Outcome of Twin Deliveries at a Tertiary Care Centre of Eastern Nepal.

BACKGROUND: Twins, compared to singletons, have higher perinatal mortality and morbidity. The aim of this study was to describe the twinning rate, epidemiological variables and hospital outcome of twin deliveries and to find out ways of better management of twins in our part. METHODS: A retrospective evaluation of the outcome of 92 twin pregnancies during one year study period (1st January 2014 to 31st December 2014) was conducted at BPKIHS. Twins delivered within the institution were included but cases less than 28 weeks gestation were excluded. Maternal and neonatal data were retrieved and analysed. RESULTS: The twinning rate was 9.2/1000 (92/10,031). The mean birth weight was 1636.30 ±339.21 grams and mean gestational age 34.31±2.67 weeks(28 - 40 weeks). One hundred eighty-two babies (98.9%) were low birth weight (LBW) while 32.1% were small for gestational age (SGA). There was mild, moderate and severe growth discordance in 63 (68.5%)22 (23.9%)and 7 (7.6%) respectively. Three (3.26%) of 92 pairs had twin-to-twin transfusion syndrome. The hospital mortality rate was 10.87% (20/184) and 69 (37.5%) babies had complications. The clinical causes of death were hyaline membrane disease in 7 (3.3%), severe birth asphyxia in 5 (2.7%), congenital malformations in 3(1.6%) and sepsis in 3 (1.6%) babies. CONCLUSIONS: Twin deliveries are common in this hospital and have poor hospital outcome with more complications and mortality. Hence there is a need for further studies with long term follow-ups to plan for better management of twins in our part.

Imaging Informatics: 25 Years of Progress.

The science and applications of informatics in medical imaging have advanced dramatically in the past 25 years. This article provides a selective overview of key developments in medical imaging informatics. Advances in standards and technologies for compression and transmission of digital images have enabled Picture Archiving and Communications Systems (PACS) and teleradiology. Research in speech recognition, structured reporting, ontologies, and natural language processing has improved the ability to generate and analyze the reports of imaging procedures. Informatics has provided tools to address workflow and ergonomic issues engendered by the growing volume of medical image information. Research in computeraided detection and diagnosis of abnormalities in medical images has opened new avenues to improve patient care. The growing number of medical-imaging examinations and their large volumes of information create a natural platform for "big data" analytics, particularly when joined with high-dimensional genomic data. Radiogenomics investigates relationships between a disease's genetic and gene-expression characteristics and its imaging phenotype; this emerging field promises to help us better understand disease biology, prognosis, and treatment options. The next 25 years offer remarkable opportunities for informatics and medical imaging together to lead to further advances in both disciplines and to improve health.

Human papillomavirus/p16 positive head and neck cancer in India: Prevalence, clinical impact, and influence of tobacco use.

BACKGROUND: Limited data are available on the prevalence and prognostic significance of human papillomavirus (HPV) in squamous cell carcinoma of head and neck (SCCHN) in the Indian population. AIM: The present study aimed to determine the prevalence of HPV and p16 in an Indian cohort of SCCHN and assess their correlation and influence of tobacco use on patient outcomes. MATERIALS AND METHODS: The p16 and HPV status of 170 patients of SCCHN treated with curative chemoradiotherapy was determined using immunohistochemistry and polymerase chain reaction, respectively, and further correlated with their demographic characteristics. In addition, genotyping of HPV-positive samples was performed. Survival outcomes were analyzed and compared for both p16 positive (p16 +ve) and p16 negative (p16 -ve) population. The influence of tobacco use on outcomes was assessed. RESULTS: p16 expression was observed in 20% (34/170) cases whereas HPV positivity was detected in 39.4% (67/170) of SCCHN patients with HPV16 being the most common (91%) subtype. About 73.5% patients were p16 +ve among the tobacco users in this cohort (83.5%). Interestingly, p16 positivity was significantly associated with nonusers of tobacco (P = 0.02) and younger females (P = 0.06). The p16 +ve and p16 -ve groups did not exhibit a significant difference in the 5-year cause-specific survival (CSS) (79% vs. 72.2%), disease-free survival (DFS) (78.3% vs. 68.3%, P = 0.5), and locoregional control (LRC) (82.2% vs. 71.5%, P = 0.4). However, the outcome analyses in tobacco nonusers revealed a definite large improvement in CSS (P = 0.08) and a trend toward improvement in DFS (P = 0.15) and LRC (P = 0.11) in the p16 +ve versus the p16 -ve groups. CONCLUSION: The low prevalence of p16 positivity (20%) and dual HPV and p16 positivity (38.8%) in the studied Indian cohort indicates the low utility of p16 as a surrogate for HPV in the background of high tobacco burden. The outcomes are largely improved in a small subset of SCCHN cases comprising p16 +ve tobacco nonusers.

