after contacting 195 prescribers, filledin questionnaires were obtained from 147 prescribers (response rate 75.38%) which included 101 interns (68.7%), four medical officers (2.7%), 12 residents (8.2%), 24 lecturers (16.3%), four associate professors (2.7%) and two professors (1.4%). four claimed that they have not searched for any di in the last six months. among the participants who had searched for di in the last six months, almost all (95.80%) admitted that they have consulted textbooks and / or online medical sites as a source (table 1). mjsbh vol 21 issue 2 jul-dec 2022 27 original articledrug information sources utilized by medical practitioners; prasad p, et al. table. 1 sources consulted for di (as one participant may have consulted more than one source, the percentage will not add up to 100. n= 143) type of reference sources consulted frequency percent % tertiary textbooks 137 95.80 secondary online medical sites (medscape, uptodate, webmd, websites of medical associations) 137 95.80 health magazines 46 32.17 review article 45 31.47 newspaper 34 23.78 systematic review 25 17.48 meta-analysis 17 11.89 cochrane database 14 9.79 primary observational studies (cohort study, case-control studies, descriptive studies) 45 31.47 randomised control trials 25 17.48 non-randomized controlled trials 10 6.99 others online non-medical sites (google, wikipedia, etc) 112 78.32 medical representatives 74 51.75 the participants were also asked how often they felt that the sources used by them were biased. the majority of the respondents felt that online medical sites are sometimes biased (58.39%). a similar proportion of participants that used online non-medical sites as sources of di (57.38%) felt that these sources are sometimes biased. some of the respondents also felt that sources like review articles, meta-analyses, non-randomized control trials, observational studies, online non-medical sites, newspapers, health magazines and medical representatives are always biased (figure 1). figure 1: level of biasness of the sources of di most of the participants also admitted that the di they used did not answer their queries at all instances. only 33 (24.09%) participants reported that textbooks answered their queries at all instances. the majority of the participants (31, 41.89%) admitted that sr solved their queries in less than 40% of instances (figure 2). figure 2: instances when queries are answered using different di sources the participants were also asked if they felt they will be benefitted by having an independent dis at the hospital and what common drug queries they have. less than half of the participants (41.25%) believed that they will absolutely be benefitted from dis at the hospital followed by probably benefitted (33.78%). most of the participants had queries related to dosage and administration of drugs mjsbh vol 21 issue 2 jul-dec 202228 original article drug information sources utilized by medical practitioners; prasad p, et al. (92.50%) followed by adverse drug reactions (82.50%) (see table 2). table 2. types of drug queries (n = 147) types of drug queries frequency percentage dosage / administration 136 92.50 adverse drug reaction 121 82.50 contraindications 119 81.25 interactions 108 73.75 indications 107 72.50 cost/availability 81 55.10 efficacy 79 53.75 drug therapy 74 50.34 poisoning 62 42.50 pharmacokinetics 42 28.75 pharmacodynamics 40 27.50 others 17 11.25 discussion most of the participants (75%) responded within the completely filled questionnaire. a similar response rate was reported in a study from india in which 100 out of 125 clinicians completed the questionnaire.11 an online study conducted in utah among pharmacists had a response rate of 15.19%.12 almost all participants admitted that they have consulted tertiary sources like textbooks and / or secondary sources like online medical sites (oms) as a source of di. spiller et al13 reported in their study that 75% of physicians considered medical books (like physician drug reference) extremely useful. a study done by schjott et al14 also reported that the studied dics utilized tertiary reference to answer drug queries in 124 (50.8%) instances.14 behera et al3 reported that websites were commonly used references for answering drug query received by them. as our study centre is a medical college with undergraduate (mbbs) and postgraduate (md / ms) programs, easy accessibility to textbooks and preference of faculties for answers from textbooks could have led to higher utilization of textbooks for di. the easy availability of oms due to mobile phones and internet facilities, the need for answers in a short time, technology-friendly nature of young participants included in this study could also have led to similar utilization of oms by participants in our study. a study from pakistan also reported that 28% of doctors included in their study spent half an hour studying drug information.15 the majority of the respondents felt that both medical and non-medical online sites are sometimes biased. this would help them to be critical of the information they receive and would verify using some other sources as well. though participants realised that the sources could be biased, they were still found to be using them. of many possible reasons, this could have occurred due to the easy availability of these sources, and the short time required to get answers to their queries. internet search engines are frequently sought sources of information and there is a substantial risk that these search engines may contain biased and unreliable information.16 a study conducted by law et al17 reported that when canadian version of google® is used to seek for di, non-medical site like wikipedia® is commonly displayed at first. riley et al18 has reported that non-medical sites lack information related to medicines in terms of accuracy and completeness. only 33 (24.09%) participants reported that textbooks answered their queries at all instances. the study from scandinavia also reported that only one type of source of information is not sufficient.14 gitanjali et al reported that drug advertisements published in indian and british editions of the british medical journal also contained inadequate scientific information.19 tertiary sources of di like the european summaries of product characteristics were also reported to be deficient by several studies as information related to prescribing medicines in special situations was inadequate.20-22 this could have been found in our study as information related to cost, drug interactions, off-label uses, new instructions with respect to dosage and administration and availability is commonly not found in textbooks. it was reported that to remain up-to-date with di relevant to their daily practice by a clinician, she / he was expected to require to spend more than 600 hours in a month.6 however, it is estimated that physicians spend about 12 minutes searching for di.7 majority of the participants (31, 41.89%) admitted that mr solved their queries in less than 40% of instances. anderson et al reported in their study that 57% of the physician surveyed relied on pharmaceutical industry sources like company mailings and mr for information related to new medicines.23 in a study from brazil it was reported that most of the participants (62, 57%) found sr somewhat useful.13 there are various purposes for which a di can be sought. it can be requested to address specific concerns during patient care, for educational purposes, or to support decision-making for a broad population.4 di prepared in response to a request will usually answer the question of interest and can be related to any aspect of medicine (dose, indication, adverse reactions, toxic effects, availability, therapeutic guidelines, etc.).3 in our study, most of the participants (61, 41.25%) believed that they will absolutely be benefitted from dis at the hospital. mjsbh vol 21 issue 2 jul-dec 2022 29 original articledrug information sources utilized by medical practitioners; prasad p, et al. dis can provide its service to the general public, clinicians, students, faculties, preceptors, alumni, law enforcement and attorneys. the history of dis services dates back to 1996 ad in nepal and by 2020, there are studies reporting the existence of six dis in nepal.24 the concept of dis is still relevant in this internet age.16,25 a study from indianapolis in 1999 estimated that over three months period, the service provided by their dis had 57.76 practitioner hours saved, which had a monetary value of us$ 5,548.08.26 most of the participants had queries related to dosage and administration of drugs (136, 92.50%) which was also reported by a study conducted in saudi arabia and ethopia.27,28 behera et al reported that queries related to antimicrobial use was most commonly received (25, 45.46%) by at their dic.3 based on our findings, we would like to make some recommendations. continued medical education sessions should be conducted for prescribers to create awareness regarding biasness of different di sources and help them to critically analyse these sources. a study to understand the functioning of dis in nepal would be preferable so that an effective dis could be established at our centre. there are some limitations of this study. though to minimise the recall bias of participants, we limited the data collection from prescribers who had sought di within the last six months, some recall bias could still exist. higher response rate could have been achieved with an on-site filling of questionnaires either by the participants or by the researchers themselves, multiple follow-ups and reminders to the excluded prescribers. conclusions the prescribers were found to use different di sources, commonly textbooks and oms. the prescribers are aware that the sources of di they commonly use have the potential to be biased. most of the prescribers agree that they will be benefitted from an independent dis at the institute. the drug query related to dosage and administration is most commonly sought di by the prescribers at this institute. acknowledgements to the participants, assoc. prof. dr. binod kumar verma, head of department, department of pharmacology, lumbini medical college and teaching hospital, nepal. references 1. hall v, gomez c, fernandez-llimos f. situation of drug information centers and services in costa rica. pharm pract (granada). 