Nerve Conduction and Heart Rate variability in Patients with Hypothyroidism at a Tertiary Care Centre in Eastern Nepal.

INTRODUCTION: Thyroid hormone effects on many organs including central and peripheral nervous systems. However, these hormones do not affect all systems/organs to a similar extent. Thus, we conducted this study to explore the effect of thyroid hormones on somatic nervous system assessed by Nerve conduction study and cardiac autonomic activity assessed by heart rate variability. METHODS: The study included newly diagnosed hypothyroid patients and healthy controls. In all subjects NCS were performed in median, ulnar, tibial and sural nerves using Nihonkohden machine Cardiac autonomic control was assessed using Short-term Heart Rate Variability and parameters were analyzed by Time Domain and Frequency Domain methods. RESULTS: Both the groups were comparable in term of age, Body Mass Index, Pulse Rate, Systolic Blood Pressure and Diastolic Blood Pressure. Sensory parameters of NCS showed significant decrease in left median nerve SNAP amplitude (38.24±10.23 Vs 31.59±14.06, P=0.048) and nerve conduction velocity of bilateral median nerve in hypothyroid patients. In motor parameters of NCS, onset latencies of bilateral median nerves and right ulnar nerve were significantly increased in hypothyroid patients. All Time Domain measures of HRV and Frequency Domain measures; LF Power, HF Power and Total Power were significantly decreased (P<0.05) in hypothyroid patients. These HRV parameters are indicators of parasympathetic activity. CONCLUSIONS: In newly diagnosed hypothyroid patients, especially median nerve functions (both sensory and motor) and parasympathetic activity were decreased. It reflects that in hypothyroidism both autonomic nervous system and other somatic nerves are not affected in a similar extent.

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.

Clinical and electroencephalographic profile of children.

BACKGROUND: Reports on pediatric electroencephalogram of Nepalese patients are rare. OBJECTIVE: We aimed to study the relationship between provisional clinical and electrophysiological diagnoses of pediatric patients with documentation of demographic profiles, and type and frequency of the disorders/diseases. METHODS: Electroencephalographic reports of 634 children from 2006 to 2009 were analyzed at neurophysiology laboratory, department of Basic and Clinical Physiology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal, retrospectively. Chi-Square test was applied after detail descriptive statistics. RESULTS: Male and female were 72.2 % (n=458/634) and 27.76 % (n=176/634) respectively. Most frequent EEG abnormality was seizure disorder (n=370, 59.39%), then febrile seizure (n= 94, 15.08%) and birth asphyxia with hypoxic-induced encephalopathy (n=68, 10.91%). Electroencephalogram showed significant epileptiform discharges in seizure disorder (p=0.001, OR= 2.26, 95 % CI= 1.61 to 3.18) and in cerebral palsy (p=0.049, OR=6.88, 95 % CI=0.89 to 145.95), specifically in 6 to 12 (p=0.001, OR=2.94, 95 % CI=1.43 to 6.06) and one to five (p=0.019) years, respectively. Electroencephalogram detected significantly less epileptiform discharges (p=0.001, OR=0.25, 95 % CI= 0.15 to 0.42) in febrile seizure specifically in 1 to 5 years (p=0.003, OR=0.16, 95 % CI= 0.04 to 0.63). CONCLUSION: Predominant Electroencephalographic abnormality was seizure disorder, followed by febrile seizure and birth asphyxia with hypoxic-induced encephalopathy respectively. Electroencephalographic abnormality was highly associated with seizure disorder and cerebral palsy but was not associated with febrile seizure.

Effect of sub-maximal exercise stress on cold pressor pain: a gender based study.

