Assessment of quality of life in patients of end stage renal disease on different modalities of treatment.

This study was conducted to measure quality of life of patients with end stage renal disease on different modalities of treatment. A total of 30 diagnosed cases of end stage renal disease (ESRD) attending BPKIHS were included in the study. Group 1 included 10 patients on regular maintenance hemodialysis, group 2 included 10 patients on continuous ambulatory peritoneal dialysis (CAPD) and group 3 included 10 patients on regular conservative drugs. The inclusion criteria were all diagnosed cases of ESRD based on the guidelines given by K/DOQI, 2002. A detailed history relating to the disease condition as per the designed proforma was taken, which included demographic data and clinical characteristics of the patients. For assessment of quality of life, KDQOL-SF questionnaire was used. Strata 8.0 software program was used for the analysis of collected data. Physical health was found to be the most severely affected domain of the KDQOL. The mean score for physical health was least in group 1 (33.36 +/- 16.14). Mental health was better in group 2 (54.93 +/- 9.92) than in group 1 (39.50 +/- 14.27) ( "p" value 0.01). Variables like haemoglobin, hematocrit and adequacy of dialysis have positive correlation with all the four domains of the KDQOL. There was a statistically significant correlation of physical health with mental health (p value 0.001), physical health with kidney disease issues (p value 0.001) and mental health with kidney disease issues (p value 0.007). Our study has shown that patients of ESRD have a poor quality of life despite being in some form of dialysis and the most affected domain of the KDQOL scale is physical health. Patients on CAPD have better quality of life than patients on maintenance haemodialysis especially in terms of mental health. Variables like haemoglobin, hematocrit and adequacy of dialysis have a positive correlation with all the four domains of the KDQOL scale i.e. optimizing these variables improves the overall quality of life.

Effect of preload reduction by haemodialysis on doppler indices of diastolic function in patients with end-stage renal disease.

OBJECTIVE: To assess the influence of preload reduction by haemodialysis on Doppler echocardiographic indices of cardiac diastolic function. METHODOLOGY: Parameters of left ventricular diastolic function were measured in patients with end-stage renal disease before and after a single session of haemodialysis. Patients with valvular heart disease, coronary artery disease, cardiomyopathies, pericardial disease and those not in sinus rhythm were excluded from the study. RESULTS: Seventeen subjects (12 males and 5 females, mean age 48 +/- 16 years) were studied. Over the duration of 3.7 +/- 0.6 hours of haemodialysis, 2.6 +/- 1.3 litres of ultrafiltrate was removed. The comparison of pre and post haemodialysis peak mitral E and A velocities showed a decrease in E velocity (p < 0.01) whereas the change in A velocity was not significant. The E/A ratio decreased significantly (p < 0.05).The decrease in E velocity correlated well with the amount of ultrafiltrate (r = 0.653, p < 0.01). There was a significant increase in isovolumetric relaxation time (p< 0.05) whereas deceleration time did not change (p =0.3). CONCLUSION: Ultrafiltration during haemodialysis causes a rapid reduction in preload. It results in decreased early left ventricular diastolic filling without a change in the atrial phase of filling, hence causing a decrease in calculated E/A ratio.

Exploring the iceberg of hypertension: a community based study in an eastern Nepal town.

OBJECTIVES: Hypertension is an important public health challenge in the developing and the developed world alike. However, community-based studies on cardiovascular diseases including hypertension in a developing country like Nepal have been limited. The primary aim of this study is to measure the prevalence of hypertension in the Dharan town of Eastern Nepal and to explore the 'iceberg phenomenon' of hypertension in the study population. METHODS: A population-based cross-sectional analytical study was undertaken in the Dharan municipality in 2004-5 with one thousand males aged 35 years and above as participants. The subjects were recruited by simple random sampling of the households in each ward. RESULTS: The overall prevalence of hypertension in the study population was 22.7% which was comparable to the studies from Northern and Western India. The comparison between the population with normal and high blood pressure at time of study shows significant differences in terms of age, religion, current job status, occupation, socio-economic status, physical activity and tobacco use. CONCLUSION: The study shows that while a vast majority of the hypertensive population was not aware of their high blood pressure status, at the same time, a large fraction of the population with increased blood pressure did not have their blood pressure under control. A surveillance system to detect population with high blood pressure, follow up the detected cases of hypertension, as well as motivate and/or counsel the 'hard-to-treat' cases for regular follow-up should be valuable.

Social health insurance: a knowledge-do gap in eastern Nepal.

