The effect of regional transmural agreements on the information transfer of frail older patients.

INTRODUCTION: Frail older patients are at risk for many complications when admitted to the hospital. Multidisciplinary regional transmural agreements (RTA) in which guidelines were set concerning the information transfer of frail older patients might improve outcomes. We aim to investigate the effect of implementation of the RTA on the completeness of the information transfer of frail older patients when admitted to and discharged from the hospital. METHODS: This is a retrospective cohort study in which we collected data from 400 randomly selected hospitalized frail older patients (70+) before the implementation of the RTA, January through March 2021, and after, October through December 2021. The cohort was split up into four groups, which determined what correspondence would be checked (referral letter by General Practitioner (GP) and three groups of 'hospital letters': ED letter upon admittance, clinical discharge letter to the elderly care physician and clinical discharge letter to the GP. We assessed for mention of frailty, a medication list and mention of resuscitation orders. RESULTS: In the period before implementation the mean age of patients was 82.6 years (SD 7.4) and 101 were female (50.5%), after implementation mean age was 82.3 (SD 6.9) and 112 were female (56.0%). Frailty was mentioned in hospital letters in 12.7% before and 15.3% after implementation (p = 0.09). More GP referral letters were present after implementation (32.0% vs. 54.0%, p = 0.03), however frailty was mentioned only in 12.5% before and 7.4% after (p = 0.58). There was a good handover of medication lists from the hospital (89.3% before, 94% after, p = 0.20) and even better from the GP (93.8% before, 100% after, p = 0.19). Resuscitation orders were mentioned in 59.3% of letters from the hospital before implementation and 57.3% after (p = 0.77), which is higher than in the referral letters (18.8% before and 22.2% after (p = 0.91). DISCUSSION: The implementation of RTA improved the number of GP referral letters present; however, it did not lead to other significant improvements in communication between the hospital and the GP's. Frailty and resuscitation orders are still frequently not mentioned in the reports. After a successful reimplementation, the improvements of outcomes could be investigated.

Post-tonsillectomy Hemorrhage in Patients Receiving Ketorolac Analgesic.

Background Ketorolac, the non-steroidal anti-inflammatory drug, is thought to have less sedation as well as postoperative nausea and vomiting in comparison to opioids, but with higher risk of post-tonsillectomy hemorrhage as reported in some of the literatures. There is no consensus till date in the use of ketorolac in the management of pain following tonsil and adenoid related surgeries. Objective To find out the incidence of hemorrhage following tonsil and adenoid related surgeries in patients receiving ketorolac in postoperative period. Method This is a retrospective chart review of patients undergoing tonsil and adenoid related surgeries who had received ketorolac during April, 2013 to May, 2019 at department of ENT-HNS, Patan Academy of Health Sciences (PAHS), Lalitpur, Nepal. Post-tonsillectomy hemorrhage rate was calculated in pediatric and adult patients. Result During the study period, 103 patients (male - 50 and female - 53) received ketorolac in postoperative period. Tonsillectomy and adenotonsillectomy were performed in 71and 32 patients respectively. Forty-five patients were < 18 years whereas 58 were ≥ 18 years. Most common indication for surgery was recurrent tonsillitis (66/103) followed by adenotonsillar hypertrophy (31/103). Post-tonsillectomy hemorrhage was observed in 15 patients; among them, four out 45 were < 18 years and 11 out of 58 ≥ 18 years. All five patients out of 15, who required surgical intervention for post-tonsillectomy hemorrhage, were ≥ 18 years and were operated for recurrent tonsillitis. Rest of the patients (10/15) were managed conservatively. None of the patients required blood transfusion. Conclusion Ketorolac is not associated with increased risk of post-tonsillectomy hemorrhage in children and can safely be administered. Whereas in adults, recurrent tonsillitis being the most common indication for tonsillectomy, it should be used cautiously.

Effect of Teachers Training Workshop Outcomes on Real Classroom Situations of Undergraduate Medical Students.