Skin involvement and ipsilateral nodal metastasis as a predictor of contralateral nodal metastasis in buccal mucosa cancers.

CONTEXT: In view of low incidence of contralateral nodal metastasis and increase in the morbidity, the opposite neck is not routinely addressed. However, contralateral nodal metastasis is seen frequently in a certain group of patients. Identifying those factors associated with higher chances of contralateral nodal metastasis may help in optimizing the treatment. AIMS: The aim of this study was to identify prognostic factors associated with contralateral nodal metastasis in cases of buccal mucosa cancers. SETTINGS AND DESIGN: A retrospective audit of 125 patients with squamous cell carcinoma of buccal mucosa at a tertiary cancer center. SUBJECTS AND METHODS: Those cases in which lesions were reaching or crossing midline were included in this study. All cases underwent surgery as primary modality of treatment and had bilateral neck dissection. STATISTICAL ANALYSIS USED: Chi-square test is used for evaluating the variables predicting contralateral nodal metastasis. Finally, a multivariate analysis was performed using binomial logistic regression to identify those variables that were independently associated with the risk of contralateral nodal metastasis. RESULTS: Among 125 patients, 53 cases were node negative. Ipsilateral nodal metastasis was seen in 44/125 (35.2%) patients, 26/125 (20.8%) had bilateral neck node metastasis, and 2/125 (1.6%) had isolated contralateral nodal metastasis. Among these 28 patients with contralateral nodal metastasis, 26 patients had ipsilateral nodal metastasis. Ipsilateral nodal metastasis and skin involvement were independently predictive of contralateral nodal metastasis. CONCLUSIONS: Contralateral nodal metastasis in the absence of ipsilateral nodal metastasis is very rare and frozen section of ipsilateral neck dissection specimen can be an important pointer for addressing contralateral neck.

Recurrence Risk of Febrile Seizures in Children.

BACKGROUND: Identifying children with febrile seizure who are at risk for recurrence is important so that special attention can be given to them. The objective of this study was to identify the risk factors for recurrence of febrile seizures in children. METHODS: This prospective hospital based study was conducted from July 2013 to August 2014 'among children of 6 months to 6 years of age at Bishweshwar Prasad Koirala Institute of Health Sciences (BPKIHS), Nepal. Children meeting the selection criteria were enrolled in study. Clinical, investigation, treatment and outcome parameters were analyzed. RESULTS: A total of 92 children with febrile seizure were enrolled in study. Males accounted for 70% and females 30%. Simple febrile seizure was present in 48% and complex febrile seizures were seen in 52%. Recurrence of seizure was seen in one third of cases. Loss of consciousness was most common post-ictal phenomenon followed by confusion and lethargy. Upper respiratory infection was the most common precipitating factor. Generalized Tonic Clonic Seizure was the most common seizure type present in 79% of cases. Significant risk factors for recurrence occurred in males (p=0.088), age less than 1 year (p=0.003). Most of the recurrence occurred within one year of first seizure. CONCLUSIONS: Febrile Seizure is common in males. Almost one third of children with febrile seizure are at risk for recurrence. The significant risk factors for recurrences are male gender and age <1year.

Effect of sitting posture on development of scoliosis in Duchenne Muscular Dystrophy cases.

BACKGROUND: Scoliosis is a frequent association in boys with Duchenne Muscular Dystrophy when the ability to walk is lost around nine to 12 years of age. This study assessed the contribution of physical factors including lumbar posture to scoliosis in non-ambulatory youth with DMD in Nepal. METHODS: Linear regression was used to assess effects of time since loss of ambulation, muscle strength, functional severity and lumbar angle as a binary variable on coronal Cobb angle; again logistic regression was used to assess effects of muscle strength and cross-legged sitting on the presence of a lordotic lumbar posture in 22 non-ambulant boys and young men. RESULTS: The boys and young men had a mean (SD) age of 15.1 (4.0) years, had been non-ambulant for 48.6 (33.8) months and used a median of 3.5 (range 2 to 7) postures a day. The mean Cobb angle was 15.1 (range 0 to 70) degrees. Optimal accuracy in predicting scoliosis was obtained with a lumbar angle of -6° as measured by skin markers, and both a lumbar angle ≤-6° (P=0.112) and better functional ability (P=0.102) were associated with less scoliosis. Use of cross-legged sitting postures during the day was associated with a lumbar angle ≤-6° (OR 0.061; 95% CI 0.005 - 0.672; P=0.022). CONCLUSIONS: Use of cross-legged sitting posture was associated with increase in lumbar lordosis. Higher angle of lumbar lordosis and better functional ability are associated with lesser degree of scoliosis.