Health care costs, and those for inpatient care in particular, pose a barrier to seeking health care, and cost be a major cause of indebtedness and impoverishment, particularly among the poor. The Ministry of Health in Nepal intends to initiate alternative financing schemes such as community and social health insurance schemes as a means to supplement the government health sector financing source. Social Health Insurance (SHI) is a mechanism for financing and purchasing / delivering health care to workers in the formal sector regulated by the government. Considering all these facts BP Koirala Institute of Health Sciences (BPKIHS) has introduced SHI scheme in 2000 as an alternative health care financing mechanism to the community people of Sunsari and Morang districts. In the beginning small area was elected as a pilot project to launch the scheme. A major objective of SHI is to reduce poverty caused by paying for health care and to prevent already vulnerable families from falling into deeper poverty when facing health problems. A total of 26 organizations with 19799 populations are at present in SHI scheme. Sixteen rural based organizations with 14,047 populations and 10 urban based organizations with 5752 people are the beneficiaries in this scheme. BPKIHS SHI Scheme is the outcome of the visionary thinking on social solidarity and as an alternative health care financing mechanism to the community. BPKIHS is mobilizing people's organizations and is offering health services through its health insurance scheme at subsidized expenses. This has helped people to avail with health facilities who otherwise would have been left vulnerable because of their penetrating health needs. There is huge gap between premium collection and expenditures. The expenditures are more and this may be due to knowledge - do gap in the program. If conditions are unsuitable, SHI can lead to higher costs of care, inefficient allocation of health care resources, inequitable provision and dissatisfied patients. It can also be more difficult to realize the potential advantages of SHI in future. The future challenges confronting the scheme are to give the continuity and sustainability of the program to its catchments areas. This might entail a shift in its program operation mechanism. People's active involvement is required, which will further provide a sense of ownership in the scheme amongst the people.

Association of lipid profile and body mass index (bmi) in hypertensive patients of Eastern Nepal.

Dyslipidemia is closely associated with hypertension. Out of different fractions of lipoprotein, definite association of elevated LDL-Cholesterol (LDLc) and other lipid parameters has been well observed in hypertensive patients. The present cross sectional study was undertaken at BP Koirala Institute of Health Sciences with the aim to find out association of different lipid parameters and Body Mass Index (BMI) among newly diagnosed hypertension without any medications in Eastern Nepal. 80 hypertensive patients fulfilling JNC-7 criteria and 80 healthy controls were enrolled in this study. Lipid parameters (TC, TG, LDLc, VLDLc, HDLc) were estimated by Enzymatic Colorimetric test. Quetlet's formula was used to calculate BMI. Results were analyzed with student's 't' test and Pearson correlation analysis. Mean age of patients and controls were 36.30 +/- 7.73 yrs & 32.13 +/- 7.21 yrs respectively. There was significant increase in different lipid parameters namely TC (170.18 22.53 vs 145.23 21.13,P<0.005), TG (146.60 53.87 vs 119.77 35.61, P<0.005), LDLc (100.71 23.74 vs 79.25 20.10,P<0.05) and VLDLc (29.32 1077 vs 23.92 7.12, P<0.05) in patients as compared to the healthy controls. However there was no any significant difference in HDLc value. Pearson correlation analysis shows positive correlation of BMI with all the four lipid parameters even though it was not statistically significant. Thus this study shows direct association of BMI, dyslipidemia in hypertensive patients of the Eastern Nepal.

Spontaneous bacterial peritonitis (SBP) in cirrhotic ascites: a prospective study in a tertiary care hospital, Nepal.

BACKGROUND: Spontaneous bacterial peritonitis (SBP) is one of the potentially lethal complications of cirrhosis and is defined as infected ascites in the absence of any recognizable secondary cause of infection. Objective was to study the occurrence of SBP, clinical and laboratory characteristics and the response to antibiotics. METHODS: We had prospectively evaluated 81 cirrhotic patients with ascites during one-year period. All SBP patients were treated with cefotaxime, 2gm IV, every 12h for 5days. RESULTS: Of these 81 patients, 24.67% of patients (n=20) had SBP and its variants (classical SBP n= 4, CNNA n=13 and bacterascites n=3). There were thirteen males and 7 females in the study.85% of the cases had Child;s class C cirrhosis. UGI bleeding and abdominal pain were the most common presenting symptoms of SBP. Culture positives were 35% (n=7). The most frequent organisms were Escherichia coli (n=3) and Streptococcus pneumoniae (n=2). 94% of the patients responded to therapy after 48 hours of treatment. Total resolution after 5 days of therapy was 73% and in-hospital mortality was 15% (n=3). CONCLUSION: SBP, if diagnosed early can be treated with very good success rate up to 73%. Appropriate treatment of SBP with cefotaxime can help in reducing mortality and morbidity in patients with chronic liver disease.

Sinonasal inverted papilloma in eastern part of Nepal.