2006 jul 31;4(2):83-7. pmid: 25246999 2. hämeen-anttila k. strategic development of medicines information: expanding key global initiatives. res social adm pharm. 2016;12(3):535-40. doi: 10.1016/j.sapharm.2015.07.001. 3. behera sk, xavier as, gunaseelan v, ravindra bk, selvarajan s, chandrasekaran a, et al. drug information center as referral service in a south indian tertiary care hospital. int j pharma investig. 2017;7:182-7. doi: 10.4103/jphi.jphi_90_17 4. ghaibi s, ipema h, gabay m. ashp guidelines on the pharmacist’s role in providing drug information. am j health syst pharm. 2015;72(7):573-7. doi: 10.2146/sp150002 5. ali aa, yusoff sm, joffry sm, wahab msa. drug information service awareness program and its impact on characteristics of inquiries at dis unit in malaysian public hospital. arch pharma pract. 2013;4:9-14. doi: 10.4103/2045-080x.111576 6. alper bs, hand ja, elliott sg, kinkade s, hauan mj, onion dk, et al. how much effort is needed to keep up with the literature relevant for primary care? j med libr assoc. 2004;92(4):429. pmid: 15494758 7. gorman p. information needs in primary care: a survey of rural and nonrural primary care physicians. stud health technol inform. 2001;10(pt 1):338-42. doi: 10.3233/978-1-60750-928-8-338 8. george b, rao pg. assessment and evaluation of drug information services provided in a south indian teaching hospital. indian j pharmacol. 2005;37(5):315. doi: 10.4103/0253-7613.16856 9. chauhan n, moin s, pandey a, mittal a, bajaj u. indian aspects of drug information resources and impact of drug information centre on community. j adv pharm technol res. 2013;4(2):84. doi: 10.4103/2231-4040.111524 10. world health organization. ethical criteria for medicinal drug promotion. geneva. 1988. 11. sharma s, akhoon n, moe hw, nair dr, shashidhar v. a study of perceptions and exposure of drug promotional literature among clinicians in a teaching hospital. perspect clin res. 2021 jul-sep;12(3):140-145. doi: 10.4103/picr.picr_36_19 12. moorman kl, macdonald ea, trovato a, tak cr. assessment and use of drug information references in utah pharmacies. pharm pract (granada). 2017;15(1):839. doi: 10.18549/pharmpract.2017.01.839 13. spiller ld, wymer jr ww. physicians’ perceptions and uses of commercial drug information sources: an examination of pharmaceutical marketing to physicians. health mark q. 2001;19(1):91-106. doi: 10.1300/j026v19n01_07 14. schjott j, bottiger y, damkier p, reppe la, kampmann jp, christensen hr, et al. use of references in responses mjsbh vol 21 issue 2 jul-dec 202230 original article drug information sources utilized by medical practitioners; prasad p, et al. from scandinavian drug information centres. medicines (basel). 2018;5(3):66. doi: 10.3390/medicines5030066 15. akhtar t, hussain a, shah su, ishaque rz, iqbal a. to study and compare source of drug information used by doctors (gps & specialist ), pharmacist and nurses in government & private tertiary care hospitals in islamabad. int j basic medical sciences and pharmacy. 2011;1(1). 16. hoover rm, hunter ml, krueger kp. survey of faculty workload and operational characteristics for academic drug information centers. curr pharm teach learn. 2018;10(5):579-83. doi: 10.1016/j.cptl.2018.02.003 17. law mr, mintzes b, morgan sg. the sources and popularity of online drug information: an analysis of top search engine results and web page views. ann pharmacother. 2011;45(3):350-6. doi: 10.1345/aph.1p572 18. reilly t, jackson w, berger v, candelario d. accuracy and completeness of drug information in wikipedia medication monographs. j am pharm assoc (2003). 2017;57(2):1936 e1. doi: 10.1016/j.japh.2016.10.007. 19. gitanjali b, shashindran c, tripathi k, sethuraman k. are drug advertisements in indian edition of bmj unethical? bmj. 1997;315(7106):459. doi: 10.1136/bmj.315.7106.459 20. arguello b, fernandez‐llimos f. clinical pharmacology information in summaries of product characteristics and package inserts. clin pharmacol ther. 2007;82(5):566-71. doi: 10.1038/sj.clpt.6100198. 21. arguello b, salgado tm, fernandez‐llimos f. assessing the information in the summaries of product characteristics for the use of medicines in pregnancy and lactation. br j clin pharmacol. 2015;79(3):537-44. doi: 10.1111/bcp.12515 22. beers e, egberts tcg, leufkens hgm, jansen paf. information for adequate prescribing to older patients. drugs aging. 2013;30(4):255-62. doi: 10.1007/s40266-013-0059-y. 23. anderson bl, silverman gk, loewenstein gf, zinberg s, schulkin j. factors associated with physicians’ reliance on pharmaceutical sales representatives. acad med. 2009;84(8):994-1002. doi: 10.1097/acm.0b013e3181ace53a. 24. shrestha s, khatiwada ap, gyawali s, shankar pr, palaian s. overview, challenges and future prospects of drug information services in nepal: a reflective commentary. j multidiscip healthc. 2020;13:287. doi: 10.2147/jmdh.s238262 25. marrone cm, heck am. impact of a drug information service: practitioner hours saved. 2000;35(10):1065-70. doi: 10.1177/001857870003501018. 26. escalante-saavedra pa, marques-batista g, maniero hk, bedatt-silva r, calvo-barbado dm. brazilian drug information centre: descriptive study on the quality of information 2010-2015. farm hosp. 2017;41(3):334-45. doi: 10.7399/fh.2017.41.3.10641. 27. almazrou da, ali s, alzhrani ja. assessment of queries received by the drug information center at king saud medical city. j pharm bioallied sci. 2017;9(4):246-50. doi: 10.4103/jpbs.jpbs_166_17. 28. asmelashe gd, binega mg, birarra mk. the needs and resources of drug information at community pharmacies in gondar town, northwest ethiopia. biomed res int. 2017;2017:8310636. doi: 10.1155/2017/8310636. 35civil med j | vol 01 | issue 01 | jan, 2023 original article mjsbh vol 21 issue 2 jul-dec 2022 post covid health problems; babita s, et al. most of the covid-19 infected people recover within few weeks of illness but some of them have experienced a variety of midand long-term effects after recovery from acute illness which is known as post covid-19 conditions or long covid. these people may experience tiredness, dyspnea, fatigue, headache, persistent loss of smell or taste, cough, depression, low-grade fever, muscle pain, and joint pains etc. these consequences are the result of organ damage during acute covid-19 infection, neurobehavioral abnormalities due to disease process, hospital admission, isolation and societal stigma etc.1,2 many studies suggest a higher incidence of covid-19 infections among healthcare workers. however, information about the long-term complications affecting this population is lacking. the healthcare professionals have been at the forefront of the battle against covid-19 as they are the front-liners who are directly involved in caring covid patients. therefore, they are vulnerable to this highly infectious disease. after being infected with this, most of them may experience post covid conditions which adversely affects their health and quality of life.3-5 the studies of general people reported that considerable number of people with covid infection suffered from post covid health problems.6,7 however, there is limited information on this issue among nepalese healthcare workers. the aim of this study was to identify the post original article introduction post covid health problems faced by covid-19 infected healthcare professionals of a tertiary level hospital 1 shree birendra hospital, chhauni, kathmandu, nepal 2 college of nursing, nepalese army institute of health sciences, bhandarkhal, sanobharyang, kathmandu, nepal babita sapkota1, gita dhakal2 chalise, sarala shrestha2 introduction: covid-19 is an infectious disease which predominantly affects the lungs but it can also affect other organs such as gastro-intestinal system, brain, heart etc. the substantial proportion of infected people experience mild to moderate symptoms and recover with no after-effects. some people with covid19 can experience long term health problems, known as post-covid health problems. these are inflammatory or host response towards virus that occurs after four weeks of initial infection and beyond. the aim of this study was to find out the post covid health problems faced by covid-19 infected healthcare professionals of a tertiary level hospital. methods: this was a descriptive cross-sectional study carried out among healthcare professionals recovered from covid-19 infection who were selected by using non -probability purposive sampling technique. a semi-structured self-administered questionnaire was used for data collection. the collected data were analyzed by using descriptive and inferential statistics. results: out of 108 healthcare professionals who participated in the study, 42.6% were experiencing various post-covid health problems. these problems included fatigue (78.3%), persistent cough (54.3%), headache (37%), malaise (34.8%), body ache (32.6%) and others. no significant association of the experience of postcovid health problems among respondents with their age, sex and covid-19 vaccination status was revealed at 0.05 level of significance. conclusions: a considerable proportion of health professionals are liable to experience various post-covid health problems after being infected with covid19. their age, sex and covid-19 vaccination status do not tend to influence on their post-covid health problems. abstractcorresponding author gita dhakal chalise, associate professor, college of nursing, nepalese army institute of health sciences, bhandarkhal, sanobharyang, kathmandu, nepal e-mail: gita.dhakal@naihs.edu.np online access keywords covid-19 infection; healthcare professionals; post-covid health problems post covid health problems; babita s, et al. © the author(s) 2023. this work is licensed under a creative commons attribution 4.0 international license. (cc by-nc) doi: 10.3126/mjsbh.v21i2.47361 received date: 09 aug, 2022 accepted date: 17 dec, 2022 https://creativecommons.org/licenses/by/4.0/ 36 mjsbh vol 21 issue 2 jul-dec 2022 original article post covid health problems; babita s, et al. covid-19 health problems faced by covid-19 infected health care professionals of a tertiary level hospital in nepal. methods this was a descriptive cross-sectional study carried out among the health professionals (doctors and nurses) of shree birendra hospital, chhauni, kathmandu, nepal, in february 2022. a