INTRODUCTION: The time of presentation of acute coronary syndrome from the onset of chest pain determines the treatment modality and prognosis. Delayed presentation is associated with a poor outcome. In the present study, we tried to find out the causes of late presentation of ACS in a tertiary care center in the eastern part of Nepal.

METHODS: It was a cross-sectional descriptive study that included 100 consecutive patients with ACS presenting to our institute over a period of 8 months. They were studied for their demographic profile, delay in presentation, the management done at the local centers and their final diagnosis.

RESULTS: We found that patients living within Dharan City reached BPKIHS within 20 hours of the onset of chest pain while those from outside the city who came directly reached within 63 hours. Other patients reached their respective local centers (health posts, district hospitals and private clinics) within 39 hours. The commonest cause of delay was vehicular problem followed by unnecessary delay at the local centers. The work up for chest pain was inadequate in these centers. Late presentation to our institute significantly affected the optimal management.

CONCLUSIONS: We found that significant number of patients with ACS from eastern Nepal presented late in our tertiary care center. In order to improve ACS outcome in this region, we advise equipping the local centers with electrocardiogram machines, improvement in ambulance services and a greater emphasis on coronary artery disease awareness programs as well as initiating preventive measures.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):1-4.

INTRODUCTION: Retained non-radiopaque foreign body inside soft tissue can be a cause of prolonged morbidity. Detection and localization is difficult task with conventional radiography. Ultrasonography, CT and MRI are other modes of evaluation but both of CT and MRI are expensive and not easily available.

METHODS: Twenty three patients were evaluated with ultrasonography (8 MHz linear probe) and X-ray for clinically suspicious non-radiopaque foreign body in soft tissue of extremities. Clinical presentation, duration of symptoms, anatomical location and foreign bodies retrieved after surgical explorations were recorded.

RESULTS: X-ray could not detect any foreign body in all 23 patients. Ultrasound findings were suggestive of foreign body in 19 patients (male: female=2:1, mean age 31.68+/-11.8 years, range 12 - 54 years) which was confirmed after surgical exploration except in one where only foreign body granuloma was found. 4 (21%) weren't aware of prick injury. Fifteen patients had attempted removal of foreign body themselves or at medical shop or local health post. Interval between injury / symptoms appearance to hospital ranged from 4-56 days. Foot and ankle was involved in 10 (52.6%), calf in 3 (15%), dorsum of hand in 2 (10.5%), palm in 2 (10.5%), shoulder in 1 (5.2%) and knee in 1 (5.2%) case. Foreign bodies retrieved were wood in 12 (63%), thorn in 4 (21%) and bamboo twig in 2 (10.5%) patients.

CONCLUSION: Plain X-ray isn't sensitive for detection of non-radiopaque foreign body in soft tissue. Ultrasonography is sensitive and specific for detection and localization of foreign body which should be included in evaluation for clinically suspicious retained non-radiopaque foreign body in soft tissue of extremities.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):5-9.

INTRODUCTION: Inadequate dialysis accounts for the high mortality in patients with end stage renal disease (ESRD). In Nepal, due to various factors including financial and logistic limitations, hemodialysis is mostly performed twice-a-week. This study was undertaken to look at adequacy of dialysis in patients undergoing maintenance hemodialysis in Nepal where the patients profile, in terms of diet, body muscle mass, nutritional status etc are different from western world.

METHODS: In this cross sectional observational study, 40 patients on maintenance hemodialysis in the dialysis unit were evaluated and enrolled if patients were regularly undergoing twice-a-week hemodialysis in preceding 6 months with each session of dialysis prescription consisting of 4 hours (240 minutes). Patients were excluded if they were admitted in the hospital for some acute problems or had received acute hemodialysis in preceding 6 months. Only 14 patients fulfilled the inclusion criteria. Hemodialysis adequacy was measured using well established urea kinetic modeling.

RESULTS: The mean age of the patients was 49 +/- 24 years. Mean predialysis urea and post dialysis urea were 163.7 +/- 60.05 mg/dL, and 73.7 mg/dL +/- 30.55 respectively. Mean URR was 65.3%. Mean Kt/v as assessed by Jindals equation was 0.99.