BACKGROUND: Analgesic effect of exercise is a well established fact; however available reports are contradictory on gender differences in pain perception following exercise stress test. OBJECTIVE: The current study is prospectively designed to evaluate and compare the effect of acute bout of sub-maximal exercise stress on cold pressor pain in normal adult males and females. METHOD: The experimental study design involved healthy adults (n= 41); females (n = 18) and males (n=23) aged between 18 to 25 years and included them into four sets of experiments: SET I (Control), "resting blood pressure, radial pulse and respiratory rate were recorded after 15 minutes of complete supine relaxation. SET II (Cold Pressor Pain Test): Pain Threshold, Pain Tolerance, and Pain Duration in seconds were taken. SET III (Exercise Stress Test): Sub-maximal exercise of 70 to 75% of maximum predicted heart rate was given for 6 minutes. SET IV (Cold Pressor Pain Test immediately after Exercise Stress Test): At 0 minute of recovery again the pain parameters; Pain Threshold, Pain Tolerance, and Pain Duration in seconds were taken. SET I, SET II were performed in order on the first day and SET III and SET IV on the second day to ensure only a single Cold Pressor Pain Test is performed in each day. RESULT: The data (Mean ± SD) analysis showed significant increased in pain threshold (males: 14.36 ± 10.6 Vs 21.47 ± 13 seconds, p< 0.001, females: 14.1 ± 11.5 Vs 23.81 ± 20.22 seconds, p<0.001) and pain tolerance time (males: 41.3 ± 19.31 Vs 54.1 ± 21.7 seconds, p<0.001) in both sexes after 6 min of acute bout of sub-maximal exercise stress test with comparable age, BMI and baseline resting values of pain parameters and pulse rate and blood pressure. The percentage increment pain tolerance time following the exercise stress in female is higher than male (78.6 Vs 68.9%). CONCLUSION: The result suggests that pain sensation decreases immediately after a brief period of exercise challenge irrespective of gender, and the analgesic effect of the acute bout of exercise in terms of pain tolerant time is more enhanced in females than males.

Examination of relationship of scores obtained in grades 10 and 12 with the entry and success in undergraduate medical education.

BACKGROUND: Entrance examination (admission test) is the most important and widely accepted method of student selection for admission into medical schools in Nepal. For many schools it is the only criterion of student selection. OBJECTIVES: To examine relationships of scores obtained in schooling (grade 10 and 12), medical entrance and MBBS professional examinations in a cohort to identify predictive strength for entry into medical school and success in medical education. METHODS: Exam scores from grade 10 to medical entrance and professional exams of undergraduate medical education of a total of 118 medical students who entered medical school between 1994 and 1998 only through the merit of open competitive medical entrance examination at the BP Koirala Institute of Health Sciences (BPKIHS) were assessed. RESULTS: Student selection for admission in MBBS course at BPKIHS and their subsequent success were not determined by difference in outcomes of public and private management of schools at grade 10 (selection p= 0.80 and success p= 0.32 ) and grade 12 (selection p= 0.59 and success p= 0.55). Grade 12 averaged scores had no relationship in getting these students selected for admission into medical course (r= 0.08, p= 0.37), but did show correlation with the overall success in medical education (r= 0.32, p= 0.00). Scores in physics at grade 12 retained predictive strength in success in medical education (r= 0.19, p= 0.04). CONCLUSION: The present student selection criteria for medical education are not appropriate and need to incorporate other attributes of candidates along with cognitive aspects.

Effect of posture on heart rate variability in school children.