non-probability purposive sampling technique was used for the selection of study subjects. the healthcare professionals who were infected with covid-19 at least six weeks prior to data collection period were included in the study. the sample size was calculated by using slovin’s formula i.e. n = n/1 + ne2 where, n = size of the study population (there were in total 345 doctors and nurses meeting the criteria); n = required sample size and e = margin of error (set at 8% i.e., 0.08). using this formula, the required sample size was 108. a semi-structured self-administered questionnaire which consisted of questions on sociodemographic characteristics and vaccination status, smoking and alcohol habits prior to covid infection, questions related to covid-19 infection and post covid health problems and their lifestyle after covid-19 infection. the ethical approval for this study was taken from the institutional review committee (irc) of nepalese army institute of health sciences (ref. 560, february 2022). the permission for data collection was taken from the administration of shree birendra hospital. written informed consent was taken with each respondent. the respondents were also informed that they would be free to withdraw their participation from the study at any time if they wish. anonymity was maintained by using serial numbers instead of respondents’ names. data were entered in the statistical package for the social sciences (spss) version 16 software and analyzed by using descriptive statistics i.e. frequency, percentage, mean and standard deviation and inferential statistics i.e. chi-square test. results in this study, 75.9% of respondents were of the age group of ≤ 30 years (mean age = 28.48 years, sd ± 5.829). majority of the respondents were females (68.5%) and belonged to brahmin / chhetri ethnicity (60.2%). almost all (95.4%) had completed two doses of covid-19 vaccine. among them, 87.4% had covishield vaccination. in this study, only 3.8% of the respondents had suffered from chronic health problems and they were thyroid problems (75%) and hypertension (25%). table 1 shows that majority (68.5%) of the respondents were infected with covid-19 once whereas 6.5% were infected repeatedly i.e. three or more times. the majority (73.1%) of them had mild symptoms of covid-19 infection. the duration of illness from covid-19 was one week among 57.3% respondents whereas among 5.6% respondents it was more than or equal to four weeks. table 1. frequency of covid-19 infection, severity, and duration of recovery in the latest covid-19 (n = 108) variables no. percent frequency of infection 1 time 74 68.5 2 times 27 25.0 ≥ 3 times 7 6.5 severity of latest infection mild 79 73.1 moderate 26 24.1 severe 3 2.8 duration of recovery in latest infection 1 week 62 57.3 2 weeks 34 31.5 3 weeks 6 5.6 ≥ 4 weeks 6 5.6 regarding the experience of post-covid health problems, table 2 reveals that 42.6% of the respondents had experienced post-covid health problems. with regards to the type of health problems, highest proportion (78.3%) of them experienced persistent fatigue followed by chronic cough (54.3%), headache (37%), malaise (34.8%) and body ache (32.6%). table 2. experience of post-covid health problems variables number percent post-covid health problems experienced (n = 108) yes 46 42.6 no 62 57.4 type of health problems experienced* (n = 46) fatigue 36 78.3 chronic cough 25 54.3 headache 17 37.0 malaise 16 34.8 body ache 15 32.6 37civil med j | vol 01 | issue 01 | jan, 2023 original article mjsbh vol 21 issue 2 jul-dec 2022 post covid health problems; babita s, et al. shortness of breath 14 30.4 joint pain 14 30.4 loss of smell 11 23.9 loss of taste 11 23.9 chest pain 8 17.4 diarrhea 8 17.4 poor memory and concentration 6 13.0 mood changes 6 13.0 weight loss 4 8.7 dizziness 4 8.7 persistent fever 3 6.5 difficulty in sleeping 3 6.5 anxiety 3 6.5 repeated disturb ing and unwanted thought 1 2.2 * multiple responses with regard to the lifestyle following covid-19 infection, 46.3% of the respondents used to sleep for less than six hours and a similar percentage of respondents used to sleep for six to eight hours at night (table 3). the majority (69.4%) of the respondents took rest in-between work sometimes, 52.4% used to perform yoga and meditation sometimes and 93.9% of respondents used to perform deep breathing exercise after covid-19 infection. table 3. lifestyle of respondents after covid-19 infection variables no. percent duration of sleep at night (in hours) (n = 108) 6 > 50 46.3 8 6 50 46.3 8 < 8 7.4 rest in between work (n = 108) never 28 26.0 sometimes 75 69.4 frequently 5 4.6 frequency of yoga and meditation (n = 21) sometimes 11 52.4 frequently 7 33.3 always 3 14.3 type of breathing exercise (n = 33) deep breathing exercise 31 93.9 pursed lip breathing exercise 2 6.1 the higher proportion (53.8%) of the respondents belonging to > 30 years age had experienced post-covid health problems in comparison to ≤ 30 years (39.0%) respondents however this was not statistically significant (table 4). likewise in terms of sex of the respondents, the higher proportion of female respondents (48.6%) had experienced post-covid health problems in comparison to the male respondents (29.4%) but again it was statistically insignificant. no significant association of the experience of post-covid health problems was seen with marital status of the respondents. table 4. association of experience of post-covid health problems with socio-demographic variables (n = 108) variables experience of postcovid health problems chi-square value pvalue no no. (%) yes no. (%) (age (in years ≤ 30 50 (61.0) 32 (39.0) 1.774 0.183 > 30 12 (46.2) 14 (53.8) sex male 24 (70.6) 10 (29.4) 3.526 0.06 female 38 (51.4) 36 (48.6) marital status married 23 (54.8) 19 (45.2) 0.197 0.657 unmarried 39 (59.1) 27 (40.9) there was no significant association of post-covid health problems with covid-19 vaccination status and smoking and alcohol habits (table 5). 38 mjsbh vol 21 issue 2 jul-dec 2022 original article post covid health problems; babita s, et al. table 5. association of post-covid health problems with covid-19 vaccination status and smoking and alcohol habits (n = 108) variables post-covid health problems chi square value -p value no yes completion of vaccine yes 59 (57.3) 44 (42.7) 0.014 1.000# no 3 (60.0) 2 (40.0) smoking habit yes 6 (66.7) 3 (33.3) 0.344 0.557 no 56 (56.6) 43 (43.4) alcohol habit yes 13 (48.2) 14 (51.9) 1.262 0.261 no 49 (60.5) 32 (39.5) #fisher’s exact test discussion covid-19 infection is a complex condition which affects many survivors of covid-19 infections. till date, the exact pathology of this disease is poorly understood but it has a huge negative impact on survivor’s health and occupation.8 the post-covid conditions are found more often in people who had severe covid-19 illness, but anyone who has been infected with sars-cov-2 can experience post-covid conditions, even people who had mild illness or no symptoms from covid-19. few people who had been infected with severe covid-19 may experience symptoms of multi-organ effects or autoimmune conditions lasting weeks or months.9 as the population of patients recovering from covid-19 grows, it is necessary to establish an understanding of the healthcare issues surrounding them. in the present study, 42.6% of the respondents experienced one or more post-covid symptoms. this finding is similar to the study conducted among 138 healthcare workers in uk where 45% reported persistent symptoms after covid-19 infection.8 similarly, 46% patients developed post-covid symptoms in bangladesh.10 covid-19 is recognized as a multi-organ disease with a broad spectrum of manifestations. there are increasing reports of persistent and prolonged effects after acute covid-19 similar to post-acute viral syndromes described in survivors of other virulent coronavirus epidemics.11 as part of post-acute covid-19 syndrome, dyspnoea and cough were found to remain persistent in most infected people beyond four weeks from the onset of symptoms. the mechanisms of dyspnoea after covid-19 are multifactorial, including parenchymal sequelae, dysfunctional breathing, cardiovascular dysfunction and muscular deconditioning.12,13 the present study reveals that more than half of the respondents had chronic cough followed by shortness of breath after covid-19 infection. this finding is consistent with the study conducted among wrightington, wigan and leigh nhs teaching trust (wwl) staff from the uk where 40% experienced mild-to-moderate shortness of breath and moderate-tosevere fatigue (39%).8 the findings from another study conducted in sukra raj tropical and infectious disease hospital among 118 patients revealed that 40.7% of the post-covid patients had dyspnea and 27.1% had cough.5 cough after covid-19 was due to activation of the vagal sensory nerves, which leads to a cough hypersensitivity state and to neuro-inflammatory events in the brain.14 the corona viruses produce a wide variety of acute cns symptoms including headaches, cognitive dysfunction, motor difficulties and loss of consciousness.15 as per robert belvis, acute headache during covid-19 is attributed to systemic viral infection, primary cough headache, tensiontype headache and headache attributed to heterophoria; and headache attributed to hypoxia and a new headache can appear if the second phase related to the cytokine storm.16 in the present study, 37% of respondents experienced headache and 6.5% experienced persistent fever. this was in contrast to the study conducted among bangladeshi patients where 20% experienced headache and 62% experienced persistent fever.10 this discrepancy might be due to differences in population and setting of the study. in the present study, more than two-fifth of respondents experienced loss of smell and loss of taste. this is consistent with a study conducted among 1250 patients in the united states of america, where 13.1% had loss of taste and smell.17 another study from germany among 442 patients also documented that 12.4% respondents experienced loss of smell and loss of taste (11.1%).18 the exact pathophysiology of olfactory test disorder in patients with covid-19 remains to be elucidated, but local mucosal inflammation and olfactory epithelial destruction appear to be the main mechanisms.19,20 fatigue may be the most frequent symptom reported by