CONCLUSIONS: Our study showed that twice-a-week of maintenance hemodialysis did not achieve recommended adequacy of hemodialysis in our patients.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):10-13.

INTRODUCTION: Urinary tract infection is certainly one of the most common childhood infections. Emerging resistance to the antibiotics is not unusual. Current hospitalization for children with urinary tract infection is reserved for severe or complicated cases. The aim of the present study was to determine the antibiotic resistance pattern among children with recurrent or complicated urinary tract infection.

METHODS: A retrospective study carried out at Prince Hashem hospital, Zarqa city, eastern Jordan and involved 336 episodes of culture proved urinary tract infection obtained from 121 patients with recurrent UTI, who used prophylactic antibiotics during the period from April 1, 2004 to December 31, 2006. The isolated microorganisms and there antibiotics susceptibility were studied.

RESULTS: Seventy three patients (60.3%) were found to have some forms of urinary tract anomaly, significantly more prevalent among male children P<0.001. Vesicoureteral reflux being the most common (58.9%). Renal scars were significantly more prevalent among those with complicated rather than recurrent urinary tract infection (64.3% vs. 16.6%, P<0.001). Gram negative organisms were the most frequent isolates in patients with recurrent and complicated urinary tract infection. Proteus, Pseudomonas and Candida spp. were more prevalent in patients with complicated (P<0.001), and isolates in patients with UTA were significantly more resistant to most antibiotics tested.

CONCLUSIONS: Pediatric urine culture isolates are becoming increasingly resistant to commonly used antibiotics. Empirical treatment with Trimethoprim-Sulfamethoxazole (TMP-SMX) or Cephalexin as the initial drug is ineffective. Nitrofurantoin and Nalidixic acid can be considered as the first line antibiotics for prophylaxis and or treatment of patients with recurrent UTI, while Meropenam and Ciprofloxacin can be used empirically in treating patients with complicated UTI.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):14-19.

INTRODUCTION: Diabetes mellitus is an established risk factor for congestive cardiac failure in which the diastolic function is impaired earlier than the systolic function and majority of these patients maybe asymptomatic without signs of overt heart failure.

METHODS: A cross sectional hospital based study was done which included 100 asymptomatic patients with type 2 diabetes without evidence of coronary artery disease, congestive heart failure, thyroid or overt renal disease. LVDD was evaluated by Doppler echocardiography, which included the valsalva maneuver to unmask the pseudonormal pattern of left ventricular filling. The prevalence of LVDD and the associated risk factors were assessed.

RESULTS: LVDD was found in 71 subjects (71%), of whom 60 had impaired relaxation and 11 had a pseudonormal pattern of ventricular filling. Systolic function was normal in all subjects, and there was no correlation between LVDD and indexes of metabolic control. It was also found that age >/=45 years was associated with an almost three times higher risk for the development of diastolic dysfunction in type 2 diabetes. Females were at a two times higher risk of developing diastolic dysfunction than when compared to men. Duration of diabetes >/= two years was associated with a two times higher risk for developing diastolic dysfunction.

CONCLUSIONS: LVDD is much more common than previously reported in subjects with well-controlled type 2 diabetes who are free of clinically detectable heart disease. The high prevalence of this phenomenon in this high-risk population suggests that screening for LVDD in type 2 diabetes should include procedures such as the valsalva maneuver to unmask a pseudonormal pattern of ventricular filling.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):20-23.

INTRODUCTION: Due to unavailability of vaccine against HIV/AIDS, there are no ways other than relying on ART. We select group of late stage HIV/AIDS with CD4<50 so that opportunistic infections and outcome of patients in this late stage of severe immunosuppression after initiation of ART can be known.

METHODS: A cross sectional study was carried out in 53 HIV patients with CD4 count <50 cells/cu mm blood undergoing ART in Seti Zonal Hospital Dhangadi between December 2006 and May 2008 with objectives to explore the treatment outcome in this late stage of immunosuppression. Only those patients with CD4 count <50 were consecutively selected and recommended for various laboratory test on the basis of which ART regimen were prescribed.

