Liver fluke in a young Nepalese girl: A rare diagnostic puzzle.

Key Clinical message: Fascioliasis poses diagnostic challenges to clinicians for its broad spectrum of hepatobiliary symptoms and lower detection rates. Timely and precise identification avoids long-standing hepatic complications. Abstract: Fasciola hepatica, a trematode parasite, inhabits snails and sheep. Human hepatic fascioliasis is a neglected tropical disease with no specific tests. In this instance, the significance of clinical awareness, appropriate imaging, and serological investigations is demonstrated. A young Nepalese girl was diagnosed and managed successfully.

Tuberous Sclerosis Complex in a 17-month-old: A Case Report.

Tuberous sclerosis complex is a rare autosomal dominant genetic disorder that affects multiple organ systems, primarily affecting the central nervous system. It develops with a pathogenic mutation in tumour suppressor genes i.e. Tuberous Sclerosis Complex 1 or Tuberous Sclerosis Complex 2 which codes for protein hamartin and tuberin leading to unopposed hyperactivation of the mammalian target of the rapamycin signalling pathway. It presents with a triad of facial angiofibroma, intellectual disability, and epilepsy. We present a case of a 17-month female toddler with abnormal body movement with loss of consciousness and later developing into generalised jerky movements. On magnetic resonance imaging, a diagnosis of tuberous sclerosis was made. The patient underwent symptomatic management with anti-epileptic. As seizures in these cases are subtle, they remain undiagnosed for a long time leading to delays in management and developing refractory seizures. Keywords: angiofibroma; case reports; seizures; tuberous sclerosis; tumor suppressor gene.

Hypoplastic Left Heart Syndrome: A Case Report.

Hypoplastic left heart syndrome is a rare critical congenital heart defect constituting a prevalence of 1/3,500 to 1/12,500 live births in which there is obstructions to the blood flow within the left heart. Here we present a case of a full-term 38 weeks male baby with a birth weight of 3.5 kg, and no obvious physical deformity referred to our centre at 22 hours of life for respiratory distress and cyanosis. At 23 hours of life, he was diagnosed with hypoplastic left heart syndrome and kept on Prostaglandin E1 infusion till the 12th day of life. The baby had a large ventricular septal defect and atrial septal defect with a severely hypoplastic left ventricle, hypoplastic aortic root, ascending aorta and post-ductal coarctation of the aorta. The diagnosis was reconfirmed by computed tomography cardiac angiography on the 10th day of life with the same cardiac findings suggestive of hypoplastic left heart syndrome. Keywords: case reports; congenital heart disease; hypoplastic left heart syndrome.

Diaphragmatic Hernia in a Preterm with Congenital Heart Defects with Successful Outcome: A Case Report.

Congenital diaphragmatic hernia is an anatomical defect of the diaphragm that is often associated with serious cardiopulmonary complications. It can also be associated with many other problems like multi systemic anomalies, chromosomal aneuploidy and prematurity. Of these, cardiac defects, liver herniation and prematurity seem to have a pivotal role in affecting the outcomes of repair. We hereby present a preterm newborn with such multiple defects repaired on 15th day of life and post operatively managed in a Neonatal Intensive Care Unit with a successful outcome. The key learning objective for our team in this case was to identify the steps taken that led to a successful management of a low birth weight preemie with multiple defects in a resource limited set up. Keywords: congenital diaphragmatic hernia; preterm; surgical repair; ventricular septal defect.

The Epidemiology of Injuries in Adults in Nepal: Findings from a Hospital-Based Injury Surveillance Study.

This study aimed to develop and evaluate a model of hospital-based injury surveillance and describe the epidemiology of injuries in adults. One-year prospective surveillance was conducted in two hospitals in Hetauda, Nepal. Data were collected electronically for patients presenting to emergency departments (EDs) with injuries between April 2019 and March 2020. To evaluate the model's sustainability, clinical leaders, senior managers, data collectors, and study coordinators were interviewed. The total number of patients with injuries over one year was 10,154, representing 30.7% of all patients visiting the EDs. Of patients with injuries, 7458 (73.4%) were adults aged 18 years and over. Most injuries (6434, 86%) were unintentional, with smaller proportions due to assault (616, 8.2%) and self-harm (408, 5.5%). The median age of adult patients was 33 years (IQR 25-47). Males had twice the rate of ED presentation compared with females (40.4 vs. 20.9/1000). The most common causes were road traffic accidents (32.8%), falls (25.4%), and animal/insect related injuries (20.1%). Most injured patients were discharged after treatment (80%) with 9.1% admitted to hospital, 8.1% transferred to other hospitals, and 2.1% died. In Nepal, hospital-based injury surveillance is feasible, and rich injury data can be obtained by embedding data collectors in EDs.