patients after the initial infection in various studies. as cited by montani et al, fatigue has been reported among 40– 70% of patients in all the reported cases during six months of the post-acute phase.21 the present study also identified that more than three-fourth of the respondents experienced fatigue and very few experienced sleeping difficulties after recovery from covid-19 infection. this https://headachejournal.onlinelibrary.wiley.com/action/dosearch?contribauthorraw=belvis%2c+robert https://headachejournal.onlinelibrary.wiley.com/action/dosearch?contribauthorraw=belvis%2c+robert 39civil med j | vol 01 | issue 01 | jan, 2023 original article mjsbh vol 21 issue 2 jul-dec 2022 post covid health problems; babita s, et al. finding is consistent with the findings of a study from china among 1733 patients where 63% had fatigue and 26% had sleeping difficulties and among 431 patients from switzerland where 55% experienced fatigue.4, 22 in the present study, almost one third of the respondents had joint pain and 17.4% had chest pain. this finding is consistent with the study conducted in italy among 143 patients where 27.3% reported joint pain and 21.7% reported chest pain.23 covid-19 can also generate acute psychiatric consequences and symptoms which can persist over time after the acute phase. the anxiety-provoking social media context, the fear of a serious form of the disease, the fear of not being able to benefit from appropriate care, the lack of established curative treatment, the lack of visits from relatives for hospitalized patients, brain damage caused by the virus itself, and inflammatory and immune imbalance have favored anxiety or depressive symptoms. in the present study also, 13% respondents experienced poor memory and concentration followed by mood changes (13%) and anxiety (6.5%). similar findings were reported in various studies from different countries.5, 21 conclusions significant number of health professionals are likely to experience various post-covid health problems. the most common health problems are fatigue, persistent cough, headache, malaise, body ache, shortness of breath and joint pain. their age, sex, marital status, covid-19 vaccination status, smoking habits and alcohol intake do not tend to influence on post-covid health problems. acknowledgements we would like to express our cordial thanks to all the respondents for providing valuable information for the study. our sincere thank go to assoc. prof. bibhav adhikari for his valuable statistical guidance and suggestions. references 1. world health organization. coronavirus disease (covid-19): post covid-19 condition [homepage on the internet ]. [updated 2021 dec 16; cited 2022 aug 6]. available from https://www.who.int/news-room/questionsand-answers/item/coronavirus-disease-(covid-19)-postcovid-19-condition 2. chippa v, aleem a, anjum f. post-acute coronavirus (covid-19) syndrome. [updated 2022 jun 19]. in: statpearls [internet ]. treasure island (fl): statpearls publishing; 2022 jan. available from https://www.ncbi.nlm.nih.gov/books/ nbk570608/ 3. wu l, wu y, xiong h, mei b, you t. persistence of symptoms after discharge of patients hospitalized due to covid-19. front med (lausanne) [internet ]. 2021 nov 22;8:761314. doi: 10.3389/fmed.2021.761314. 4. huang c, huang l, wang y, li x, ren l, gu x, et al. 6-month consequences of covid-19 in patients discharged from hospital: a cohort study. the lancet [internet ]. 16 jan 2021;397(10270):220-232. doi: 10.1016/s0140-6736(20)32656-8. 5. bastola a, nepal r, shrestha b, maharjan k, shrestha s, chalise bs, et al. persistent symptoms in post-covid-19 patients attending follow-up opd at sukraraj tropical and infectious disease hospital (stidh), kathmandu, nepal. trop med infect dis. 28 jun 2021;6(3):113. doi: 10.3390/tropicalmed6030113 6. pandey sk, sharma v. a tribute to frontline corona warriorsdoctors who sacrificed their life while saving patients during the ongoing covid-19 pandemic. indian j ophthalmol [internet ]. 2020. may;68(5):939-942. doi: 10.4103/ijo.ijo_754_20. 7. shrestha rm, kunwar ar. covid-19 impact on doctors and health workers. orthod. j. nepal [internet ]. 2020 sep 11;10(2):2-5. 8. gaber tak, ashish a, unsworth a. persistent post-covid symptoms in healthcare workers. occup med (lond) [internet ]. 2021 jun 16;71(3):144-146. doi: 10.1093/occmed/kqab043. 9. centers for disease control and prevention. long covid or post-covid conditions [homepage on the internet ]. [updated 2022 july 11; cited 2022 aug 6]. available from https: //www.cdc.gov/coronavirus/2019-ncov/long-termeffects/index.html 10. mahmud r, rahman mm, rassel ma, monayem fb, sayeed sj, islam ms, et al. post-covid-19 syndrome among symptomatic covid-19 patients: a prospective cohort study in a tertiary care center of bangladesh. plos one [internet ]. 2021 apr 8;16(4):e0249644. doi: 10.1371/journal.pone.0249644 11. nalbandian a, sehgal k, gupta a, madhavan mv, mcgroder c, stevens js, et al. post-acute covid-19 syndrome. nat. med [internet ]. 2021 apr;27(4):601-15. doi: 10.1038/s41591-021-01283-z 12. bellan m, soddu d, balbo pe, baricich a, zeppegno p, avanzi gc, et al. respiratory and psychophysical sequelae among patients with covid-19 four months after hospital discharge. jama netw. open. [internet ]. 2021 jan 4;4(1):e2036142-. 13. debeaumont d, boujibar f, ferrand-devouge e, artaudmacari e, tamion f, gravier fe, et al. cardiopulmonary exercise testing to assess persistent symptoms at 6 months in people with covid-19 who survived hospitalization: a pilot study. physical therapy [internet ]. 2021 jun;101(6):pzab099. doi: 10.1093/ptj/pzab099 14. song wj, hui ck, hull jh, birring ss, mcgarvey l, mazzone sb, et al. confronting covid-19-associated cough and the post-covid syndrome: role of viral neurotropism, neuroinflammation, and neuroimmune responses. lancet 40 mjsbh vol 21 issue 2 jul-dec 2022 original article post covid health problems; babita s, et al. respir med. [internet ]. 2021 may 1;9(5):533-44. doi:10.1016/s2213-2600(21)00125-9 15. ritchie k, chan d, watermeyer t. the cognitive consequences of the covid-19 epidemic: collateral damage? brain communications [internet ]. 2020;2(2). doi: 10.1093/braincomms/fcaa069 16. belvis r. headaches during covid‐19: my clinical case and review of the literature. headache: the journal of head and face pain [internet ]. 2020 jul;60(7):1422-6. doi:10.1111/head.13841 17. chopra v, flanders sa, o’malley m, malani an, prescott hc. sixty-day outcomes among patients hospitalized with covid-19. ann. int. med [internet ]. 2021 apr;174(4):5768. doi: 10.7326/m20-5661 18. augustin m, schommers p, stecher m, dewald f, gieselmann l, gruell h, et al. post-covid syndrome in non-hospitalized patients with covid-19: a longitudinal prospective cohort study. lancet regional health-europe [internet ]. 2021 jul 1;6:100122. doi: 10.1016/j.lanepe.2021.100122 19. eliezer m, hamel al, houdart e, herman p, housset j, jourdaine c, et al. loss of smell in patients with covid-19: mri data reveal a transient edema of the olfactory clefts. neurology [internet ]. 2020 dec 8;95(23):e3145-52. doi: 10.1212/wnl.0000000000010806 20. niesen m, trotta n, noel a, coolen t, fayad g, leurkinsterk g, et al. structural and metabolic brain abnormalities in covid-19 patients with sudden loss of smell. eur j nuc med mol. imaging [internet ]. 2021 jun;48(6):1890-901. doi: 10.1007/s00259-020-05154-6 21. montani d, savale l, noel n, meyrignac o, colle r, gasnier m, et al. post-acute covid-19 syndrome. eur respir rev [internet ]. 2022 mar 31;31(163). doi: 10.1183/16000617.0185-2021. 22. menges d, ballouz t, anagnostopoulos a, aschmann he, domenghino a, fehr js, et al. burden of post-covid-19 syndrome and implications for healthcare service planning: a population-based cohort study. plos one [internet ]. 2021 jul 12;16(7):e0254523. doi: 10.1371/journal.pone.0254523 23. carfì a, bernabei r, landi f. persistent symptoms in patients after acute covid-19. jama [internet ]. 2020 aug 11;324(6):603-5. doi: 10.1001/jama.2020.12603 6 mjsbh vol 21 issue 2 jul-dec 2022 original article analysis of chemical composition of urolithiasis; basukala s, et al. infrared spectroscopic analysis of chemical composition of urolithiasis among serving nepalese soldiersan institutional study department of urosurgery, shree birendra hospital, nepalese army institute of health sciences, sanobharyang, bhandarkhal, kathmandu, nepal bharat bahadur bhandari, sunil basukala, narayan thapa, bikash bikram thapa, anjit phuyal original article urolithiasis can be defined as solid biogenous formations of the urinary system with crystalline structure and size more than one milimeter.1 urolithiasis is one of the oldest recorded diseases of mankind with documentation of urinary stone treatments in ancient egyptian medical literatures dating from 1500 bc.2 known as randall’s plaques, on renal papillary surfaces. crystal formation and retention within the terminal collecting ducts, the ducts of bellini, leading to the formation of randall’s plugs, is the other pathway. both pathways require supersaturation leading to crystallization, regulated by various crystallization modulators produced in response to changing urinary conditions. high supersaturation, as a result of a variety of genetic and environmental factors, leads to crystallization in the terminal collecting ducts, eventually plugging their openings into the renal pelvis. stasis behind the plugs may lead to the formation of attached or unattached stones in the tubular lumen. deposition of crystals on the plug surface facing the pelvic or tubular urine may result in stone formation on the randall’s plugs. kidneys of idiopathic stone formers may be subjected to oxidative stress as a result of increased urinary excretion of calcium / oxalate / phosphate and / or decrease in the production of functional crystallization inhibitors or in relation to co-morbidities such as hypertension, atherosclerosis, or acute kidney injury. we have proposed that production of reactive oxygen species (ros) the prevalence of urolithiasis in asia ranges from 1 to 5% with highest incidence in saudi arabia with 19.1%.3,4 the recurrence rates among asian population was 6 to 17% at one year, rises to 21-53% at three-five introduction introduction: various pathologic and metabolic diseases might manifest as renal stones. acquiring knowledge of the urinary