BACKGROUND: Faculty development by conducting regular training, workshops and research related to medical education has been a key feature to upgrade quality of medical education. OBJECTIVE: The aim of this study was to explore responses of the health science teachers, students and peers after the workshop after providing training on student assessment tools and teaching-learning methods. METHOD: Two teacher-training workshops were conducted to the faculty members of B.P. Koirala Institute of Health Sciences from the departments of basic, clinical and allied sciences in Oct. 2010 and Jan. 2011. Qualitative questionnaire based study was conducted, and the questions were validated before the study by expert peer review process. The effect of the training workshop in real classroom outcomes was assessed incorporating student's feedback, evaluation by peers and the self-evaluation by the teacher trainees. RESULT: Pre-test and post-test scores of the participating teachers, before and after the workshop were 62.53 and 71.17 respectively. Among the participants 90.3% teachers expressed enhanced in their role as a teacher for medical undergraduates after the workshop. CONCLUSION: In present study, the faculty members showed accrued interest to participate in teacher's training workshops. The peer evaluation of teacher's performance in their real classroom situations were rated higher than evaluation by the students. Therefore, such training workshops will have a greater impact on the ability of teachers in effective teaching in real classroom situations.

Graphene supported plasmonic photocatalyst for hydrogen evolution in photocatalytic water splitting.

It is well known that the noble metal nanoparticles show active absorption in the visible region because of the existence of the unique feature known as surface plasmon resonance (SPR). Here we report the effect of plasmonic Au nanoparticles on the enhancement of the renewable hydrogen (H2) evolution through photocatalytic water splitting. The plasmonic Au/graphene/TiO2 photocatalyst was synthesized in two steps: first the graphene/TiO2 nanocomposites were developed by the hydrothermal decomposition process; then the Au was loaded by photodeposition. The plasmonic Au and the graphene as co-catalyst effectively prolong the recombination of the photogenerated charges. This plasmonic photocatalyst displayed enhanced photocatalytic H2 evolution for water splitting in the presence of methanol as a sacrificial reagent. The H2 evolution rate from the Au/graphene co-catalyst was about 9 times higher than that of a pure graphene catalyst. The optimal graphene content was found to be 1.0 wt %, giving a H2 evolution of 1.34 mmol (i.e., 26 µmolh(-1)), which exceeded the value of 0.56 mmol (i.e., 112 µmolh(-1)) observed in pure TiO2. This high photocatalytic H2 evolution activity results from the deposition of TiO2 on graphene sheets, which act as an electron acceptors to efficiently separate the photogenerated charge carriers. However, the Au loading enhanced the H2 evolution dramatically and achieved a maximum value of 12 mmol (i.e., 2.4 mmolh(-1)) with optimal loading of 2.0 wt% Au on graphene/TiO2 composites. The enhancement of H2 evolution in the presence of Au results from the SPR effect induced by visible light irradiation, which boosts the energy intensity of the trapped electron as well as active sites for photocatalytic activity.

Prevalence of metabolic syndrome in chronic kidney disease: a hospital based cross-sectional study.

BACKGROUND: The components of metabolic syndrome (MetS) are the established risk factors of chronic kidney disease (CKD). Therefore, MetS and interplay of its various components, have deleterious effects on patients with chronic kidney disease. The aims of our study was to find out the prevalence of MetS in chronic kidney disease patients and to find out the association of each component of MetS with chronic kidney disease. METHODS: A Hospital based cross-sectional study was carried out from February 2008 to August 2009. One hundred and sixty confirmed chronic kidney disease diagnosed patients were included in this study. Chronic kidney disease was defined from national kidney foundation guidelines. Anthropometric measurements of subjects were noted in a semi-structured pro-forma. Fasting blood sample was collected for the estimation of fasting blood glucose, triglyceride and HDL-cholesterol. Chronic kidney disease patients were diagnosed as having the metabolic syndrome by using the modified National Cholesterol Education Program Adult Treatment Program III criteria. Data were assessed by the t-test and Chi Square Test. RESULTS: Sixty (37.5%) of the chronic kidney disease patients had MetS according to modified National Cholesterol Education Program Adult Treatment Program III criteria. The prevalence of hypertension, high fasting blood glucose, high triglyceride, low HDL Cholesterol and high waist circumference in chronic kidney disease patients was 112 (70.0%), 36 (22.5%), 74(46.25%), 98 (61.25%) and 30 (18.75%) respectively. Among the five components of the metabolic syndrome, waist circumference has the highest positive predictive value (73.34%) for chronic kidney disease. CONCLUSIONS: MetS occurs in more than one-third of chronic kidney disease patients. The prevalence of individual components of MetS is higher in chronic kidney disease patients.

Benign sinonasal masses: a clinicopathological and radiological profile.

