Journal of Institute of Medicine Nepal

Surgical Training in Resource-Limited Settings: Cost-Effective, Portable and Reproducible Personal Laparoscopic Endotrainer

2024-04-03T10:01:17+00:00

Introduction

Minimal invasive surgery (MIS) is standard of approach for many surgical pathologies. The best way to enhance the psychomotor skills for MIS is through the disciplined and structured time with the Endotrainer. The cost and portability of available Endotrainer is the main reason for surgeons and residents allocating minimal time for training. Our goal was to create cost-effective and portable Endotrainer that enables skill development at home and classroom setting.

Methods

The framework of this Endotrainer was made-up of local plywood. The anterior surface was divided into nearly equal superior and inferior surface by horizontal plywood stick. A rectangular window was created at the anterior surface for mobile phone or tablet or iPad placement. Similarly, two 8 mm hole were drilled and padded with locally available rubber washer inferior and lateral to rectangular window as laparoscopic ports. For light commercially available mini dimmable LED was installed. The final trainer box was similar in shape and size of medium suitcase, which was portable and could house laparoscopic hand instruments and training pads.

Conclusion

The Endotrainer was easy and cost-effective to assemble. Embodying the essence of portability and reproducibility, this trainer box offers a personal practice tool that empowers trainee to sharpen their skills at their home or classroom.

Metabolic Syndrome in patients with Urinary Tract Stone Disease: A Hospital based Single Center Study

2024-04-03T11:46:04+00:00

Introduction

Patients with urinary tract stones (UTS) are at an increased risk of developing metabolic syndrome (MetS). Assessment for MetS could be useful for patients presenting with UTS. We assessed the prevalence of MetS and each of its components in patients with UTS. Correlation of 24-hour urinary and serum calcium and uric acid levels with components of MetS was also done.

Methods

A cross-sectional study was conducted at Tribuvan University Teaching Hospital, Institute of Medicine (IOM) from August 2021 and July 2022. After the approval from the Institutional Review Committee, 118 consenting adult patients with unilateral or bilateral UTS who fulfilled inclusion criteria were studied. Patients with congenital renal abnormalities, ADPKD, advanced chronic kidney disease with eGFR of <30 ml/min/1.73m2, proven metabolic causes of stone disease, those with cancer and pregnant women were not included. All patients underwent measurement of waist circumference, systolic and diastolic blood pressure, fasting blood sugar, serum triglycerides, high density lipoprotein cholesterol, uric acid, calcium, electrocardiography (ECG), renal function test, and 24-hour urinary calcium and uric acid. MetS was defined as per The International Diabetic Federation criteria. SPSS Version 25.0 was used for statistical analysis.

Results

Thirty-five (29.7%) stone formers had MetS. Among them, 23 (65.7%) were males, and 12 (34.3%) females. The mean body mass index (BMI) of patients with MetS was 25.96 ± 4.62 kg/m². In patients with MetS, 24 (68.8%) had high BP and impaired plasma FBS. Twenty-one (60.0%) patients had increased serum triglyceride levels, and 54.3% had reduced HDL-cholesterol. Systolic Blood Pressure (SBP) had a significant correlation with hypercalciuria (P=0.011) and hyperuricemia (P=0.046). Serum triglyceride (TG) levels was significantly correlated with hypercalcemia (P=0.045). The mean estimated glomerular filtration rate (eGFR) of the study population was 83.48 ± 32.37 mL/min/1.73 m².

Conclusion

Patients with urinary tract stone disease are associated with metabolic syndrome. Assessment for metabolic syndrome should be considered in patients with urinary tract stone disease.

Surgery for Solid Pseudopapillary Neoplasm: Observational Study at a Nepalese Tertiary Center

2024-04-04T08:54:15+00:00

Introduction

Solid pseudopapillary neoplasms (SPN) are rare, relatively indolent tumors with potential malignant behavior. The incidence of these tumors is increasing due to the widespread use of cross-sectional imaging. This study aimed to analyze the clinicopathological details, surgical management, and short- and long- term outcomes of operated cases of SPN.

Methods

This is an observational descriptive study of diagnosed SPNs confirmed histopathologically after surgical resections at Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal from 2006 November to 2019 January. Patient’s clinical details, surgical procedures, perioperative outcomes, and follow-up were recorded. Long-term follow-up was evaluated for a minimum of three years post-surgery.