Development and Evaluation of a Community Surveillance Method for Estimating Deaths Due to Injuries in Rural Nepal.

Almost 10% of global deaths are secondary to injuries, yet in the absence of routine injury surveillance and with few studies of injury mortality, the number and cause of injury deaths in many countries are not well understood. This study aimed to develop and evaluate the feasibility of a method to identify injury deaths in rural Nepal. Working with local government authorities, health post staff and female community health volunteers (FCHVs), we developed a two-stage community fatal injury surveillance approach. In stage one, all deaths from any cause were identified. In stage two, an interview with a relative or friend gathered information about the deceased and the injury event. The feasibility of the method was evaluated prospectively between February 2019 and January 2020 in two rural communities in Makwanpur district. The data collection tools were developed and evaluated with 108 FCHVs, 23 health post staff and two data collectors. Of 457 deaths notified over one year, 67 (14.7%) fatal injury events were identified, and interviews completed. Our method suggests that it is feasible to collect data on trauma-related deaths from rural areas in Nepal. These data may allow the development of injury prevention interventions and policy.

Culture Positive Cases of Ophthalmia Neonatorum in a Tertiary Care Centre of Nepal: A Descriptive Cross-sectional Study.

INTRODUCTION: Ophthalmia neonatorum although runs a benign course mostly, sometimes may progress to sight threatening complications. The study was conducted to find the prevalence of culture positive cases of opthalmia neonatorum. METHODS: It was a descriptive cross-sectional study conducted at a tertiary care center from January to December 2019. Ethical clearance was obtained from institutional review committee of Kathmandu Medical College. Convenience sampling was done. All data were entered into excel and, then for analysis, exported to Statistal Package for Social Sciences version 21. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: The prevalence of culture positive cases of opthalmia neonaturum is 10 (55.55%) (32.61-78.49 at 95% Confidence Interval). The causative organisms were coagulase negative Staphylococcus 4 (40%), Staphylococcus aureus 3 (30%), Klebsiella 2 (20%) and Pseudomonas 1 (10%). Culture sensitivity of the isolated organisms were different according to the patient even in case of the same organism. Vancomycin 7 ( 70%) was the most sensitive antibiotic followed by Ciprofloxacin 6 (60%), Amikacin 5 (50%) and Cloxacillin 5 (50%) while Azithromycin 1 (10%), Cefixime 1 (10%) and Cotrimoxazole 1 (10%) were the least sensitive. CONCLUSIONS: Staphylococcus species was the most common organism isolated from neonates with ophthalmia neonatorum and vancomycin was the most sensitive antibiotic.

Epidemiology of paediatric injuries in Nepal: evidence from emergency department injury surveillance.

BACKGROUND: Globally, injuries cause >5 million deaths annually and children and young people are particularly vulnerable. Injuries are the leading cause of death in people aged 5-24 years and a leading cause of disability. In most low-income and middle-income countries where the majority of global child injury burden occurs, systems for routinely collecting injury data are limited. METHODS: A new model of injury surveillance for use in emergency departments in Nepal was designed and piloted. Data from patients presenting with injuries were collected prospectively over 12 months and used to describe the epidemiology of paediatric injury presentations. RESULTS: The total number of children <18 years of age presenting with injury was 2696, representing 27% of all patients presenting with injuries enrolled. Most injuries in children presenting to the emergency departments in this study were unintentional and over half of children were <10 years of age. Falls, animal bites/stings and road traffic injuries accounted for nearly 75% of all injuries with poisonings, burns and drownings presenting proportionately less often. Over half of injuries were cuts, bites and open wounds. In-hospital child mortality from injury was 1%. CONCLUSION: Injuries affecting children in Nepal represent a significant burden. The data on injuries observed from falls, road traffic injuries and injuries related to animals suggest potential areas for injury prevention. This is the biggest prospective injury surveillance study in Nepal in recent years and supports the case for using injury surveillance to monitor child morbidity and mortality through improved data.

Perceptions of injury risk in the home and workplace in Nepal: a qualitative study.