stone constituents is important. kidney stone analysis is recommended in the basic evaluation of stone disease. this study aims to identify the chemical composition of renal stones and briefly identify the predisposing factors. methods: this was a retrospective analytical study conducted from may 01 2018 to may 30, 2020 for a period of two years in a 750-bedded tertiary care hospital, shree birendra hospital (sbh), kathmandu, nepal. all patients who underwent fourier transform infrared spectroscopy (ft-ir) analysis of the retrieved calculi were included in the study. the type of surgery performed was decided by the operating surgeon based on the treatment options available at the center and the recent evidences on management of the stone. the study was conducted after an approval from institutional review board (irb) of naihs. results: a total 400 patients underwent infrared spectroscopic analysis (ft-ir) for the retrieved stone. among them, majority of urolithiasis was seen among male population 277 (69.2%) with an age group between 31 – 45 years {204 (51%)}. calcium oxalate was detected in majority of cases 257 (64.25%) followed by struvite 90 (22.5%) and mixed stones 53 (13.2 %). conclusions: majority of the patients in our study had kidney stone followed by ureteric stone. the predominance of calcium oxalate stones was seen in kidney stones followed by struvite and mixed stones. abstractcorresponding author sunil basukala assistant professor, department of surgery, nepalese army institute of health sciences, sanobharyang, bhandarkhal, kathmandu, nepal. email: sunilbasukala@naihs.edu.np online access keywords urolithiasis, infrared spectroscopy, struvite analysis of chemical composition of urolithiasis; basukala s, et al. © the author(s) 2023. this work is licensed under a creative commons attribution 4.0 international license. (cc by-nc) doi: 10.3126/mjsbh.v21i2.42802 received date: 30 jan, 2022 accepted date: 17 dec, 2022 https://creativecommons.org/licenses/by/4.0/ 7civil med j | vol 01 | issue 01 | jan, 2023 original article mjsbh vol 21 issue 2 jul-dec 2022 analysis of chemical composition of urolithiasis; basukala s, et al. years and the lifetime recurrence approximately 60 to 80%.3 various pathologic and metabolic diseases might manifest as renal stone. a stone might be one of the first manifestation of systemic and metabolic disorders.5 stone analysis helps to identify the cause of stone formation and its growth by collecting all relevant information from the stone. investigations of blood and urine biochemistry of each stone former can help to identify metabolic disorders or risk factors involved in lithogenesis. but these metabolic investigations might fail in actual diagnosis of the lithogenic disease if stone composition does not match.5-8 there are no documented research regarding spectroscopic analysis of urolithiasis among nepalese soldiers. this study thus aims to identify the chemical composition of renal stones and briefly identify the predisposing factors among nepalese soldiers. methods this retrospective study was conducted from may 2018 to may 2020 at shree birendra hospital, kathmandu, nepal. this is a tertiary care teaching hospital affiliated with nepalese army institute of health sciences with a capacity of 750 beds. all patients who underwent any form of stone removal surgery in sbh with stone fragments retrieved after the study were included in the study. data were collected from hospital medical records section which included information on socio-demographic profile, past medical, personal and drug histories. information of various blood parameters, urine tests, computed tomography (ct) findings, chemical composition of stones and stone clearance in post-operative ultrasound were gathered. those case sheet with incomplete information were excluded from the study. data regarding stone fragments were from a private laboratory in kathmandu for fourier transform infrared spectroscopy (ft-ir). data from the completed questionnaires were entered in excel sheet. after editing, the data were exported to spss 20.0 for analysis. categorical variables were summarized using percentages, proportions, means, medians and standard deviations. continuous data with normal distribution were presented as mean with standard deviation while data with non-normal distribution were presented as median with inter quartile range. comparison between groups was done using analysis of variance (anova) and p value of < 0.05 was considered statistically significant. the level of significance was set at p < 0.05. this study was conducted after an approval from institutional review board (irb) of naihs ref no. 245/ reg. no. 470. results a total of 400 patients meeting the inclusion criteria were included in the study. among them, majority 277 (69.2%) were males and 123 (30.8%) were females. the age distribution ranged from 22 years to 44 years with a mean of 32.02 ± 4.64 years. among them majority of patients belonged to age group between 3145 years 204 (51%) table 1. most of the patients, 343 (85.7%) were from the hilly region and 57 (14.3%) were from terai madesh region. majority of patient with urolithiasis belonged to janjatis followed by brahmins with 30.75% and 24.25% respectively. a total of 304 (76.75%) of patient belonged to lower rank soldiers including non-commissioned officers (nco) and junior commissioned officers (jco) as shown in table 1. table 1. demographic profile of the patient with urolithiasis variables frequency(n) percentage (n%) age in years 18 30 31 45 46 60 > 60 91 204 58 47 22.75 51.0 14.5 11.75 sex male female 277 123 69.2 30.8 geographical location hill terai / madhesh 343 57 85.7 14.3 ethnicity brahmin chhetri janjati dalit medeshi 97 70 123 65 45 24.25 17.5 30.75 16.25 11.25 army personnel ranks nco jco officers 184 123 93 46.0 30.75 23.25 majority of the patients in our study had kidney stone 224 (56 %) followed by ureteric stone 176 (44%) as shown in table 2. all patients with kidney stones underwent percutaneous nephrolithotomy (pcnl) and patients with ureteric stones were managed with ureteroscopic lithotripsy (ursl). kidney stones were most commonly present on lower pole calyx, followed by pelvi-ureteric junction, upper pole and mid pole, while five patients had stones in multiple calyces. among the patients with ureteric stones, three were in upper ureter and two each in mid ureter and vesicoureteral junction as depicted in table 2. 8 mjsbh vol 21 issue 2 jul-dec 2022 original article analysis of chemical composition of urolithiasis; basukala s, et al. table 2. stone localization among patient presented with urolithiasis variables frequency (n) percentage (n%) stone localization kidney stone • lower pole calyx • pelvi-ureteric junction • upper pole calyx • midpole ureteric stone • upper ureteric stone • mid ureteric stone • lower ureteric stone 224 97 67 43 17 176 81 57 38 56.0 43.30 29.90 19.19 7.5 44.0 46.02 32.38 21.59 the size of stones ranged from 8 mm to 47 mm in largest diameter with the median of 15 mm (iqr= 7). mean hounsfield unit (hu) of calcium oxalate stones was 1142.86 ± 202.8, that of struvite stones was 1259.89 ± 216.86 and that of mixed stones was 1384.6 ± 77.01. the hu differ significantly between calcium oxalate stone type (p = 0.04) and struvite stone (p = 0.23) but there were no statistically significant differences in hu value struvite stones mixed stones (p = 0.51). table 3. mean size and ct hounsfield unit (hu) of urolithiasis variables mean p value mean stone size mean hu of stone • calcium oxalate stones • struvite stones • mixed type 15 ± 7 .0 1142.86 ± 202.8 1259.89 ± 216.86 1384.6 ± 77.01 0.04 0.49 0.51 the most common type of was calcium oxalate 257 (64.25%) containing mainly 80% calcium monohydrate + 20% calcium dihydrate 112 (28%) of all the urolithiasis followed by struvite stones 90 (22.5%) composed of 80 100% of magnesium phosphate trihydrate and 20% cholesterol and mixed stones 53 (13.25%) as shown in table 4. calcium oxalate stones were mixture of variable proportions of calcium monohydrate and calcium dihydrate. majority of the stones contained at least two identifiable components. table 4. stone composition among the patient presented with urolithiasis particulars variables frequency (%) n stone composition calcium oxalate calcium mono90% hydrate + 10% calcium dihydrate 64 (16%) calcium mono80% hydrate + 20% calcium dihydrate 112 (28%) calcium mono70% hydrate + 30% calcium dihydrate 37 (9.25%) calcium mono60% hydrate + 40% calcium dihydrate 44 (11%) struvite stones 90 (22.5%) mixed stones 53 (13.2%) total 400 (100%) post-operative ultrasound showed majority of the patients had stone clearance. the stone clearance rate following pcnl was 97.12% while ursl achieved 100% clearance. one patient with residual stone had struvite stone while two had calcium oxalate stones. discussion serving soldiers are a distinct group of people with higher level of physical activities, relatively healthy with no underlying co-morbidities and sharing a similar working environment and diet with each other. as urolithiasis is a disease with high recurrence rate, knowledge about the composition of the stone could guide in further metabolic workup and individualized as well as group directed preventive measures. this is the first study regarding the composition of urinary stones done using ft-ir in nepal. previous studies done had used wet chemical analysis of stone composition. wet chemical analysis can only identify the individual ions and cannot determine the compound and also needs 10 15 mg of material which may not be always available. ft-ir on the other hand has high accuracy in determination of the relative percentages of different components and some rare stone types can only be detected by ft-ir. the mean age of the patients in our study was 32.02 ± 4.64 years which is similar to the mean age of 32.6 years among the soldiers deployed in iraq.9 the mean age however is low compared to general population as shown in study done by chou et al in taiwan which showed mean age of the patients with urolithiasis was 52.5 ± 13.5 years.10 this difference is largely due to the structure of our study population which only included young serving soldiers. this could also be due to the fact that the peak 9civil med j | vol 01 | issue 01 | jan, 2023 original article mjsbh vol 21 issue 2 jul-dec 