Role of CSF Analysis for the First Episode of Febrile Seizure among Children between Six Months to Five Years of Age.

Introduction: A febrile convulsion is defined as a seizure that occurs in association with fever in children from six months to five years of age, with no evidence of a central nervous system infection or other identifiable causes of seizure and no history of an afebrile seizure. Simple febrile seizures are brief (<15 minutes), generalized, and occur in association with fever and only once during a 24-hour period without postictal pathology. Febrile Seizures have longer duration (>15 min), or have focal features or if they recur within 24 hours are defined as complex. In May 1996, the American Academy of Paediatrics (AAP) issued practice parameters regarding the neurodiagnostic evaluation of children with a first simple febrile seizure, who present within 12 hours after the seizure. It may be due to meningitis. This study was done to find out role of cerebro spinal fluid (CSF) analysis to rule out the meningitis in different age group of children presenting with first episode of fever with seizure. Design: A prospective study was carried out from June 2008 to July 2009 at the Western Regional hospital, Department of Paediatrics, Pokhara, Nepal. A total of 110 hospitalized children between the age group five months to 5 years were included in the study. Results: 16 (14.54%) children were diagnosed to have meningitis. In the age group of 6 – 12 months, 6 (21.4%) had meningitis while in 12-18 months, 6 out of 31 (19.3%) had meningitis and in more than 18 months age group only 4 out of 51 (7.84%) were detected with meningitis. Conclusion: In cases of apparent febrile seizure, meningitis should always be considered as a differential diagnosis. Lumbar puncture is must to rule out meningitis in all children between the ages of six months to eighteen months presenting with first episode of fever with seizure to rule out meningitis, even in the absence of meningeal signs.

Outcome of supracondylar fractures of the humerus in children treated by closed reduction and percutaneous pinning.

Supracondylar fractures of humerus in children are common injuries. Displaced fractures are inherently unstable. Conservative treatment results in malunion. Open reduction and internal fixation (ORIF) is more invasive and recovery is prolonged. From September 2004 to September 2005, 102 displaced supracondylar fractures of humerus, aged between one and half year to 13 years, were treated using close reduction and percutaneous Kirschner (K) wire fixation under c-arm fluoroscopy. Seventy nine patients were treated by cross K-wires and in twenty three cases lateral two K-wires were put. Above elbow plaster of paris back slab was applied in all cases for at least four weeks. Back slab, K-wires were removed after four weeks and elbow range of motion exercise was started. Results were analyzed using Flynn's criteria. All patients were followed up to 14th week postoperatively. In cross K-wire group(N=79) 70.8% had excellent, 22.7% good, 3.8% fair and 2.5% had poor results at eight weeks follow up which was improved to 91.1% excellent, 6.3 good, 1.2% fair and 1.26% poor results at 14 weeks follow up. In lateral K-wire group (N=23) 70% had excellent, 21.7% good, 4.3% fair and 4.3% had poor result at eighth week which was improved to 91.3% excellent, 4.3% good, 4.3% fair and no poor result at 14th week follow up. Eight patients got superficial pin tract infection and seven patients sustained ulnar nerve injury post operatively. We recommend this procedure for displaced supracondylar fractures in children as it is safe and cost effective procedure with acceptable complication rates.

Use of percutaneous thread loop to hold the vermiform appendix during laparoscopic appendectomy.

INTRODUCTION: Laparoscopic appendectomy, although not as widely performed as laparoscopic cholecystectomy, it has got definite advantage over the conventional open procedure. Controversy exists regarding the closure of stump. Our institute practices intracorporeal knot tying using 3 ports. Difficulties are observed in three port technique to hold the appendix during knot tying. We use a percutaneous thread loop. Advantage of the use of loop was evaluated. PATIENTS AND METHOD: Prospective study was carried out during 18 months. Total cases were randomly divided in non-loop and with loop group. Operative procedure was same. Cases were compared in terms of operating time, post-operative hospital stay and complications. RESULTS: Total patients were 66. Thirty two in non-loop group and 34 in with loop group. Mean age was 27.89 yrs. Most of the cases were females (62%). Mean operating time was less in loop group although statistically not significant. There was no difference in post operative hospital stay. Use of loop was not associated with added complications. CONCLUSION: Use of percutaneous loop to hold the appendix reduces the operating time and replaces the need of fourth port. It is safe and effective without any increased morbidity. Key words: Laparoscopic appendectomy, Intracorporeal knot, Percutaneous loop.

Prevalence of peripheral arterial disease by ankle-brachial index and its correlation with carotid intimal thickness and coronary risk factors in Nepalese population over the age of forty years.