Foreign body penetration: a missed diagnosis

Healing of the injured site is a complex biological process of carefully orchestrated cellular events. Presence of any foreign body at the site of injury delays the healing along with inducing biological response such as inflammation, infections, allergic reactions, toxic events and tissue alterations. Such body reactions against an exogenous materials depends upon the mode of entry, chemical composition of material, quantity of material its physical form and also depends upon the body site. A careful history, clinical examination and imaging techniques should be considered for patients with any suspected penetrating injuries.

The role of the injection botulinum toxin A in cases of blepharospasm syndrome, hemifacial spasm and Meige's syndrome.

BACKGROUND: Benign Essential Blepharospasm Symdrome is a neuropathologic disorder. The cause of blepharospasm is multifactorial. It is unlikely that a single defect in this elusive control centre is the primary cause of this disease. OBJECTIVES: To evaluate the role of botulinum toxin A in treating cases of Essential Blepharospasm Symdrome, Hemifacial Spasm and Meige's Syndrome, and to assess orbicularis oculi muscle post treatment, in the patients who attended neuro-ophthalmology clinic and the general outpatient department of BP Koirala Lions Centre for Ophthalmic studies. METHODS: A prospective, interventional study was carried out on all the patients of Essential Blepharospasm Symdrome, Hemifacial Spasm and Meige's syndrome who underwent treatment with botulinum toxin A in BP Koirala Lions Centre for Ophthalmic studies during a study period of one and half years. Pre- treatment grading of the spasm was done with Jankovic spasm grading and post treatment response was seen with assessment of orbicularis oculi muscle and improvement in functional impairment scale. Relevant findings were noted. RESULTS: A total of 40 cases were enrolled in the study. The mean Jankovic spasm grading in cases of essential blepharospasm, hemifacial spasm and Meige's syndrome was 3.61 (+/- Standard deviation 0.50, range 3-4), 3.21 (+/- Standard deviation 0.63, range 2-4) and 3.67 (+/- Standard deviation 0.57, range 3-4) respectively. The mean value for reappearance of significant spasms (in months) in cases of essential blepharospasm, hemifacial spasm and Meige's syndrome was 4.3 (+/- Standard deviation 1.6, range 2.0-6.5), 5.8 (+/- Standard deviation 1.4, range 3-8) and 4.5 (+/- Std.deviation 2.8, range 2.5-6.5) respectively. Blepharoptosis was the commonest complication accounting for 66.6% of the complications. CONCLUSIONS: The movement disorders like Essential Blepharospasm, Hemifacial Hpasm and Meige's syndrome are treated by different modalities. An acceptable and effective treatment modality has been a long felt need in these cases. Our study has shown that injection of botulinum toxin A has been a safe and effective method of treating these cases in Nepal.

Comparative study of post operative wound infection following emergency lower segment caesarean section with and without the topical use of fusidic acid.

The study was undertaken to see the infection rate of wound following emergency caesarean section with and without the use of topical fusidic acid. The study was carried out at Himal Hospital from April 2006 to Jan. 2008. A total of 70 child bearing patients who underwent emergency caesarean sections were included. All of the patients were given absorbable subcuticular stitches. Out of the 70 patients, 35 patients had topical fusidic acid immediately after subcuticular stitches followed by dry dressing. The other 35 patients had simple dressing with povidone- iodine. Six patients (17.1%) out of the 35 patients who had dressing with povidone-iodine developed wound infection at the surgical site and only 1 patient (2.8%) out of the 35 patients with fusidic acid developed wound infection. The use of fusidic acid reduced the infection rate by six times. The relation of fusidic acid to wound infection was statistically significant (p = 0.0460).

Etiological profile of short stature.

OBJECTIVE: To study the frequency of various causes of short stature and their etiological contribution in a referral endocrinology and metabolism clinic at a tertiary care hospital. METHODS: 352 children with growth retardation attending endocrine clinic between Feb 1999 to Mar 2001 were investigated for etiology of short stature. Agrawal's growth chart was used for percentiles and height velocity. Various relevant radiological, biochemical and hormonal investigations were performed. RESULTS: Normal variant short stature was the most common cause of short stature followed by endocrine causes. CONCLUSION: In males most common cause of short stature was constitutional growth delay, while in females most common cause of short stature was familial short stature.