RESULTS: Among 53 patients, 42 (79.2%) were males and 11 (20.8%) were females, with predominant age group of 30-40 years (49.1%). Fever (71.7%), diarrhea (56.6%), pneumonia (52.8%), weight loss (52.8%) and oral thrush (33.9%) were found to be the major clinical presentation/Opportunistic infections. 19 (35.8%) patients showed normal activity throughout the treatment period with increase in CD4 count, 10 (19%) were recovered and transferred out. Only 1 (1.8%) showed decrease in CD4 count even after taking ART. Significant relationship was established between the intake of ART and increase in CD4 level (pair t = 7.88, p<0.05).

CONCLUSIONS: ART service was found to be efficient enough to increase the CD4 count significantly after 6 months of therapy but the prevalence of OIs/clinical manifestations were sufficiently higher in this group of patients with low CD4 count.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):24-27.

INTRODUCTION: A randomized controlled trial was designed to test the impact of involving husbands in antenatal health education on women's maternal health knowledge.

METHODS: Total 442 women receiving antenatal services at a hospital in Kathmandu, Nepal were randomized into three groups: women who attended education sessions with their husbands, women who attended education sessions alone, and women who attended no education sessions (controls). At baseline and after delivery, women's maternal health knowledge and change in knowledge levels were compared between the groups.

RESULTS: Compared to control group women, women educated with husbands increased their knowledge scores by an average of 0.61 points (95% CI=0.32-0.89, P<0.001), while women educated alone increased their scores by only 0.34 points (95% CI=0.04-0.65, P<0.05). Women educated with partners could identify more pregnancy complications and family planning methods than women in both other groups.

CONCLUSIONS: These findings suggest that women learn and retain the most information when they are educated with their partners.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):28-34.

INTRODUCTION: Pattern of leukemia is known to vary widely throughout the world. The characterization of distribution patterns of different subtypes of leukemia in Nepal needs further study. We wanted to study the leukemia pattern in our institute.

METHODS: A retrospective study of 196 cases of leukemia, diagnosed at BPKIHS, between January 1997 to December 2002 was done. We analyzed the pattern of leukemia at BPKIHS by morphological subtype, gender, age at diagnosis, time period of diagnosis (seasonality), and geographic distribution.

RESULTS: Morphological sub typing showed that 121 cases were of acute leukemia and 75 of chronic leukemia. Chronic myeloid leukemia constituted the single largest group comprising 35.2 % of all cases, followed by acute myeloid leukemia (28.57 %) and acute lymphoid leukemia (19.9 %). Maximum numbers of cases were from the lowlands while least number of cases were from the mountain districts. Results were compared with literature from Nepal and other countries. This is the second series of leukemia from Nepal.

CONCLUSIONS: The data published in this study reflects the leukemia pattern in the eastern region of Nepal. The pattern and distribution of AML, CML, ALL was similar to that in the developed western countries while the lesser frequency of CLL was similar to that in Southeast Asian region.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):35-40.

INTRODUCTION: In the present study, we investigated the relationship between potency of oxidative stress and BPH and this may assist to contribute to the realistic explanation of the ethiopathogenesis of BPH.

METHODS: Seventy four newly diagnosed men with BPH (mean age: 54+/-11.2), who had not undergone any previous treatment for BPH, and 62 healthy volunteers (mean age: 55+/-14) were enrolled in the present study. To determine the antioxidative status of plasma, total antioxidant capacity (TAC) was calculated, and to determine the oxidative status of plasma (TOS) total peroxide levels were measured. The ratio of TAC to total peroxide was accepted as an indicator of oxidative stress (OSI). Data are presented as mean SD +/- unless specified. Student t-test and correlation analyses were used to evaluate the statistical significance differences in the median values recorded for all parameters between BPH and control group.

RESULTS: Plasma TAC TOS were found in patients and controls (1.70 +/- 0.32, 1.68 +/- 0.19 mumol Trolox Equiv./L), (12.48 +/- 1.98, 12.40 +/- 1.14 micromol / L) respectively. OSI was calculated as 7.57 +/- 1.91, 7.48 +/- 1.33, respectively. Plasma TAC, TOS and OSI levels were not found to be significantly difference between patients and control subjects (p>0.05, p>0.05, p>0.05).