BACKGROUND: Benign nasal and paranasal sinus masses are commonly encountered in clinical practice. Though benign, certain nasal polyps, fungal sinusitis, hemangiomas and fibro-osseous tumors can present with locally destructive features and deformities, mimicking malignancies at once. OBJECTIVE: This study was carried out to recognize the great variety of benign nasal lesions and their frequency in our region. METHODS: A retrospective chart analysis of cases presenting as mass in nose and paranasal sinus that underwent surgery over three years duration at our institute was done. A provisional diagnosis was made after clinical assessment and radiological investigations, but the final diagnosis was established after histopathological examination. RESULTS: A total 331 cases presented as masses in nose and paranasal sinus presented during the period. The clinicopathological examination aided by endoscopic and imaging studies revealed the non neoplastic benign masses in 293 and neoplastic masses in 38. Polyps were the commonest lesions constituting 70% cases followed by rhinosporidiosis in 10%. Fungal sinusitis, squamous papillomas, hemangiomas and inverted papillomas were found to be in order of 4.5%, 4%, 3.5% and 3% respectively. Rare cases like "rhinooto- cereberal" form of mucormycosis, angiomyoma, and psammomatoid ossifying fibroma were also observed in the study. CONCLUSION: Most of the nasal polyps/fungal sinusitis can be diagnosed clinically. However many a times Computer tomography (CT) scan and biopsy are necessary to differentiate them from each other and treatment plan. Certain benign tumors have high potential for malignant transformation while others can present with locally destructive features and deformities.

Spectrum of thyroid dysfunction in patients visiting Kantipur Hospital, Kathmandu, Nepal.

Thyroid disorder is most common endocrine abnormality in the general population and its prevalence increases with age. The screening of thyroid disorder is advised in high risk population. This hospital based cross-sectional study was conducted in Department of Biochemistry, Kantipur Hospital, Kathmandu, Nepal. Patients having complains of thyroid disease from February 2010 to January 2011 were enrolled in this study. Thyroid parameters such as FT3, FT4 and TSH were measured by ELISA technique. Among total 472 subjects 393(83.27%) were female whereas 79(16.73%) were male. The prevalence of thyroid dysfunction was 36.0% (n=170). The different patterns of thyroid dysfunction in Kathmandu valley were: hypothyroid (11.6%), subclinical hypothyroid (16.9%), hyperthyroid (4.0%), and subclinical hyperthyroid (3.6%) respectively. Subjects having all thyroid parameters normal i.e. euthyroid were 63.9%. In conclusion, this study reveals a higher prevalence of thyroid dysfunction in Kathmandu region. This study recommends community based nationwide epidemiological studies on a regular basis to monitor thyroid dysfunction in Nepalese populations.

Pattern of head and neck malignancies in eastern part of Nepal.

The term head and neck refers to the upper aerodigestive tract, the salivary glands, the thyroid, parathyroid glands, the sino-nasal tract and the skin of the head and neck region. Malignancies at these sites are important due to the divergence in their behaviors and prognosis. A retrospective, cross sectional, series of cases were studied to determine the pattern of head and neck malignancies in our department from January, 2005 to July, 2006. A total of 90 cases of head and neck malignancies proven on histopathology were studied. Pharynx 25 (27.78%) was the commonest site involved by cancer. In the pharynx, malignancies at the nasopharyngeal region contributed to the bulk of the tumor constituting 12 (48.00%). Histopathologically, squamous cell carcinoma was seen in 61, (67.77%) subjects. Most of the patients presented in IIIrd or IVth stage of disease. The commonest treatment strategy adopted was surgery with post operative radiotherapy. Nasopharyngeal carcinoma is a major concern in this part of the region.

Adenosine deaminase in CSF and pleural fluid for diagnosis of tubercular meningitis and pulmonary tuberculosis.

Tuberculosis (TB) is one of the most common infectious diseases in developing countries including Nepal. Delay in diagnosis and treatment of tuberculosis results in poor prognosis of the disease. This study was conducted to estimate diagnostic cut off values of Adenosine Deaminase (ADA) in cerebrospinal fluid (CSF) and pleural fluid and to evaluate the sensitivity, specificity, positive and negative predictive values ofADA in pleural fluid and CSF from patients with tuberculous and non-tuberculous disease. A total of 98 body fluid (CSF: 24, Pleural fluid: 74) specimens were received for the estimation of ADA. ADA activity was measured at 37 degrees C by spectrophotometric method of Guisti and Galanti, 1984 at 625nm wavelength. Among the patients enrolled for the study subjects for which CSF were received (n = 24) included 8 tuberculous meningitis (TBM), and 16 non-tubercular meningitis (NTM). Pleural fluid samples (n = 74) were received from 19 pulmonary TB with pleural effusion, 17 PTB without pleural effusion and 37 of non-tuberculous disease patients. CSF ADA activity were (11. 1 +/- 2.03 IU/L) and (5.3 +/- +1.89 IU/L) (p <00001) in TM and non-NTM groups and Pleural fluid ADA activity were (10 +/- 22.18 IU/L) and (23.79 +/- 11.62 IU/L) (p < 0.001) in PTB and non-TB groups respectively. ADA test in body fluids, which is simple, cost-effective and sensitive, specific for the tubercular disease is recommended to perform before forwarding the cumbersome and expensive procedures like culture and PCR for TB diagnosis.