2022 analysis of chemical composition of urolithiasis; basukala s, et al. age of stone formation in men is 30 years and in women is 35 and 55 years. the male to female ratio was 9:1 in our study. studies by hesse et al6 in germany showed males were more prone to nephrolithiasis. but very high male to female ratio in our study is probably the reflection of male predominance in the army. in our study, the most common location of stone was kidney. the study done by tang r et al11 showed that most common anatomical location of stone was kidney (45.29%) followed by bladder and ureter.12 the most common type of calculi in our study was calcium oxalate stones. the risk factors for calcium stones includes hypercalciuria, hyperparathyroidism, hypocitraturia and renal tubular acidosis but in our study population there were no reported comorbidities however detailed workup for the presence of co-morbidities were not carried out.13 the consumption of animal protein which leads to increased excretion of oxalate in urine could be one of the risk factors for calcium oxalate stones in our population. the second most common stone in our study was struvite stone. these stones are mainly result of urinary tract infection by urease forming organisms like proteus and escherichia coli. in our population, only three patients with struvite stone gave history of urinary tract infection. this could be because of recall bias or lack of diagnosis due to unavailability of proper health facilities in rural parts of the country. durgawale et al13 reported the stone analysis reports of 125 patients from maharastra, india showed magnesium ammonium phosphate (struvite) stone was most predominant constituent of followed by calcium oxalate and calcium carbonate.13 liu et al reported findings of 10,000 urinary stone analyses showed that 73% of stones were calcium oxalate containing stones, 9.22% stones were struvite stones, 7.48 % were uric acid stones, 6. 6 % were calcium apatitie stones and remaining were rare stones.14 mandel et al15 showed that 41% of stones were comprised of single component, 42% had two components and 17% had three identifiable components when they reported 88,768 kidney stones.15 however in our study, majority of the stones contained at least two identifiable components (73.8%), 16.67% had single component and all were struvite stones and 9.5% of stones had three identifiable components. kadlec et al showed that among patients with bilateral stones 74.6% had the same primary stone in both kidneys, while 25.4% of the patients had discordant stones. most of the discordant stone formers were younger, with better renal function and larger stones.16 as all the patients in our study had undergone intervention on only one side, we do not have data on discordance of stone composition but as our patients are mostly young soldiers with normal renal function stone discordance should be considered. ct scan is the modality of choice in evaluation of suspected urinary stones. patel et al17 demonstrated that hu measurement on ncct may be useful in distinguishing calcium oxalate monohydrate and calcium oxalate dihydrate stones.17 in our study, there was statistically significant differences in hu measurement of calcium oxalate and mixed stones (p = 0.04) but there was no difference in hu values of struvite stones compared with calcium oxalate or mixed stones. as most of the stones were composed of calcium oxalate monohydrate, the difference between calcium oxalate monohydrate and calcium oxalate dihydrate could not be studied. torricelli et al18 showed that single energy ncct may be inadequate in definitive differentiation of stones due to overlap in radiographic profiles of cystine and uric acid stones.18 our study also showed high stone clearance rate of 91.42% with pcnl and 100% with ursl. as there was no difference in stone clearance rate among different stone types in our study, and also due to high rate of stone clearance in endourological procedures, stone composition might not play any significant role in predicting stone clearance in endourological procedures. our study did not include description of imaging findings, histopathology and intraoperative / postoperative comp lications. also, the findings of this single institution study done among the serving personnel of nepalese army may not be generalizable to the entire population of the country. conclusions calcium oxalate stone was the most the most common type of stone in the serving soldiers followed by struvite and mixed stones. stone clearance rates following endourological procedures are independent of stone composition. acknowledgements we would like to acknowledge staffs of medical record section for helping in tracing of the details of the case sheet of the patients for the study. references 1. schubert g. stone analysis. urol res. 2006 apr 14;34(2):146–50. doi: 10.1007/s00240-005-0028-y 2. bird vy, khan sr. how do stones form? is unification of theories on stone formation possible? arch esp urol. 2017;70(1):12–27. doi: 10.1007/978-1-84800-362-0_5  3. yoshida o, okada y. epidemiology of urolithiasis in japan: a chronological and geographical study. urol int. https://doi.org/10.1007/s00240-005-0028-y https://doi.org/10.1007/978-1-84800-362-0_5 10 mjsbh vol 21 issue 2 jul-dec 2022 original article analysis of chemical composition of urolithiasis; basukala s, et al. 1990;45(2):104–11. doi: 10.1159/000281680 4. stamatelou kk, francis me, jones ca, nyberg lm, curhan gc. time trends in reported prevalence of kidney stones in the united states: 1976–199411.see editorial by goldfarb, p. 1951. kidney int. 2003 may;63(5):1817–23. doi: 10.1046/j.1523-1755.2003.00917.x 5. scales cd, smith ac, hanley jm, saigal cs. prevalence of kidney stones in the united states. eur urol. 2012 jul;62(1):160–5. doi:  10.1016/j.eururo.2012.03.052 6. hesse a, brändle e, wilbert d, köhrmann k-u, alken p. study on the prevalence and incidence of urolithiasis in germany comparing the years 1979 vs. 2000. eur urol. 2003 dec;44(6):709–13. doi: 10.1016/s0302-2838(03)00415-9. 7. sohgaura a, bigoniya p. a review on epidemiology and etiology of renal stone. am j drug discov dev. 2017;7(2):54–62. doi: 10.3923/ajdd.2017.54.62  8. trinchieri a. epidemiology of urolithiasis: an update. clin cases miner bone metab. 2008 may;5(2):101–6. doi: 10.1007/978-1-84800-362-0_35  9. pugliese jm, baker kc. epidemiology of nephrolithiasis in personnel returning from operation iraqi freedom. urology. 2009 jul;74(1):56–60. doi: 10.1016/j.urology.2008.10.079  10. chou yh, li cc, wu wj, juan ys, huang sp, lee yc, et al. urinary stone analysis of 1,000 patients in southern taiwan. the kaohsiung j med sci. 2007 feb 1;23(2):63-6. doi: 10.1016/s1607-551x(09)70376-6 11. tang r, nancollas gh, giocondi jl, hoyer jr, orme ca. dual roles of brushite crystals in calcium oxalate crystallization provide physicochemical mechanisms underlying renal stone formation. kidney int. 2006 jul 1;70(1):71-8. doi: 10.1038/sj.ki.5000424 12. memon jm, naqvi sqh, bozdar ag, khaskheli mh, athar ma. the composition of urinary stones in central sindh. ann king edward med univ. 1970 jan 1;20(1 se-):85. doi: 10.21649/akemu.v12i2.886  13. durgawale p, shariff a, hendre a, patil s, sontakke a. chemical analysis of stones and its significance in urolithiasis. biomed res. 2010;21(3):305–10. doi: 10.1007/978-1-4899-0873-5_225  14. liu y, yasheng a, chen k, lan c, tusong h, ou l, et al. difference in urinary stone composition between uyghur and han children with urolithiasis. urolithiasis. 2017 oct;45(5):435-40. doi: 10.1007/s00240-016-0931-4 15. mandel ns, mandel ic, kolbach-mandel am. accurate stone analysis: the impact on disease diagnosis and treatment. j urol. 1982;45(1):3–9. doi: 10.1007/s00240-016-0943-0 16. kadlec ao, fridirici zc, acosta-miranda am, will th, sakamoto k, turk tmt. bilateral urinary calculi with discordant stone composition. world j urol. 2014;32(1):281–5. doi: 10.1007/s00345-013-1113-4 17. patel sr, haleblian g, zabbo a, pareek g. hounsfield units on computed tomography predict calcium stone subtype composition. urol int. 2009;83(2):175– 80. doi: 10.1159/000230020. 18. torricelli f, marchini g, de s, yamaçake k, mazzucchi e, monga m. predicting urinary stone composition based on single-energy non-contrast computed tomography: the challenge of cystine. j urol. 2014 apr 10;83. doi: 10.1016/j.urology.2013.12.066. https://doi.org/10.1159/000281680 https://doi.org/10.1046/j.1523-1755.2003.00917.x https://doi.org/10.1016/j.eururo.2012.03.052 https://doi.org/10.3923/ajdd.2017.54.62 https://doi.org/10.1007/978-1-84800-362-0_35 https://doi.org/10.1016/j.urology.2008.10.079 https://doi.org/10.1016/s1607-551x(09)70376-6 https://doi.org/10.1038/sj.ki.5000424 https://doi.org/10.21649/akemu.v12i2.886 https://doi.org/10.1007/978-1-4899-0873-5_225 https://doi.org/10.1007/s00240-016-0931-4 https://doi.org/10.1007/s00240-016-0943-0 https://doi.org/10.1007/s00345-013-1113-4 medical_journal_year2.pdf    1   1dr namrata rawal, consultant neuropsychiatrist,2 dr praswas thapa, consultant neuropsychiatrist,3dr yadav bista, head of dept, department of neuropsychiatry, shree birendra hospital, kathmandu, nepal abstract objectives: psychiatric consequences are very common following rta. the study is sought to identify the prevalence of psychiatric morbidity (e.g. depressive symptoms, anxiety symptoms and symptoms related to ptsd(post traumatic stress disorder) following injury sustained victims and psychiatric symptoms. methods: the 102 (male=83,female=19) patients were interviewed using a questionnaire to collect the sociodemographic data, the self rating questionnaire (srq) -beck depression inventory(bdi),beck anxiety inventory(bai) and the impact of event scale -revised (ies-r). patients were prospectively followed up for 1 month. patients were aged between 20-69 years. the impact of injury was assessed by iss (injury severity scale) and abi (abbreviated injury scale). results:the mean age was 33.93 years (range 20-69). overall, the prevalence rate o of anxiety symptoms-19.6%, depressive symptoms-21.6% and ptsd symptoms-35.3%. females had a higher rate of ptsd symptoms 52.6% (n = 10), compared to the males 31.3% (n=26). the majority of those with ptsd (47.2%) were young, 20 29 years. symptoms 51% and then anxiety symptoms30.4%. the symptoms gradually reduced in the fourth week to ptsd 