OBJECTIVE: Injuries are a global health problem. To develop context-specific injury prevention interventions, one needs to understand population perceptions of home and workplace injuries. This study explored a range of views and perceptions about injuries in a variety of settings and identified barriers and facilitators to injury prevention. DESIGN: Qualitative study: interviews and focus groups. SETTING: Three administrative areas: Hetauda submetropolitan city, Thaha municipality and Bakaiya rural municipality in Makwanpur, Nepal. PARTICIPANTS: Nine focus groups (74 participants) and nine one-to-one interviews were completed; workers from diverse occupations, residents (slum, traditional or modern homes) and local government decision-makers participated in the study between May and August 2019. The interviews and discussions were audio-recorded, transcribed verbatim, translated to English and analysed thematically. RESULTS: Six themes were developed: unsafe home and workplace environment; inadequate supervision and monitoring; perceptions that injuries are inevitable; safety takes low priority: financial and behavioural considerations; safety education and training; and government-led safety programmes and enforcement. Key barriers to injury prevention were perceived to be lack of knowledge about injury risk and preventive measures both at the community level and at the workplace. Facilitators were community-level educational programmes and health and safety training to employees and employers. Participants stressed the importance of the role of the government in planning future injury prevention programmes in different environments. CONCLUSIONS: This study highlighted that both home and workplace injuries are complex and multifactorial. Lack of knowledge about injury risks and preventive measures, both at the community level and at the workplace, was found to be a common barrier to injury prevention, perceived to be mitigated by educational programmes. Together with previously published epidemiological evidence, the barriers and facilitators identified in this study offer useful basis to inform policy and practice.

Home-related and work-related injuries in Makwanpur district, Nepal: a household survey.

OBJECTIVE: To describe the epidemiology of home-related and work-related injuries, their mechanisms, inequalities and costs associated with these injuries. METHODS: A household survey was undertaken in three palikas of Makwanpur district between April and June 2019. Data were collected electronically on non-fatal injuries that occurred in the previous 3 months and fatal injuries that occurred in the previous 5 years. FINDINGS: 17 593 individuals were surveyed from 3327 households. Injury rates were 8.0 per 1000 population for home injuries and 6.4 per 1000 for work-related injuries; 61.0% of home injuries were among women and 69.9% of work-related injuries among men. Falls were the cause of 48% home injuries, affecting 50.9% of men and 46.5% of women. Burns/scalds were higher in women than men, affecting 17.4% of women reporting home injuries. Cuts and piercings accounted for 39.8% of all work-related injuries and 36.3% were falls. Injury incidence varied by ethnic group: home injuries were highest in Brahmin (12.0 per 1000) and work-related injuries highest in Rai groups (21.0 per 1000). The total mean costs (transport and treatment) of work-related injury was US$143.3 (SD 276.7), higher than for home injuries (US$130.4, SD 347.6). The number of home (n=74, 64.9%) and work-related (n=67, 77.9%) injuries were higher in families below the poverty line than families in the next income bracket (home: n=22, 19.3%; work: n=11, 12.8%). CONCLUSIONS: Home-related and work-related fall injuries are common. The inequalities in injury identified in our study by rurality, age, sex, income level and ethnic group can help target injury prevention interventions for vulnerable groups.

Micro-Erythrocyte Sedimentation Rate in Neonatal Sepsis of a Tertiary Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Neonatal sepsis is the most important cause of morbidity and mortality among low birth weight and preterm babies in developing countries. The main objective of this study is to find the level of micro-Erythrocyte sedimentation rate in neonatal sepsis. METHODS: This is a descriptive cross-sectional study conducted at the neonatal unit over six months period (November 2019 to April 2020). All preterm, term and post-term babies with neonatal sepsisdelivered at Kathmandu Medical College Teaching Hospital were enrolled. Ethical clearance was received from the Institutional Review Committee of Kathmandu Medical College (Ref: 181020191). Convenient sampling method was applied and statistical analysis was done with Statistical package for social sciences 19 version. RESULTS: Out of 75 babies, confirm sepsis is 13 (17.3%), probable sepsis is 40 (53.4%) and suspected sepsis is 22 (29.2%). Micro-Erythrocyte sedimentation level is elevated (≥15mm in 1st hr) in 25 (33.3%) babies with a mean micro-Erythrocyte sedimentation level 9.32±5.4 (2-18) mm in 1st hr. The elevated micro- Erythrocyte sedimentation level was seen in relation to sepsis types and C-reactive protein. CONCLUSIONS: The bedside micro-Erythrocyte sedimentation level aids in the diagnosis of neonatal sepsis.

Establishing injury surveillance in emergency departments in Nepal: protocol for mixed methods prospective study.