OBJECTIVES: Noninvasive measures of subclinical atherosclerosis such as the ankle brachial index (ABI) and common carotid artery intima-media thickness (CCA IMT) could improve risk prediction and provide more focused primary prevention strategies. This report describes the prevalence of subclinical atherosclerotic vascular disease in a Nepalese population over the age of forty years as measured by ABI and CCA IMT and their association with established cardiovascular risk factors. MATERIALS AND METHODS: Ultrasonic evaluation of ABI and CCA IMT was done in 195 individuals of age 40 years and above who had presented to an outpatient department. Patients with established diagnosis of coronary artery disease or symptomatic for peripheral arterial disease were excluded from the study. RESULTS: The prevalence of atherosclerotic disease as measured by ABI was 18.5% and there was a statistically significant correlation between ABI and CCA IMT and other established cardiovascular risk factors such as smoking, diabetes mellitus and hypertension. CONCLUSIONS: We recommend that ABI as measured by sphygmomanometer be incorporated into routine cardiovascular screening and when found to be abnormal further confirmed by Doppler assessment of ABI and CCA IMT as surrogate markers of atherosclerotic vascular disease.

Foreign body in the rectosigmoid colon.

A 55 years old male presented with history of assault and insertion of a "glass object" through his anus. Examination and investigation of the patient revealed a bottle in the rectosigmoid colon. The bottle was manipulated and delivered out transanally under general anesthesia.

Thyroglossal duct remnant: seven years analysis.

To analyze the clinico-pathological findings and surgical outcome in a patient population that underwent surgical procedures for the excision of the thyroglossal duct remnant (TGDR) i.e., cyst or sinus. A retrospective descriptive study was performed to include all patients of thyroglossal duct remnant who underwent the surgical procedures at National Academy of Medical Sciences, Nepal form April, 1998 to April, 2005 A.D. Age, sex, position of the thyroglossal duct remnant, histopathology of the lesion, type of surgery and its outcome with particular emphasis on recurrence were noted. All data were obtained from the patients' admission charts. Thirty clinically diagnosed thyroglossal duct remnant were enrolled in this study. Twenty-seven were histopathologically confirmed thyroglossal duct remnant and remaining three patients were dermoid cyst and tuberculous lymphadenopathy and were excluded from the study. The sex distribution was almost equal. The commonest age group affected by TGDR was less than twenty years (70.38 %) and commonest site was midline subhyoid (85.19 %). The post-operative complication rate of thyroglossal duct remnant was 18.51 % in the present study. Thyroglossal duct remnant is the commonest congenital cervical lesion in the pediatric population. Other clinical conditions of neck can masquerade as thyroglossal duct remnant so histopathological confirmation is mandatory. Sistrunk operation is the standard treatment to minimize recurrence.

Total thyroidectomy: the treatment of choice in differentiated thyroid carcinoma.

INTRODUCTION: Clinically detectable thyroid carcinoma constitutes less than 1% of human cancers. Ninety percent of all thyroid malignancies are differentiated papillary and follicular carcinoma. Surgery plays a key role in differentiated thyroid carcinoma as it carries excellent prognosis, lower recurrence rate and low mortality rate but controversy persists for extent of surgery and optimal surgical management of lymph node metastasis. PATIENT AND METHOD: A retrospective analysis was done for the cases that underwent total thyroidectomy with lymph node dissection for differentiated carcinoma of thyroid in Kathmandu Medical College during two year periods (Oct 2001 to Oct 2003). RESULT: In our experience with 18 cases of Differentiated Thyroid Carcinoma (DTC) treated with total thyroidectomies and lymph node dissection, papillary carcinoma was predominant with 83% incidence. Disease was prevalent in 50 to 60 year age group. Except two cases of transient hypocalcaemia and few wound related complications, there have been no other complications. CONCLUSION: Total thyroidectomy with lymph node dissection is safe and effective, so, the treatment of choice in cases of differentiated thyroid carcinoma.

Stripping without a stripper.

Varicose veins afflict some 10 to 20% of the population in the west. It is believed to be less prevalent in the developing nations. Though there are absolute indications of surgery for varicose veins, people in Nepal come for treatment of the varicose veins either to join the army or to work abroad. Not all hospitals in Nepal are equipped with a vein stripper. In KMCTH, we studied 29 patients who had their long Saphenous veins stripped either with a stripper or by tunnelling around the Saphenous vein. We found that the long Saphenous vein could be stripped via the tunnelling method with an additional incision above the knee joint which is cosmetically accepted by our patients Moreover the patients were much satisfied because of minimal or no bruises in the post operative period as compared to those who had the long Saphenous vein stripped with a stripper.