35.3%, depression21.6% and anxiety-19.6%. the study also showed higher scales of psychiatric symptoms in major injuries in comparison to minor injuries showing direct correlation of psychiatric morbidity with severity of injury. conclusion: psychiatric symptoms are frequent and severe after major injuries and less severe after minor rta. psychopathology following injury is a frequent and persistent occurrence. early information and advice might reduce psychological distress and symptoms. introduction motor vehicle accidents therefore are a may occur even in those who have not suffered physical injuries. (1, 2) on stress ts with only a few maj and a n x i e t y. w l and pop some of this vari in this may also to the (3) involving drivers, passengers, pedestrians or cyclist. the term ‘accident’ erroneously suggests that all collisions are random (unpredictable) and accidental (unpreventable). (4) injury is a disease resulting from an interaction of agent, host and environment. once a person enters a health system for treatment of an injury, only then it is considered a health problem. (5) injury now ranks among the leading causes of morbidity and mortality as the primary cause of disease among children in the age group of 5 to 14 years, and the third leading cause among people between the ages of 15 to 29 years in 2000. there is an increasing realization that trauma can have marked and sustained psychological effects. up to 25% of severely injured patients experience some patients these reactions can be long lasting and have profound adverse effects on quality of life. those effective treatment can be administered. (6) in nepal fall from a height accounting for the address for correspondence: namrata_mahara@yahoo.com 2 accident is the commonest cause males are involved twice as the females which may be because males are being exposed to the risks of accidents. (7) the motor vehicle accidents are the single post traumatic stress disorder (ptsd).(8) prevalence of ptsd following mva, ranges from 10% (8) to 46% . (9) in another study by (10) reported that most of accidents in nepal. however there are few studies related to accidents and injuries. but there are many studies in western and european countries. in a study it is reported that in nepal 61.5% of spinal injuries are due to many factors like overcrowded roads, poor conditions of roads etc. (11) thus the present study is an attempt to identify the prevalence psychiatric consequences that some guidelines may be developed in future for the with other departments. whiplash injuries commonly occur in road somatic symptoms. (12) these somatic symptoms often accompanied by psychological symptoms such as initial ‘shock’ ‘dazed feeling, anxiety, anger. depression, libido altered appetite and weight, and in some cases, feeling of helplessness horror, despair and reliving experiences.(13) in severe cases where there has been an accompanying head injury with loss of consciousness, similar disorder may occur but post traumatic stress disorders appear to be less frequent. (14) personality changes and cognitive impairment may occur following countercoup and penetrating head injuries. (15) patients with posttraumatic stress disorder experience disabling memories and anxiety related to leading cause of post-traumatic stress disorder since vietnam war. (16) the primary psychosocial consequences of motor vehicle accidents as beyond ptsd fall into the emerging. first, mood disorders, especially new cases of major depression, are most common co-morbid problem: second, study it was (17) found that 27.4% of survivors with ptsd had another current co-morbid anxiety disorder. third, several studies mse a measure to constitute a psychiatric case .finally there is travel anxiety and driving reluctance: (18) found that 18.4% had travel anxiety at 1 year post mva assessment; other (19) reported 18.2%. methods patients and procedures;this prospective cross sectional study includes 102 patients, 83 men and 19 women, mean age 33.9 years (range: 20–69 years), who were admitted at orthopedic department after injury sustained due to rta. after obtaining informed consent, patients were followed by other instrument to assess the symptoms of anxiety, depression and post traumatic stress disorder. injury severity was assessed by administering iss and abi. patients were again followed up after 4 weeks and the same scale used for the assessment. the questionnaires ask the patients to estimate their anxi ety by using bai (beck anxiety inventory) (20) and depression by bdi (beck depression inventory) (21) and hies (horowitz’s impact of event scale) (22) to explore the psychological impact of a variety of traumas. the injury severity was assessed with use of abi (abbreviated injury score). (23) major injury caused the trauma in 55 patients and minor injury in 47 patients. most patients had upper secondary level education (n-53); third had primary education (n19), fourth had lower secondary education (n-13) and some had a university education (n-2). to compare age groups, patients were divided into 5 groups as shown in table 2. data about the patients participating in the study were collected and analyzed using spps-10 for window. instruments semi structured performa: self-designed semi structured performa was prepared to obtain the sociodemographic characteristics of the patients. it is used to record patient’s name, age, sex address, education, marital status, occupation, religion, economic status and presenting complaints. bdi (beck depression inventory): this inventory assesses depression for patient’s subjective perception. the subject has to rate according to how he has been feeling during the past two weeks on a 4 point. scale ranging from 0-3, maximum total score is 63. the total score is categorized into mild, moderate and severe depression. the inventory is considered as a standard scale for measuring severity of the symptoms of depression. the 21 item which are rated on a 4 point scales covers the wider psychopathology of depression. bai (beck anxiety inventory): bai is a 21 item self  3 rated questionnaire that describes common symptoms of anxiety. this scale has a reliability value of 0-92 and a validity that ranges from 82-87 and inventory is considered as a standard instrument to measure anxiety symptoms. scores have implication for both in measuring severity and assessing changes in symptoms due to intervention. ies (horowitz’s impact of event scale): ies was originally developed in 1979, later it was used for exploring the psychological impact of a variety of traumas. although many measures of ptsd symptoms have emerged (24), the ies remains widely used. the ies does not measure the hyper arousal symptoms of ptsd described in dsm-iv (25) injury severity score (iss): iss is used to assess abbreviated injury scale which is assigned a value form 1 to 6, with: minor injury (1) moderate injury (2) severe but not threatening (3) lifethreatening but survival likely (4) critical with uncertain survival (5) fatal (6) and its value correlates with the risk of mortality. results 102 patients (83 males and 19 females) were enrolled in study. the mean age was 33.93 years (range 20-69).the majority of rta patients were male age group between 20-29(49.4% n=41) and female age group between 30-39 ( 38.8% n=7). most of the participants were married (64.7% n = 66), hindu by religion (88.8% n=90) and of secondary level educated (34.3% n=35). the majority of them were service holder (24.55 n=25) and from middle socio economic status (68.6% n=70). table 1: above shows the prevalence of anxiety, depression and ptsd in 1 st and 4th week of patients of rta. the anxiety symptoms in 1st and 4th st and 4th duration anxiety symptoms 2 yes (%) no (%) 1st week 31(30.4) 71(69.6) p=0.075 4th week 20(19.6) 82(80.4) duration depressive symptoms 2 yes (%) no (%) 1st week 52(51.0) 50(49.0) p=0.000014th week 22(21.6) 80(78.4) duration ptsd symptoms yes (%) no (%) 2 1st week 95(93.1) 7(6.9) p=0.0000 4th week 36(35.3) 66(64.7) 4 age (years) anxiety symptoms p-valuefirst week fourth week no (%) yes (%) no (%) yes (%) 20-29 30(63.9) 17(36.1) 38(80.9) 9(19.1) p=0.065 30-39 18(78.2) 5(21.8) 20(86.9) 3(13.1) p=0.699 40-49 16(76.3) 5(23.7) 16(76.1) 5(23.9) p=1 50-59 5(62.5) 3(37.5) 6(75.0) 2(25.0) p=1 60-69 2(66.7) 1(33.3) 2(66.7) 1(33.3) p=1 total 71(69.6) 31(30.4) 82(80.4) 20(19.6) p-valueage (yrs) depressive symptoms 20-29 19(40.5) 28(59.50) 32(68.1) 15(31.9) 30-39 14(60.8) 9(39.2) 21(91.3) 2(8.7) p=0.007 40-49 13(61.9) 8(38.1) 18(85.7) 3(14.3) p=0.038 50-59 2(25.0) 6(75.0) 6(75.0) 2(25.0) p=0.16 60-69 2(66.7) 1(33.7) 3(100) p=0.132 total 50(49.0) 52(51.0) 80(78.4) 22(21.6) p=1.0 ptsd symptoms pvalue age (yrs) no (%) yes (%) no (%) yes (%) 20-29 4(8.5) 43(91.50 30(63.8) 17(36.2) p=0.000001 30-39 1(4.3) 22(95.7) 16(69.6) 7(30.4) p=0.00002 40-49 1(4.7) 20(95.2) 13(61.9) 8(38.1) p=0.0003 50-59 1(1.5) 7(87.5) 5(62.5) 3(37.5) p=0.119 60-69 3(100) 2(66.7) 1(33.3) p=0.40 total 7(6.9) 95(93.1) 66(64.7) 36(35.3)  5 table 2: st and 4th week. the ptsd symptoms in few of age group in 1 st and 4th 20-29years (p=0.000001), 30-39years (p=0.00002) and 40-49years (p=0.0003). table 3 table 3: 0.014 respectively) in 1st week but however in 4th minor and major injury (p=0.018 and p=0.013 respectively). using the iss patients of minor injuries were 47(male=38, female=9) and major injuries were 55 (male=45, female=10). using bai, the prevalence of anxiety in 4th week 20 (19.6%) was found among the patients enrolled in the study. the age of 20-29 years had maximum anxiety symptoms (19.1% n=9) and female (47.4% n=9) were affected more than male (26.5% n=22).according to severity of injury anxiety predominant in major injury patients (29% n=16) in comparison to minor injury patients (8.5% n=4). likewise the prevalence for depression was found to be 22 (21.6%) in 4 th week. the age group affected more was 20-29 (31.9% n=15) and sex affected more was female (47.4% n=9) than male (51.8% n=43). depression was found more with major injury (30.9% n=17) and less with minor injury (10.65 n=5). an overall prevalence of 35.3% (n=36) ptsd was found in 4th week among the patients interviewed. the rate was higher among the females: 10 patients (52.6%) met the diagnostic criteria used compared to 26 more common among the middle aged patients. the majority, (38.1%) of the mva survivors