Cerebral salt wasting syndrome in a patient with a pituitary adenoma.

Cerebral salt wasting syndrome (CSWS) is often an unrecognized cause of hyponatremia that occurs in the setting of intracranial lesions. It is important to differentiate CSWS from the syndrome of inappropriate ADH secretion, as this would alter the management of hyponatremia. We describe a case of CSWS that occurred in association with a non-functioning pituitary adenoma.

Immunoreactive insulin response to a single dose of glimepiride in lean type 2 diabetic subjects.

BACKGROUND: The best method for glucose lowering in lean type 2 diabetes remains controversial and this study was undertaken to study the 24 hour insulin response of these diabetics to glimepiride, a sulfonylurea with distinctive properties. METHODS: Twenty five consecutive newly diagnosed diet-unresponsive lean type 2 diabetics (BMI < 19 kg/m2) without any vascular complications were given single dose (1 mg) of glimepiride and insulin responses were measured 2,4,8,12 and 24 hours later. Pre and post-glimepiride blood glucose levels were also measured. RESULTS: All the post-glimepiride insulin levels were significantly higher than basal values. Increase in insulin secretion peaked at four hours and benefits lasted for at least 24 hours. This was accompanied by clinically and statistically significant reductions in fasting and postprandial blood glucose levels. Maximum secretory response correlated positively with beta cell function (HOMA) and negatively with fasting glucose. CONCLUSIONS: Glimepiride improved insulin secretion and hyperglycemia in lean type 2 diabetic subjects, with benefits lasting for 24 hours. The degree of response was proportional to the beta cell reserve, and occurred irrespective of the presence or absence of markers of insulin resistance.

Clinical and biochemical profiles of young diabetics in North-Eastern India.

OBJECTIVE: We compared the clinical and biochemical profiles of young diabetics in North Eastern India. METHODS: Seventy diabetics who were detected at less than 30 years of age were studied. Patients with ketoacidosis or ketonuria on insulin withdrawal were grouped as insulin dependent diabetes mellitus (IDDM), patients with history of chronic abdominal pain with or without exocrine pancreatic dysfunction who either on ultrasonography (USG) or endoscopic retrograde cholangiopancreaticoduodenography (ERCP) revealed pancreatic calcification and/or ductal dilatation were grouped as fibrocalculous pancreatic diabetes (FCPD), those having BMI < 19 kg/m2 with history or stigmata of childhood malnutrition and who were ketosis resistant were taken to be protein deficient diabetes mellitus (PDDM)/malnutrition modulated diabetes mellitus (MMDM) and those who neither had ketonuria nor history of chronic abdominal pain, malabsorption or stigmata of malnutrition were grouped as NIDDM of young (NIDDY). RESULTS: Amongst the young diabetics studied FCPD constituted 32.9%, IDDM 28.6%, MMDM 21.4% and NIDDY 17.11%. USG abnormalities were observed in 21 of the 23 patients of FCPD. Seven out of these showed pancreatic head calcification on X-ray while 14 showed pancreatic duct dilatation and calcification or calculi on USG. In the two remaining patients, ERCP revealed tortuousity of main pancreatic duct and calcification which were not detected on USG. Majority of FCPD and MMDM patients revealed insulin resistance on insulin tolerance test (ITT). HDL was significantly lower in NIDDY, while VLDL and triglycerides were significantly higher in FCPD and MMDM as compared to controls. Microvascular complications of diabetes were seen in all these groups, with peripheral neuropathy being more common in FCPD (43.5%) and background diabetic retinopathy in NIDDY (41%). CONCLUSIONS: We conclude that FCPD and MMDM together form majority (54.29%) of young diabetics at our center and a sizeable proportion of them may have microvascular complications, even at the time of diagnosis.

Iridoschisis associated with lens subluxation.

The etiopathogenesis of iridoschisis is unclear, although age-related degeneration and angle-closure glaucoma are its most common associations. We report the case of a 50-year-old man with lens subluxation (familial) in 1 eye and ipsilateral iridoschisis. The inferotemporal edge of the lens was directed anteriorly, pushing the iris forward; this led to iridoschisis and shallowing of the anterior chamber. The patient had bilateral angle-closure glaucoma. A subluxated lens rubbing against the iris may be a mechanical precipitating factor in the development of iridoschisis.