Results

Over 13 years, a total of 15 cases with a median age of 22 years (11-52) were encountered and had female predominance (14). Five cases were diagnosed incidentally, while pain abdomen (five) was the most common presentation followed by lump (four). There were four tumors in the head of the pancreas, two in the uncinate process, two in the neck, four in the body, and three in the tail of the pancreas. Four cases underwent pancreaticoduodenctomy, three cases underwent enucleation, and four cases underwent central pancreatectomy. Similarly, one patient underwent spleen preserving distal pancreatectomy and three patients underwent distal pancretosplenectomy. Margins were negative in all cases with a median tumor size of six cm (2.5 -18). Postoperatively, 20% developed major complications with Clavien-Dindo (grade III & above) out of which one patient had mortality. Over the median follow-up of 72 months, no recurrences were noted.

Conclusion

Solid pseudopapillary neoplasms were relatively rare. Complete surgical resection was the most commonly used surgical management, post-operative complications were minimal and survival rate was excellent.

Factors Associated with Antenatal Care Visit Dropout among Mothers attending Immunization Clinic

2023-06-12T17:08:11+00:00

Introduction

Developing nations continue to have high maternal mortality rates. Prenatal care helps to improve the mother's and the unborn child's health. The purpose of this study is to identify the variables linked to mothers' antenatal care visit Drop out. The purpose of this study was to identify the variables linked to mothers' antenatal care visit droput.

Method

A cross-sectional study was carried out using the multi-stage sampling technique in the four urban and four rural randomly chosen municipalities of Morang district. In total, 134 postnatal mothers who skipped four focused ANC visits were chosen as cases at a ratio of 1:2, and 266 postnatal mothers who completed four focused ANC visit from the same vaccination facilities were chosen as controls. Using a semi-structured questionnaire and the consecutive sampling approach, data were gathered through interviews. The final model was chosen by employing the backward elimination technique after doing bivariate and multivariate analysis.

Results

This study found that the majority (56.0%) of cases was from the age group of 21-30 years and 35.1% of cases were janajatis. The number of factors were linked to ANC dropout, including age (OR 2.49, 95% CI 1.07-5.82), ethnicity (OR 2.29, 95% CI 1.05-4.99), education (OR 4.64, 95% CI 1.99- 10.81), income (OR 3.49, 95% CI 1.75- 6.95), and the existence of complications (OR 1.15, 95% CI 0.54-2.44).

Conclusion

The risk factors for ANC dropout were age, ethnicity, education, income, and the presence of complications during previous pregnancy. It suggests that efforts should be made to spread the information about the value of four focused ANC visits.

Incidence and Outcomes of Re-exploration in Adult Cardiac Surgery at a Tertiary Care Hospital

2023-07-19T16:56:51+00:00

Introduction
Postoperative bleeding is a significant complication following cardiac surgery, with a global re-exploration incidence of 2-5%. This study aims to investigate re-exploration rates, risk factors, and outcomes within the unique context of a tertiary care center in Nepal.

Methods

In this retrospective, single-center study, we analyzed all consecutive adult patients (≥18 years) who underwent cardiac surgery with cardiopulmonary bypass (CPB) at the Manmohan Cardiothoracic Vascular and Transplant Centre (Nepal) between 2018-2021. Data on demographics, clinical characteristics, operative details, re-exploration, and outcomes were extracted from medical records. Statistical analysis included descriptive statistics, chi-square tests, independent samples t-tests, and logistic regression.

Results
Of 720 patients, 56 (7.8%) required re-exploration for bleeding. Emergency procedures were strongly associated with higher re-exploration (p<0.05). Non-surgical bleeding was the primary cause in 42.9% of cases. Independent risk factors included preoperative deranged LFTs (OR=2.1, 95% CI: 1.2-3.7), elevated creatinine (>1.5 mg/dL, OR= 3.2, 95% CI: 1.8-5.6), prolonged CPB time (>120 min), and substantial transfusion requirements. Modified Bentall's procedures had the highest re-exploration rate (21.4%). Re-explored patients experienced higher AKI rates (87.5%), longer hospitalizations (13.6 vs. 7.2 days, p<0.001), and increased in-hospital mortality confined to emergency cases (1.94%).

Conclusions

Emergency procedures had higher rate of re-exploration. Preoperative deranged LFTs, elevated creatinine, prolonged CPB time, and substantial transfusion requirements were independent risk factors for re-exploration. Re-explored cases experienced higher complication. In-hospital mortality were confined to emergency cases only.

Assertiveness of Nursing Professionals Working in a University Hospital of Nepal

2024-04-03T11:47:21+00:00

Introduction

To provide patients with appropriate treatment and foster therapeutic interactions, nurses must possess assertiveness. The study objective was to find out the assertiveness of nurses.