OBJECTIVE: To evaluate the clinicopathological profile of sinonasal inverted papilloma in a tertiary referral center in eastern part of Nepal. METHODS: A prospective study consisting of total 28 histologically proven cases of sinonasal inverted papilloma was conducted in the ENT department of the center. The study period was from April 2002 to November 2005. RESULT: Out of 28 cases studied, 21 were males and 7 were females with male to female ratio of 3:1. The highest incidence was seen in the 5th and 6th decades of life. The duration of symptoms varied from 5 months to 20 years with mean duration of 3.9 years. The lateral nasal wall and nasal cavity involvement was seen in all 28 cases. Maxillary sinus was involved in 27(96.4%) subjects followed by ethmoid (20), sphenoid (10) and the frontal sinus (7). The principle presenting symptom was nasal obstruction seen in 96.4% of the patients. Twenty two cases were treated by lateral rhinotomy with medial maxillectomy while, orbital exenteration was done in two cases. Associated carcinoma was noticed in 10.15% of all the subjects studied. CONCLUSION: Sinonasal papilloma mostly presented in fifth to six decades of life mainly affecting the male patients. Majority of the patients were treated by lateral Rhinotomy with medial maxillectomy surgery. Early presentation would have given chances for endoscopic surgery.

Chest radiographs and their reliability in the diagnosis of tuberculosis.

Radiology plays an important role in the diagnosis of pulmonary tuberculosis. Many medical practitioners believe in and rely primarily on the chest x-ray for the diagnosis of pulmonary tuberculosis. This study attempts to evaluate the reliability and validity of chest radiographs. This study was carried out in the tuberculosis clinic of BPKIHS. 75 radiographs were chosen for the study and viewed by 25 physicians of varying qualifications. Their findings were compared with the gold standard. The overall sensitivity and specificity was 78% and 51% respectively. There was poor agreement between the best physician and the best radiologist. This study has demonstrated an unsatisfactory sensitivity and specificity of chest x-rays in the diagnosis of pulmonary tuberculosis. The over-diagnosis and over-treatment due to chest x-rays could lead to an unmanageable burden on the resources of a poor country like Nepal. Private practitioners should be made aware about the importance of bacteriological diagnosis of tuberculosis before initiating drug therapy.

Association of obesity and physical activity in adult males of Dharan, Nepal.

OBJECTIVES: Obesity is one of the most apparent-yet most neglected public health problems. Physical activity is a crucial element in the development of obesity but still its importance in the occurrence of obesity varies in different populations. This paper aims to study the burden of obesity and its association with physical activity was carried out in a rapidly urbanizing town. METHODS: A cross-sectional study to investigate the prevalence of obesity and its association with physical activity was carried out in one thousand adult males of Dharan municipality. Tools of data collection included interview and physical measurements such as blood pressure, height and weight measurements, and waist and hip circumferences. Odds ratios (ORs) and their 95% confidence intervals for obesity were computed across various demographic and other variables without adjusting and then adjusting for physical activity. RESULTS: The prevalence of overweight and obesity in the population was 32.9% and 7.2% respectively. The study showed that physical inactivity is more importantly associated with obesity in the older population. The trend of young being more obese is reversed after adjusting for physical activity so that those in the older age were more obese than the younger ones. Similarly, those in to the business, vocational and clerical works, those who were more literate and those in the higher socio-economic status were significantly associated with obesity even after correcting for physical activity. CONCLUSION: The prevalence of overweight and obesity is high in the males of Dharan. The value and effect of physical activity seem to vary across different age-groups and socio-economic status and occupations. The young, the technical persons or businessmen and the more prosperous ones probably need to bring down their calorie intake along with emphasis on physical activity in order to bring down their weight and cardiovascular risk.

Pott's spine and paraplegia.

Spinal tuberculosis is usually secondary to lung or abdominal involvement and may also be the first manifestation of tuberculosis. Spinal tuberculosis (often called Pott's disease) is by definition, an advanced disease, requiring meticulous assessment and aggressive systemic therapy. Physicians should keep the diagnosis in mind, especially in a patient from a group with a high rate of tuberculosis infection. This review aims on updating the knowledge on spinal tuberculosis and its management. Skeletal involvement has been reported to occur in approximately 10% of all patents with extrapulmonary tuberculosis, and half of these patients develop infection within the spinal column. Symptoms of spinal tuberculosis are back pain, weakness, weight loss, fever, fatigue, and malaise. It is much more prone to develop neurological manifestation, paraplegia of varying degree. The palpation of spinous process in routine clinical examination is the most rewarding clinical method and is an invaluable measure for early recognition. Diagnosis of spinal tuberculosis is made on the basis of typical clinical presentation along with systemic constitutional manifestation and the evidence of past exposure to tuberculosis or concomitant visceral tuberculosis. Magnetic resonance imaging can define the extent of abscess formation and spinal cord compression. The diagnosis is confirmed through percutaneous or open biopsy of the spinal lesion. Surgery is necessary as an adjunct to antibiotic therapy if the vertebral infection produces an abscess, vertebral collapse, or neurologic compression. Some patents need aggressive supportive care owing to tuberculous meningitis or encephalopathy. Moreover, the importance of immediate commencement of appropriate treatment and its continuation for adequate duration along with the proper counseling of the patient and family members should not be underestimated for successful and desired outcome.