Identification of Leptosphaeria maculans Pathogenicity Group 4 Causing Blackleg on Winter Canola in Oklahoma.

Winter canola (Brassica napus L.) is a relatively new crop to Oklahoma and other southern U.S. states where it is considered a desirable rotation crop with wheat. In 2009, approximately 15,000 ha of winter canola were harvested in Oklahoma (3); that area is expected to almost double in 2010. Blackleg, a potentially devastating canola disease, was detected in Oklahoma in 2009. Blackleg is caused by Leptosphaeria maculans (Desmaz.) Ces. & de Not (anamorph = Phoma lingam (Tode:Fr.) Desmaz.). In early 2010, leaf samples showing typical symptoms of blackleg were collected from four canola fields near the town of Enid in Garfield County, OK. Small portions of infected tissues were surface disinfested in an aqueous solution of NaOCl (0.5% a.i.) for 1 min, rinsed twice in sterile distilled water, and plated on V8 medium. Seven colonies were isolated and when grown in pure culture, all produced 2 × 4.5 µm guttulate, unicellular, hyaline spores in pycnidia that ranged from 200 to 480 µm in diameter. These morphological characteristics correspond with those of P. lingam (1). To verify the pathogenic nature of the isolates and establish the pathogenicity group (PG) to which they belong, a standard inoculation protocol was followed on a set of three differential cultivars, Quinta, Glacier, and Westar (2). Briefly, for each isolate, tiny puncture wounds were made with sterile needles on the cotyledons of six 10-day-old plants of each differential and a 10-µl aliquot of a pycnidiospore suspension (1 × 107 spores ml-1) was deposited on the wounds. Also, a set of differentials were inoculated with distilled water (mock inoculation). Inoculated plants were incubated overnight in a misting chamber at 21°C in the dark and returned the next day to the greenhouse. Disease severity was recorded 10 days after inoculation using a 0 to 9 scale in which 0 to 2 = resistant, 3 to 6 = intermediate, and 7 to 9 = susceptible. This process was repeated three times. Two of the seven isolates evaluated were highly virulent on all three differentials, an indication they belong to pathogenicity group 4 (2). The other five isolates produced small lesions on Westar (resistant reaction) but failed to develop symptoms on the other two differentials. This phenotypic reaction has been associated with strains of PG-1. Mock-inoculated plants did not develop lesions. To our knowledge, this is the first time blackleg isolates from Oklahoma have been identified to the PG level. While this information will assist breeders in the development of both spring and winter canola lines with resistance to blackleg, additional studies are necessary to determine the relative prevalence and diversity of the various PG in Oklahoma. References: (1) G. H. Boerema. Trans. Br. Mycol. Soc. 67:289, 1976. (2) A. Mengistu et al. Plant Dis. 75:1279, 1991. (3) USDA. National Agricultural Statistics Service. Retrieved from http://www.nass.usda.gov/Statistics_by_State/Ag_Overview/ AgOverview_OK.pdf , September 20, 2010.

Penetrating neck injury by an arrow: a paradigm of age old assault.

Penetrating neck injuries by traditional weapons are rare entity in the modern era of sophisticated weapons. We report an unusual case of penetrating neck injury by a metallic arrow entering anterior neck in zone II and its tip coming out of neck posteriorly causing difficulty for patient to lie down as well as posing challenge to intubate. Arrows are low velocity projectile and from a close proximity they can cause penetrating trauma similar to a low powered handgun. Management of the case was discussed.

Primary salivary gland tumors in eastern Nepal tertiary care hospital.