Methods

In this cross-sectional study, 272 nurses were recruited using a proportionate stratified random sampling at Tribhuvan University Teaching Hospital (TUTH), Nepal. Assertiveness was measured with a self-administered questionnaire, 30-item Simple Rathus Assertiveness Schedule. Data analysis was done in SPSS version 16. Independent Sample t-test, Pearson Chi-square test, Fisher’s Exact test, and odds ratio were used to examine the association.

Results

Among nurses, 192 (70.6%) were assertive with a mean assertiveness score of 18.1±14.7. There was a significant association of nurses’ assertiveness with their marital status (p = 0.02), nursing degree (p=0.03), professional designation (p=0.04), employment type (p= 0.03), and additional training (p=0.004). Nurses with bachelor-level nursing degrees were 1.8 times more assertive (95% CI = 1.05-3.07) than those nurses with certificate-level nursing degrees. Nursing officers were 2.1 times more assertive (95% CI = 1.02 – 4.2) than staff nurses. Further, permanently employed nurses were 2.63 times more assertive (95% CI = 1.35-5.12), and nurses who received additional training were 2.2 times more assertive (95% CI = 1.29-3.83).

Conclusion

More than two-thirds of nurses working in the university hospital were assertive. Nurses with bachelor-level nursing degrees, with professional designation as “nursing officers”, with permanent employment, and those who received additional training were more assertive. These things should be taken into consideration by the hospital administration to increase assertiveness among nurses.

Mean Dimensions of Normal Coronary Arteries in a Tertiary Cardiac Center Kathmandu

2024-04-03T11:46:02+00:00

Introduction

Coronary artery disease is the major cause of morbidity and mortality worldwide, with >4.5 million deaths occurring in the developing world. The knowledge of normal coronary artery dimensions is fundamental during the percutaneous coronary intervention for appropriate sizing of the coronary balloons and stents. The dimensions of the coronary arteries differs among individuals of various countries, even among the different ethnicities. So, this study is done to find out the normal coronary artery dimensions.

Methods

This study was done in randomly selected 100 normal coronary angiograms. The diameter and the length of different segments of coronary artery were measured with the use of software as quantitative coronary angiography.

Results

Mean diameter of left main (LM) coronary artery was 4.06±0.68 mm. Similarly, mean diameters of prox-left anterior descending (LAD) artery, mid-LAD, dist-LAD, prox-left circumflex (LCx) artery and dist-LCx were 3.26±0.48 mm, 2.67±0.49 mm, 2.01±0.44 mm, 2.91±0.48 mm and 2.38±0.44 mm respectively. And, the mean diameters of prox-right coronary artery (RCA), mid-RCA and dist-RCA were 3.2±0.51 mm, 2.89±0.5 mm and 2.43±0.51 mm respectively. The mean lengths of LM, proximal/mid and distal LAD were 10.06±3.12 mm, 17.91±6.09 mm, 18.28±6.81 mm, 67.94±15.57 mm respectively. The mean lengths of proximal and distal LCX were 18.95±10.13 mm, and 52.1±17.78 mm respectively. Similarly, the mean lengths of proximal, mid, and distal RCA were 17.2±4.74 mm, 33.82±9.4 mm, 33.43±12.01 mm respectively. The mean diameter and mean length of ramus intermedius (RI) was 2.32±0.56 mm and 70.77±19.75 mm.

Conclusion

The mean dimensions of normal coronary arteries in patients visiting this center have been determined.

Measurement of Optic Nerve and Optic Nerve Sheath Diameter in MRI Brain

2024-04-03T11:45:59+00:00

Introduction

Many diseases affect the size of the optic nerve and optic nerve sheath, measurement of which is important for the diagnosis and treatment of many pathologies of the brain and orbit. This study aimed to measure the diameter of the optic nerve and optic nerve sheath in MRI brain examinations. We also studied their variation according to age, gender, and laterality.

Methods

This cross-sectional, quantitative study was performed in the Radiology Department of Tribhuvan University Teaching Hospital (TUTH). The diameter of the optic nerve and optic nerve sheath were measured in the T2 weighted Dixon Turbo Spin Echo axial images. The diameter was measured at the level of 3mm and 8mm behind the eye globe. The study was completed over a period of 3 months (August 2023 to October 2023).

Results

The mean diameters of the optic nerve were 2.187±0.35 mm/2.14 ± 0.35 mm at 3 mm behind the eye globe and 2.056 ± 0.334 mm/2.11 ± 0.35 mm at 8 mm behind the globe for the right/left sides respectively. The optic nerve sheath of the right/left sides measured 4.50 ± 0.60 mm/4.46 ± 0.56 mm at 3 mm behind the eye globe and 4.16 ± 0.50 mm/ 4.14 ± 0.47 mm at 8mm behind the eyeball.