CONCLUSIONS: The present study has shown that there were not relationship between potency of oxidative stress and BPH. Further well designed studies should be planned to find out whether the oxidative stress-related parameters play role in BPH as an interesting pathology in regard of the etiopathogenesis.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):41-45.

INTRODUCTION: Morphometric measurements of the corpus callosum (CC) are necessary to have normative values for studying sex, age and race related variations.

METHODS: Morphometry of the CC was done in preserved brain specimens and in MRI scans, in adults.The measurements included parameters like length, width, height of the cc, distances between genu and fornix, genu and anterior commissure, splenium and superior colliculus, distances from the different parts of the cc to the nearest cortical surfaces.

RESULTS: In the preserved brain group, the length CC was 6.98cm (males) and 6.86 cm (females) while the corresponding values in the MRI group were 7.57 cm and 7.1 cm. The height CC was 2.15 cm (males) and 1.92 cm (females) in the preserved group, and 3.27 cm (males) and 2.59 cm (females) in the MRI group. The splenial width values were 1.12 cm (males) and 1.01 cm (female) in the preserved brains while the corresponding MRI values were 1.15 cm and 1.17 cm.

CONCLUSIONS: The values of different CC parameters observed were almost similar to the values reported in the other two Indian studies. However, Indian values were found to be more than the Japanese values for length, height and most of the widths of CC. The length and width of CC were found to be less than those of Caucasian population. Generation of this data will help in comparing the CC structure of different sex and ages, to study variations from the normal and may help in surgical planning.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):46-51.

INTRODUCTION: To determine the histological pattern of involvement, clinical presentation, impact on fertility in women with genital tuberculosis.

METHODS: A total number of 68 cases of gynaecological tuberculosis affecting different parts of female genital tract from 56 patients were selected. The age range of the patients was 17-36 years with mean age of 25.6 years. The diagnostic procedures used included endometrial curettage and biopsy, histopathological examination, culture and Mycobacterium Tuberculosis Polymerase Chain Reaction (MTB PCR), laparoscopy, Hysterosalpingography (HSG) and Ultrasonography (USG). Most of the specimens received were biopsies of endometrial curettage for evaluation of infertility. In 7 cases, specimens of total hysterectomy with bilateral salpingo-oophorectomy were submitted with lesions involving multiple sites.

RESULTS: Patients presented with infertility (65-70%), pelvic/abdominal pain (50-55%), and menstrual disturbances (20-25%). Tuberculosis involved the endometrium in 55.88%, tubes in 23.53%, ovaries in 14.71% and cervix in 5.88% of the 68 cases. The endometrium(38 cases)was in the proliferative phase in 31 cases (81.57%), secretory phase in 4 cases (10.52%) and it was atrophic in 3 cases (7.89%).Caseation was present in 9 out of 68 cases and Ziehl-Neelsen (ZN) stain revealed Acid Fast Bacilli (AFB) in tissue sections in only 4 cases . After therapy, 9 patients conceived of which 8 suffered spontaneous abortions. Only one patient had a successful pregnancy and the baby was born through caesarean section.

CONCLUSIONS: Genital tuberculosis is an important cause of female infertility in developing countries like India, Nepal, Bangladesh and Pakistan. Successful uterine pregnancy is rare after treatment and chances of ectopic pregnancy are high.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):52-57.

Juxta-articular, subperiosteal osteoid osteomas arising around the ankle are unusual. Tumors arising on the neck of the talus commonly produce symptoms mimicking monoarticular arthritis. Patients are usually treated for arthritis or ankle sprain, which often leads to a delay in definitive diagnosis. Here we present a case of osteoid osteoma of neck of talus which was presented as ankle pain. It puzzled us until MRI was done. Diagnostic dilemma and delay can be avoided by high index of suspicion. The patient was treated with open removal of the tumor. We also present brief review of literature about juxta-articular, subperiosteal osteoid osteoma which is uncommon from the typical osteoid osteoma occurring elsewhere in the body

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):58-61.