were in the age group 40 -49 years. the results regarding injury severity was like anxiety and depression, the major injury having higher rates of ptds symptoms (41.8% n=23) than minor (27.75 n=13). discussion general population in that they were mostly young. the predominance of males in the sample could be easily explained. perhaps they were more likely to be motor vehicle drivers and hence more prone to injury compared to the females. there were greater representation of married 64.7% and unmarried were 32.4%.the representation of unmarried were higher in males 36.1% than females 15.8% marriage was identified as a possible risk factor especially females, 78.9% and for the males (64.7%) of rta patients. though these factors were associated with a greater risk and are similar to those of other studies on traumatic events other than motor vehicle accidents (26) they were not statistically professionals and students had higher rates of a c c i d e n t s and developing psychological symptoms. an explanation for this could be that the groups more affected had greater understanding of the possible consequences of the accident and feared that their life goals and ambitions could be adversely affected. the present study has several limitations. first, despite the fact that average number of patients symptoms distribution with injury score in first week symptoms minor injury major injury p value no. (%) no. (%) anxiety 7(14.9) 24(43.6) p=0.002 depression 23(48.9) 29(52.7) p=0.703 ptsd 47(100) 48(87.3) p=0.014 symptoms distribution with injury score in fourth week symptoms minor injury major injury p value no. (%) no. (%) anxiety 4 (8.5) 16 (29.0) p=0.018 depression 5(10.5) 17(30.9) p=0.013 ptsd 13(27.7) 23(41.8) p=0.136 6 participated in this study but there is no long-term follow-up, the decrease of post-traumatic stress during the study is a promising result. with regard to future research, it would be useful to investigate study population with a long time follow-up. anxiety symptoms the study showed that the anxiety symptoms seen higher in major than in minor injury and it was that the anxiety symptoms were seen higher in females than in males. the anxiety symptoms in major injury (p=0.012), this may be perhaps due to vulnerability of females to any stress. depressive symptoms the study found depressive symptoms in 51.0% 20.5%. this study was similar to other studies, o’ donnell et al, 2004 showed the rates of depression following injury ranges from 5-23%. the present study found that depression was higher in age group 20-29 years and 30-39 years in 1st and 4th the depressive symptoms in male and female differ th week (p=1). ptsd symptoms in this y were ogy in to we did not use a interview on identifying xi it is their t be an for the of ptsd this group. prevalence of ptsd (35.3%) is comparable to that found in the developed countries: range 7 39%. as in the other studies (27) the females were at a greater risk of developing ptsd. among those who developed ptsd, 38.1% were in the age group 40-49 years. it appears therefore that the middle aged subjects are more prone to developing ptsd than the younger and older subjects. it is possible that the older subjects had learned coping mechanisms from past experience and younger has enhance their ability to cope with new traumas .(28)not only has it been shown that higher age could imply a higher risk of developing post-traumatic stress symptoms,(29) but at the same time it also has been reported that no difference concerning posttraumatic stress measured with the instrument ies could be found between younger, older and middleaged individuals. of patients with ptsd none had been previously diagnosed. all were attending the clinics purely for their physical injuries. other studies of post-traumatic stress among individuals in different age groups have shown different results. in the present study, the ies was used to assess posttraumatic stress. this instrument has been used in previous studies of post-traumatic stress in vehicle related accidents mostly in whiplash injuries (31,32,33) the levels of post-traumatic stress with 102 patients suffering from moderate to severe stress symptoms in 4th week 35.3% which were clearly higher than previously reported early after injury (13%). (34) several workers (35, 36) have noted, in particular, that pre-existing major depressive disorder (mdd) developing ptsd. in the present study since the pre-existing psychiatric illness were not excluded, so which could be associated to be of greater risk of developing ptsd. in general those who had suffered psychiatric illness in the past had a greater risk of developing ptsd. similarly those who had other physical illnesses were at a greater risk. perhaps the accident acted as a further stressor to these individuals who were already overwhelmed. conclusion the majority of mva survivors do develop to identify those at risk. a multidisciplinary approach is therefore essential in the management of the rta survivors at the orthopedic and trauma clinics if their physical and psychological needs are to be adequately addressed. of all the y outafter vehicle in the that will con the of a very large public l l despite these the high levels ology in the month following that y and co-occur following a physical y health care systems targeted at have a sibility to an ly and for early atric v accidents by implementing road safety measures such as safety belts, speed limit, improved road infrastructure and strict law enforcement measures on mva and therefore ptsd and other psychiatric problems.  7 references 1. o’brien, l. s. traumatic events and mental health. university press: cambridge, 1998. 2. blanchard eb, hickling ej, taylor ae and ross w r. psychiatric morbidity associated with motor vehicle accidents. j. nervous and mental disorder 1995; 183:495-504. 3. central bureau of statistics. statistical abstract, kenya government press: n ai r ob i , 1999. 4. taylor s, koch wj, fecteav, et al. post traumatic patterns of response to cognitive behavior therapy. journal of consulting and clinical psychology, 2001; 69: 541-551. disorder. geneva: world health organization, 1992. 6. alexander da. the psychiatric consequences of trauma. hospital medicine, 2002; 63:12-25. 7. sharma k. symposium of surgical and nursing management of patients with neurotrauma. bir hospital, department of anesthesia and neurosurgery: nepal, 1998; 44-56. 8. malt uf. the long term psychiatric consequences of accidental injury. british journal of psychiatry.1988; 153:554-560. 9. blanchard eb, hickling ej, taylor ae, et al. psychological morbidity associated with motor vehicle accidents. behavior research and therapy, 1994; 32:283-290. 10. shrestha m.l, koirala b, vaidya p.pancreatic resection for trauma in children. international surgical conference of society of surgeon of nepal, 1998; 37. 11. statistical pocket book 2002: his majesty’s government national planning commission secretariat, central bureau of statistics: kathmandu, nepal. monograph of the quebec task force on whiplash management. spine, 1995; 20:715-735. 13. mayou r and radanov bp. whiplash neck injury. journal of psychosomatic medicine, 1996; 40: 461-474. 14. mayou r, bryant b. and duthie r. psychiatric medical journal, 1993; 307:647-651. 15. lishman a. the psychological consequences of cerebral disorder. organic psychiatry; 1987. 16. norris fh. epidemiology of trauma: frequency and impact of different potentially traumatic event on different demographic groups. journal of consulting and clinical psychology, 1992; 60:409419. 17. blanchard eb. hickling ej, taylor ae, et al. psychiatric morbidity associated with motor vehicle accidents. journal of nervous and mental disease, 1995; 183:495-504. accidents. international review of psychiatry, 1992; 4: 45-54. 19. kuch k, cox bj, and evans rj, et al. (1994) phobia, panic and pain in ss survivors of road vehicle accidents. journal of anxiety disorders, 1994; 8:181-187. 20. beck a t, brown g, epstein n. and steer rd. an inventory for measuring clinical anxiety. journal of consulting and clinical psychology, 1988; 56: (6), 893. 21. beck a t, ward c h, mendenlson m, et al. an inventory for measuring depression. archieves of general psychiatry, 1961; 4: 561-571. 22. horowitz m j, wilner n, kaltreider n and alvarez w. sigh and symptoms of post traumatic stress disorder. archieves of general psychiatry, 1980; 37: 85-92. 23. greenspan l, mcclellan ba. and greig h. abbreviated injury scale and injury severity score. a scoring chart. journal of trauma, 1985; 25:60-64. 24. wilson ac. assessing psychological traumas and ptsd. new york: guilford press; 1999. 25. american psychiatric association. diagnostic and statistical manual 4th edition (dsv-iv). washington dc; 1994. 26. kessler r c, sonnega a, bromet e j, hughes m and nelson c b. posttraumatic stress di s or de r i n the national co-morbidity survey. arch. general psych, 1995; 52:1048-1060. 27. lyons j. strategies for assessing the potential for positive adjustment following trauma. j traumatic stress, 1991; 4:93–111. 28. lyons jm, mcclendon ob. changes in ptsd symptomatology as a function of aging. nova-psy newsletter, 1990; 8:13–18. 29. chung mc, werrett j, easthope y, farmer s. coping with posttraumatic stress: young, middle-aged and elderly comparisons. int j geriatric psychiatry, 2004; 19 :( 4) 333–343 30. kongsted a, bendix t, qerama e, et al. acute stress response and recovery after whiplash injuries. a one-year prospective study. euro j pain, 2008; 12: (4)455–463. koopman c, classen c, cardena e, spigel d. when disaster strikes, acute stress disorder may follow. j trauma stress, 1995; 829-46. 32. harvey ag, bryant ra: the relationship between acute stress disorder and posttraumatic stress disorder: a 2-year prospective evaluation. j consult clin psychol, 1999; 67:985–988. 33. shalev ay. measuring outcome in posttraumatic stress disorder. j clin psychiatry, 2000; 61: (5) 33–42. 34. breslau n, davis g c, andreski p. and peterson e. traumatic events and post traumatic stress disorder in an urban population of young adults. arch. general psych, 1991; 48:216-222. 20. 35. baker sp, o’neil b, haddon wj, long wb. the injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. j trauma, 1974; 14:187–196. 36. t l g, j b. assessment of coma and impaired consciousness: a practical scale. lancet, 1974; 2: 81–84.