BACKGROUND: The knowledge of the distribution and pattern of salivary gland tumors in the tertiary care center can provide overview of the disease pattern in the region. It also helps in planning the strategies to treat the disease and launch the awareness program in the community to this largely curable disease. METHODS: A retrospective observational study of all the salivary gland tumors treated in the department of Otolaryngology, B. P. Koirala Institute of Health Sciences during April 2004 to March 2009 was done. Age, sex, presenting features, radiological findings, histopathological type of the tumor and type of surgery were recorded and descriptive analysis was done to calculate frequencies, percentage and their relations. RESULTS: Out of total 51 cases, 81% (n=41) were benign and 19% (n=10) malignant tumors. Male to female ratio was 1:2.1. Mean age for benign and malignant tumors were 32.3 and 46.5 years respectively. Parotid tumor outnumbered all other sites comprising 69%, followed by submandiibular 18% and minor glands 13%. Pleomorphic adenoma was the commonest tumor (76%) of all primary salivary gland tumors. Benign to malignant tumor ratio of parotid, submandibular and minor glands were 6:1, 3.5:1 and 1.3:1 respectively. Adenoid cystic carcinoma (40%) and mucoepidermoid carcinoma (30%) were commonest malignant tumors. CONCLUSIONS: The principal site for salivary gland tumors in eastern Nepal population was the parotid and the pleomorphic adenoma outnumbered all other tumors. Most of the cases in both benign and malignant group presented with painless lump often misleading the gravity of disease.

Common carotid artery pseudoaneurysm formation following foreign body ingestion.

OBJECTIVE: To report an unusual case of pseudoaneurysm formation following ingestion of a thin wire. METHOD: Case report, including management, and review of the world literature concerning pseudoaneurysm and its management. RESULTS: A 15-year-old boy presented as an emergency with a two-week history of painful swallowing, and a one-week history of a progressively enlarging, right-sided swelling of the lower neck. A foreign body had been ingested two weeks previously. Radiological investigation showed a pseudoaneurysm of the right common carotid artery. The neck was explored, the foreign body removed and the common carotid artery repaired. The patient was discharged on the 10th post-operative day without neurovascular complication. CONCLUSION: This is an unusual presentation of pseudoaneurysm of the common carotid artery following accidental ingestion of a foreign body, reported for its rarity and management.

Eccrine poroma in neck of a child--a rare presentation.

An eccrine poroma is a common benign tumour arising from the eccrine sweat gland duct epithelium in the dermo-epidermal region. Its occurrence in the neck region in pediatric age group is a rare entity. Here we report a case of an eccrine poroma in the retro-auricular area just below and behind the lobule of the left pinna in a nine years old child.

Prevalence of methicillin resistant Staphylococcus aureus in school children of Pokhara.

Present study was carried out to find out the prevalence of methicillin resistant Staphylococcus aureus (MRSA) in school children of Pokhara city in western, Nepal. A total of 184 randomly selected children younger than 15 years were included in the study. Nasal swabs collected were subjected to standard bacteriological culture. S. aureus isolates were identified by mannitol fermentation, coagulase positivity and DNase positivity. Antimicrobial susceptibility test was performed on muller-hinton agar (MHA) by modified Kirby-Bauer disc diffusion method. Out of total 184 nasal swabs, S. aureus was isolated in 31.0% (n=57). Among the isolates, 35.1% (n=20) were from male children whereas 64.9% (n=37) were from female. There was no significant sex difference in colonization of S. aureus. Out of 57 isolates, 56.1% (n=32) were MRSA. MRSA isolates indicated relatively high rate of resistance to antibiotic cloxacillin (68.7%) followed by ofloxacin (40.6%), tetracycline (15.6%), erythromycin (9.4%), ciprofloxacin (6.2%) and vancomycin (3.1%).This study showed a high prevalence of MRSA carriage in school children indicating the spread of MRSA in the community.

The morphology of central tympanic membrane perforations.

The objective of this study was to assess the extent of conductive hearing loss in relation to different sizes and sites of simple central tympanic membrane perforations. Total 100 cases attending ENT OPD, BPKIHS during period of April 2003 to Mar 2004 without any discrimination of sex, race and religion were taken for the cross sectional prospective study. Dry, clean central tympanic membrane perforations due to various causes like chronic suppurative otitis media-tubotympanic, post acute suppurative otitis media residual perforations or simple traumatic perforations with conductive hearing loss and without preexisting hearing loss were clinicoaudiologically evaluated and analyzed. Hearing loss was found to be directly proportional to the size of perforation irrespective of their cause, which was statistically significant. Hearing loss in the study was found to range from negligible to 53dB. Overall, perforations involving posterioinferior quadrant were found to have maximum hearing loss.