Kartagener Syndrome is a rare autosomal recessive disorder consisting of triad of sinusitis, bronchiectasis and situs inversus with dextrocardia. It is the subset of disorder called primary ciliary dyskinesia in which the cilia have abnormal structure and/or function resulting in multisystem diseases of various severity. Clinical manifestations include lifelong, chronic upper and lower respiratory tract diseases secondary to ineffective mucociliary clearance. Early diagnosis and management of chest infections can prevent irreversible damage to lungs and prevent potential lifelong complications. This case report is on a patient who presented with long standing history of sinusitis, bronchiectasis and on examination situs inversus with dextrocardia.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):62-65.

Down's syndrome is the most commonly encountered congenital anomaly in medical practice. These patients are of special concern to medical practice because of their associated problems with regard to respiratory, cardiovascular and other systemic problems. As these patients present for repeated surgeries like dental extraction, facial reconstruction and fixation of cervical spine, these patients pose challenges to the anesthesiologist because of their unique set of problems, namely atlantoaxial instability, small trachea, congenital heart disease and repeated chest infections due to lowered immunity. Their reactivity to inhalational anesthetics and atropine is variable. Here we present an interesting case report of a child with Down's syndrome who presented with atlantoaxial instability for MRI of cervical spine under general anesthesia.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):66-69.

Oesophageal foreign bodies are commonly removed with rigid oesophagoscopy under general anaesthesia, but spherical foreign bodies can also be removed using a foley's catheter under fluoroscopic control without anaesthesia. We present a case of successful removal of a spherical marble from the oesophagus in a four years old girl by a foley's catheter under general anaesthesia.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):70-71.

Leiomyoma is a benign tumor showing smooth muscle differentiation. Leiomyoma in the nasal cavity is a rare entity which can present with common nasal symptoms. We report a case of 19 years old male patient with nasal leiomyoma. The patient presented with recurrent episodes of nasal obstruction and epistaxis. On nasoendoscopy, there was a single grayish polypoidal mass in the right middle meatus which bled on touch. CT-scan of nose and paranasal sinus showed homogenous opacity indistinguishable from the right middle turbinate. The mass was excised endoscopically. There is no recurrence a year after the endoscopic excision of the nasal leiomyoma. Nasal leiomyoma carries a good prognosis after complete excision.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):72-74.

Abdomen is a Pandora's Box. During our routine patient evaluation we come across different types of abdominal lumps out of which some are straight forward and diagnosed after routine clinical examinations and available investigations. At times these abdominal lumps present differently from their usual presentations and create confusions despite undergoing necessary investigations. The truth is explored only after opening the Pandora's Box. We present a case of 21 years old male who presented with history of gradually increasing right sided upper abdominal lump of three years duration. He was thoroughly investigated with USG and CT scan abdomen along with other supportive investigations and was diagnosed to have Hydatid cyst of liver. Accordingly patient was prepared for surgery and it was only at the time of laparotomy that he was found to have right sided giant hydronephrosis with a nonviable renal parenchymal tissue. He underwent right sided nephrectomy and had a good postoperative recovery. So at times the abdominal lumps keep on creating diagnostic dilemmas.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):75-77.

Fine needle aspiration cytology of superficial as well as of deep seated lesions is now well recognized in diagnosis of neoplastic as well as nonneoplastic and inflammatory lesions. Recently it has also gained popularity for its diagnostic and therapeutic role in male infertility. The purpose of this article was to review various studies published on role of testicular fine needle testicular cytology in male infertility and provide a brief information on method of testicular fine needle aspiration, interpretation of testicular fine needle aspiration cytology for evaluation of spermatogenesis, its advantages, limitations and complications as compared to testicular biopsy.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):78-84.

The Millennium Development Goals (MDGs) are international objectives on poverty reduction adopted by the world community and provide the broad context for this revolution in thinking and practice. The MDGs place a central focus on public health, in recognition of the fact that improvements in public health are vital not only in their own right but also to break the poverty trap of the world's poorest economies. Nepal has been committed to achieving the MDGs since it endorsed the Millennium Declaration. As we have at present just passed the midway through the 15 years to MDGs deadline of 2015, this article reviews the status of Nepal in achieving the MDGs, the challenges it faces and whether it can achieve the MDGs by 2015.

JNMA J Nepal Med Assoc. 2009 Jan-Mar;48(173):85-91.