BACKGROUND: Globally, injuries cause more than 5 million deaths annually, a similar number to those from HIV, Tuberculosis and Malaria combined. In people aged between 5 and 44 years of age trauma is the leading cause of death and disability and the burden is highest in low- and middle-income countries (LMICs). Like other LMICs, injuries represent a significant burden in Nepal and data suggest that the number is increasing with high morbidity and mortality. In the last 20 years there have been significant improvements in injury outcomes in high income countries as a result of organised systems for collecting injury data and using this surveillance to inform developments in policy and practice. Meanwhile, in most LMICs, including Nepal, systems for routinely collecting injury data are limited and the establishment of injury surveillance systems and trauma registries have been proposed as ways to improve data quality and availability. METHODS: This study will implement an injury surveillance system for use in emergency departments in Nepal to collect data on patients presenting with injuries. The surveillance system will be introduced in two hospitals and data collection will take place 24 h a day over a 12-month period using trained data collectors. Prospective data collection will enable the description of the epidemiology of hospital injury presentations and associated risk factors. Qualitative interviews with stakeholders will inform understanding of the perceived benefits of the data and the barriers and facilitators to embedding a sustainable hospital-based injury surveillance system into routine practice. DISCUSSION: The effective use of injury surveillance data in Nepal could support the reduction in morbidity and mortality from adult and childhood injury through improved prevention, care and policy development, as well as providing evidence to inform health resource allocation. This study seeks to test a model of injury surveillance based in emergency departments and explore factors that have the potential to influence extension to additional settings.

Rare manifestations of Potter Sequence: A Case Report.

Potter sequence is a rare congenital malformation that primarily affects male fetuses and is characterized by pulmonary hypoplasia, skeletal malformation, and kidney abnormalities. The pressure of the uterine wall due to oligohydramnios leads to an unusual facial appearance, abnormal limbsor limbs in abnormal positions or contractures. The fetus generally dies soon after birth due to respiratory insufficiency. We presented a male baby of 35 wks gestation with birth weight 1200gms delivered by primi mother. She had severe oligohydramnios and virtually there was no liquor during birth. The baby had severe perinatal depression at birth requiring resuscitation. Multiple congenital anomalies like absence of left eye, congenital cataract on the right eye, right-sided choanal atresia, micrognathia, low set ears, beaked nose, bilateral clubbed foot with hip deformity were noted. After 2 hours of life,baby developed fast breathing and cyanosis and died due to respiratory failure.

Diagnosis of Achondroplasia at Birth: A Case Report.

Autosomal dominant mutations in fibroblast growth factor receptor 3 cause achondroplasia, the most common form of dwarfism in humans. Achondroplasia is a genetic disorder causing rhizomelic shortening of limbs. Head is often large with prominent forehead causing vaginal delivery difficult. A twenty-one years old multipara mother gave birth to a baby with achondroplasia via spontaneous vaginal delivery with episiotomy without any complication. Achondroplasia, in this case, was diagnosed on the basis of antenatal ultrasonography finding, clinical features and radiological finding of the baby. He was admitted in the special baby care unit for observation and discharged on the next day as no complications were noted. Keywords: achondroplasia; dwarfism; ultrasonography.

Outcome of Respiratory Distress in Neonates with Bubble CPAP at Neonatal Intensive Care Unit of a Tertiary Hospital.

INTRODUCTION: Respiratory distress is one of the commonest problem seen in neonates during admission in Neonatal Intensive Care Unit. Hyaline Membrane disease, Meconium Aspiration Syndrome, septicemia, congenital pneumonia, Transient Tachypnea of Newborn are the major causes of respiratory distress in neonates. Bubble Continuous Positive Airway Pressure is a non-invasive respiratory support delivered to a spontaneously breathing newborn to maintain lung volume during expiration. The main objective of this study was to observe the outcome of respiratory distress in neonates with Bubble Continuous Positive Airway Pressure. METHODS: This was a descriptive cross-sectional study conducted at Kathmandu Medical College Teaching Hospital over six months (October 2018 - March 2019) period. All preterm, term and post term babies with respiratory distress were included. Ethical clearance was received from Institutional Review Committee of Kathmandu Medical College and statistical analysis was done with SPSS 19 version. RESULTS: Sixty three babies with respiratory distress were included in this study with 45 (71%) male predominance. The mean birth weight receiving Bubble Continuous Positive Airway Pressure was 2661.75±84 gms and gestational age was 36.67±3.4 wks. The Bubble Continuous Positive Airway Pressure was started at 8.05±2 hr of life and duration of Bubble Continuous Positive Airway Pressure required for settling respiratory distress was 95.71±3 hrs. Out of 63 babies, improvement of respiratory distress in neonates with Bubble Continuous Positive Airway Pressure was 39 (61%) with confidence interval of 38% to 62% whereas 24 (39%) babies required mechanical ventilation and other modalities. CONCLUSIONS: This study concludes usefulness of Bubble Continuous Positive Airway Pressure in neonates with respiratory distress.