Conclusion

The measurements for the diameter of the optic nerve and optic nerve sheath complex were similar in both the right and left eyes. There was no significant difference in optic nerve and optic nerve sheath diameters with the age and gender of the participants.

Compliance with Society Guidelines in COVID 19: A Survey on Members of Society of Dermatologists, Venereologists and Leprologists of Nepal

2024-04-04T04:16:13+00:00

Introduction

COVID-19 pandemic affected the practice of dermatologists of Nepal. The Society laid down the guidelines for safe practice in the interest of its members and patients based on the available evidence at that time. The aim of this study was to assess the compliance of members to its guidelines.

Methods

This was a descriptive cross-sectional study carried out from 1st June 2020 to 1st July 2020 by circulating questionnaire via Google form to dermatologists who were members of Society of Dermatologists, Venereologists, and Leprologists of Nepal. The study variables included personal details of the participants and questionnaires related to guidelines. The responses of participants were collected, and descriptive analysis of the data was done.

Results

Out of 200 members at the time of study who were sent the mail, only 90 (45%) members responded to the questionnaire. Out of all these respondents 76 (84.4%) were following the guidelines laid down by the society. Only 43(47.8 %) of the respondents had deferred patients of outpatient department as per the guidelines. Out of all respondents, 60 (66.7%) had attended dermatological emergencies and triage was done by 50 (55.6%) members.

Conclusion

The study showed that most of the members who were responsive to the survey questions sent to them were compliant with the guidelines laid down by the society.

Hormone Receptors and HER2 Status of Patients with Breast Cancer in a Tertiary Center of Nepal: A Descriptive Cross-Sectional Study

2024-04-04T09:34:51+00:00

Introduction

The second most prevalent cancer among women in Nepal is breast cancer. The assessment of human epidermal growth factor receptor-2 (HER2), progesterone receptor (PR), and estrogen receptor (ER) status in patients with breast cancer is currently regarded as standard practice because of its prognostic and predictive value. This study aims to find the incidence of Hormone receptor and HER2 status in patients with breast cancer.

Methods

This is a descriptive observational cross-sectional study that assessed the immunohistochemistry markers of different histological types of breast cancer patients who visited a tertiary center in Nepal. Retrospective data from August 1, 2022, to July 30, 2023, were gathered from computer records of all the patients diagnosed with breast cancer who visited the Tribhuvan University Teaching Hospital (TUTH). SPSS version 26.0 was used for statistical analysis.

Results

A total of 102 patients with breast cancer were included. The mean age of the patients was 50.51±12.08 years. Only one patient was male. The analysis showed that 62 (60.78%) of total patients had ER/PR positive breast cancer and 40 (39.2%) were HER2 positive with a higher number among Janajati and the age group 41-60 years. Similarly, the incidence of triple-negative breast cancer was 21 (20.59%) of all patients.

Conclusion

The majority of breast cancer patients in our study were ER/PR positive, followed by HER2-positive and triple-negative cases. A higher prevalence was observed among the Janajati ethnic group and those aged 41-60 years.

Pyogenic Granuloma of External Auditory Canal: A Case Report

2024-04-03T08:46:57+00:00

The external auditory canal is an atypical location for Pyogenic Granuloma (PG) to originate. We report a case of PG in a 15-year-old boy's external auditory canal. He experienced reduced hearing and occasional blood-tinged ear discharge for 8 months. Examination revealed a pinkish-soft mass occluding the canal lumen. Pure tone audiogram showed 42 dB moderate conductive hearing loss in the right ear. High-resolution computed tomography showed a well-defined, homogenously enhancing soft tissue density lesion in the canal. The mass was completely excised, and post-operative histopathology confirmed the diagnosis of PG. No recurrence was observed during the six-month follow-up period. PG should be considered in the differential diagnosis of external auditory canal lesions.

Case Report of Foveolitis with Optic Neuritis: A Barely encountered Ophthalmic Manifestation of Dengue

2024-04-15T13:43:20+00:00

Dengue fever is a tropical disease which is endemic in tropical/subtropical nations like Nepal. Bilateral optic neuritis with unilateral foveolitis is an unusual dengue-related ophthalmic complication. We here present to you a case of bilateral optic neuritis with right eye foveolitis who initially presented with complaints of sudden diminution of vision in one eye following dengue fever. This report deals with prolonged treatment of rare ocular presentation of dengue infection. Patient had persistent myodesopsia and scotoma in the right eye even after 5 months of treatment with oral steroids. Dengue-related ophthalmic findings although rare, can have significant and long-lasting visual impairment if not treated timely and appropriately.