Risk factors, associated health problems, reasons for admission and knowledge profile of diabetes patients admitted in BPKIHS.

OBJECTIVES: The objective of the study was to find out the demographic profile, identify the known risk factors, assess the associated health problems, find out the reasons for admission and explore the knowledge profile of the patients admitted with diabetes in medical units of BPKIHS. METHODS: It was hospital based exploratory study conducted among the admitted DM patients during the period of 1-3-2003 to 29-2-2004 in medical units using simple random sampling, which included 35 samples. The data was analysed using Excel and SPSS programme. RESULTS: About 54% subjects were of age group between 40-60 yr., Hindu 85.7%, married 92.9%, and non-vegetarian 75.9 %. About 50% of subjects were on Insulin. About 60.7 % subject had hypertension, 39.3 % had ocular problem, and 25 % had renal problems. Majority of subject (82.1 %) had knowledge about the disease, they were suffering but limited subject had the knowledge about, causes, curability, treatment modalities, diet, and other aspects. CONCLUSIONS: As the knowledge regarding various aspects of DM is very low, there is need for information booklet in Nepali and health education programme among public will be very beneficial.

Cervical necrotizing fasciitis in an uncontrolled type II diabetic patient.

We report a case of cervical necrotizing fasciitis (CNF) in a female having uncontrolled type II diabetes mellitus. The patient was presented to us after 20 days of preliminary symptoms. The aetiology of microbial inoculation in subdermal tissue was not known. The isolate was Staphylococcus aureus. In spite of the delay in presentation, the patient was successfully treated with combined antimicrobial and surgical intervention.

Post kala-azar dermal leishmaniasis (PKDL): a first case report from Nepal.

Post kala-azar dermal leishmaniasis (PKDL) is a non-ulcerative lesion of the skin caused by Leishmania donovani, which is usually seen after completion of treatment of the kala-azar. The condition is yet to be reported from Nepal. We document and report for the first time a case of PKDL in Nepal.

Post-kala-azar dermal leishmaniasis (PKDL): the first case report from Nepal.

Post-kala-azar dermal leishmaniasis (PKDL) is condition characterized by non-ulcerative lesions of the skin caused by Leishmania donovani that is usually seen after the completion of treatment of kala-azar (visceral leishmaniasis). We document the first case report of PKDL in Nepal.

Prevalence of non-insulin dependent diabetes mellitus in urban areas of eastern Nepal: a hospital based study.

Non-insulin dependent diabetes mellitus (NIDDM), which affects millions of people throughout the world, is a widely prevalent chronic debilitating disease that causes short term and long term complications. It is a problem in a developing country like Nepal, where there has been no report of prevalence. Hence this study was undertaken to investigate the prevalence of NIDDM among urban patients attending the outpatient clinic of BP Koirala Institute of Health Sciences (BPKIHS) hospital, and coming from the eastern part of Nepal. A sample of 1,840 subjects was incorporated in the study during a period of one year. WHO diagnostic criteria (1985) were followed to establish the diagnosis of NIDDM. The prevalence of diabetes was 6.3% (1.63% previous and 4.67% new) which is relatively high in comparison to many other countries. The prevalence of NIDDM in females was relatively lower (5.75%) than in males (6.73%). The prevalence showed an increasing trend with increasing age. The high incidence (new cases) of NIDDM in Nepal as found in the study may be due to lack of public awareness regarding the problem and poor medical services in the country.

Cutaneous leishmaniasis in Nepal.

We report an imported case of cutaneous leishmaniasis in a 30 year old adult male from Nepal caused by Leishmania tropica. This case from Dharan is the first such report of imported cutaneous leishmaniasis in Nepal.

A thirty day course of sodium stibogluconate for treatment of Kala-azar in Nepal.

Twenty-seven cases of Kala-azar were treated with sodium stibogluconate at a dose of 20 mg/kg/day for 20 days (group A) and an equal number of cases were treated with the same dose but for a longer duration of 30 days (group B). Clinical and laboratory evaluation of these cases were carried out before and after therapy, during a follow up of cases every month, upto 6 months. Renal and liver function tests and electrocardiography were carried out of monitor any toxic effect of the drug during therapy. The cure rates of patients were 77.78% and 92.59% in group A and B cases respectively. Six and two patients in group A and B respectively were unresponsive to the treatment and showed relapse. Results of the study show that treatment of cases of Kala-azar with sodium stibogluconate in a dosage of 20 mg/kg/day for a longer period of 30 days is effective with a higher cure rate and minimum side effects, for treatment of cases of Kala-azar in this eastern part of Nepal, endemic for the disease.