Severe Birth Asphyxia without Sequelae: A Case Report.

Perinatal asphyxia is one of the major causes of neonatal morbidity and mortality. It mainly causes neurodevelopmental delay leading to hypoxic-ischemic encephalopathy. We present here the case of a preterm male baby of 1670 grams born at 31+3 weeks of gestation delivered by 25-year-old primi mother through vaginal delivery with history of umbilical cord prolapse. At birth, the baby had no heart rate and cyanosed following which he was resuscitated according to the Neonatal Advanced Life Support 2015 guidelines protocol. After 5 minutes of neonatal resuscitation, the baby's heart rate reappeared, but was only upto 20 beats/min and resuscitation thus continued. But heart rate did not improve despite of using all form of resuscitation procedure including intubation and drugs. After 2 hours, baby cried spontaneously and later baby was managed in Neonatal Intensive Care Unit according to the neonatal unit protocol of the hospital. Keywords: birth asphyxia; cord prolapse; hypoxic ischemic encephalopathy.

Prevalence of Perinatal Asphyxia in Neonates at a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Perinatal asphyxia is one of the major causes of perinatal and early neonatal mortality in developing countries. The main objective of this study was to observe the prevalence of perinatal asphyxia in babies born at Kathmandu Medical College Teaching Hospital. METHODS: This was a descriptive cross-sectional study conducted at Kathmandu Medical College Teaching Hospital over six month period (January to June 2019). All preterm, term and post term babies delivered at Kathmandu Medical College Teaching Hospital were included. Ethical clearance was received from Institutional Review Committee of Kathmandu Medical College (Ref.:2812201808). Convenient sampling method was applied. Data analysis was done in Statistical Package for Social Sciences (SPSS 18), point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: A total of 1284 babies delivered over six months period were enrolled in this study and 47 (3.66 %) babies were asphyxiated, at 95% Confidence Interval (2.64%-4.68%). The mean birth weight of asphyxiated babies was 2759.75±65 grams and gestational age was 37.57±2 weeks. Among asphyxiated babies, 15 (32%) babies were normal, 15 (32%) babies were in Hypoxic Ischemic Encephalopathy stage I, 14 (30%) were in stage II and 3 (6%) were in stage III. Twenty Three (49%) asphyxiated babies had antenatal risk factors and all 47 babies had intrapartum risk factors leading to asphyxia. CONCLUSIONS: Prevalence of perinatal asphyxia was lower compared to that of other similar tertiary care hospitals. Perinatal asphyxia remains a major cause of neonatal morbidity and mortality.

Cause-specific neonatal mortality: analysis of 3772 neonatal deaths in Nepal, Bangladesh, Malawi and India.

OBJECTIVE: Understanding the causes of death is key to tackling the burden of three million annual neonatal deaths. Resource-poor settings lack effective vital registration systems for births, deaths and causes of death. We set out to describe cause-specific neonatal mortality in rural areas of Malawi, Bangladesh, Nepal and rural and urban India using verbal autopsy (VA) data. DESIGN: We prospectively recorded births, neonatal deaths and stillbirths in seven population surveillance sites. VAs were carried out to ascertain cause of death. We applied descriptive epidemiological techniques and the InterVA method to characterise the burden, timing and causes of neonatal mortality at each site. RESULTS: Analysis included 3772 neonatal deaths and 3256 stillbirths. Between 63% and 82% of neonatal deaths occurred in the first week of life, and males were more likely to die than females. Prematurity, birth asphyxia and infections accounted for most neonatal deaths, but important subnational and regional differences were observed. More than one-third of deaths in urban India were attributed to asphyxia, making it the leading cause of death in this setting. CONCLUSIONS: Population-based VA methods can fill information gaps on the burden and causes of neonatal mortality in resource-poor and data-poor settings. Local data should be used to inform and monitor the implementation of interventions to improve newborn health. High rates of home births demand a particular focus on community interventions to improve hygienic delivery and essential newborn care.