Heart rate variability (HRV) refers to the beat-to-beat alteration in cardiac cycle length. The objective is to study effect of posture on HRV. Five minutes ECG of children (12 females and 20 males) with mean height 138.88 +/- 11.88 cm, weight 27.66 +/- 5.87 kg and BMI 16.11 +/- 1.38 kg/m(2) were recorded in supine, sitting and standing position. HRV parameters were compared by one-way ANOVA and Bonferroni test. Standing decreases Mean interval between successive RR waves (622.69 +/- 83.24 ms versus 721.66 +/- 89.30 ms versus 750.28 +/- 107.917, p < 0.001), the square root of the mean squared differences of successive interval (25.37 +/- 17.52 ms versus 50.16 +/- 25.03 ms, p < 0.001), numbered of RR interval differences 50ms (40.59 +/- 61.58 versus 115.72 +/- 75.408 versus 134.16 +/- 76.57, p < 0.001), percentage NN50 (9.65 +/- 15.32 versus 29.85 +/- 20.52, versus 36.18 +/- 22.33, p < 0.001), High frequency (HF) peak (152.63 +/- 254.41 versus 427.84 +/- 369.62, 540.84 +/- 452.12, p < 0.05), HF power % (34.91 +/- 17.67 versus 51.99 +/- 17.57 versus 56.94 +/- 17.06, p < 0.001), HF normalised unit (45.05 +/- 17.82 versus 61.11 +/- 17.06 versus 65.73 +/- 15.14, p < 0.001) as compared to sitting and supine. Standing increases low frequency (LF) power % (39.78 +/- 11.76 versus 31.64 +/- 12.33 versus 28.53 +/- 11.65, p < 0.05), LF normalized unit (54.95 +/- 17.82 versus 38.89 +/- 17.05 versus 34.27 +/- 15.14, p < 0.001), LF: HF ratio (1.61 +/- 1.26 versus 0.808 +/- 0.69 versus 0.63351 +/- 0.538, p < 0.001) compared to sitting and supine. This study showed significant decreased in HRV parameters reflecting vagal activity and reciprocal increase in sympathetic activity in standing as compared to sitting and supine. There was no significant change in HRV in sitting as compared to supine.

Pheripheral airway responsiveness to sub-maximal exercise in asymptomatic cigarette smokers.

BACKGROUND: Cigarette smoking is one of the cardinal causes for the development of bronchial hyperresponsiveness among the smokers. OBJECTIVES: This study was perspectively designed to determine the peripheral bronchial responsiveness to sub-maximal exercise challenge in the asymptomatic smokers. METHODS: The subjects were between age of 18-25 years without any findings of cardiorespiratory diseases. We performed the 5 min step test exercise at intensity of 80 to 90% of maximum predicted heart rate in 42 young adult male asymptomatic smokers to examine the effect of cigarette smoking on airway responsiveness. Forced expiratory spirogram was recorded before and at 0, 5, 10, 15 min after the completion of exercise. Pre- to post exercise drop in Forced Expiratory Volume in first second ≥ 15% was considered hyperresponsive to the challenge. RESULT: The analysis of data (mean ± SE) indicated the bronchial hyper-responsiveness in 22 (52%) smokers. The post exercise recovery time pattern showed drop in forced expiratory spirogram from the resting baseline in the responsive smokers and the maximum percentage fall in the parameters or increase in airway resistance which reflect the peripheral airway integrity such as Forced Expiratory Flow 25% (20.30 ± 2.18 Vs 7.88 ± 3.23, p < 0.01), Forced Expiratory Flow 50% (18.46 ± 4.40 Vs 1.93 ± 2.78, p < 0.01), Forced Expiratory Flow 75% (23.94 ± 3.68 Vs 0.80 ± 4.72, p < 0.001) and Forced Expiratory Flow 25-75% (32.50 ± 4.79 Vs 3.64 ± 3.32, p < 0.001) was significantly higher in the responsive than non-responsive subgroup of the smokers. CONCLUSION: The occurrence of peripheral airway resistance is more in the responsive than nonresponsive subset of smokers to the exercise challenge and hence more prone to develop obstructive airway disease in the long run.

Effectiveness of teachers' training in assessment techniques: participants' perception.

BACKGROUND: Medical education has experienced a rapidly changing scenario especially during the past three decades. Teachers training programs have emerged in recent years as a more in depth and comprehensive mechanisms for strengthening instructional skills and formulating assessment techniques among faculty members. OBJECTIVE: The present study was carried out with the aim of assessing effectiveness of teacher training workshop on assessment techniques at B.P. Koirala Institute of Health sciences (BPKIHS), Dharan, Nepal. Methods: In this prospective questionnaire based study, the 26 entry level teachers were enrolled. They were requested to fill the questionnaire before and after the workshop on the assessment techniques at BPKIHS, Dharan. METHODS: Twenty six teachers majority of whom were entry level teachers comprising of medical, dental, nursing and allied sciences participated in pre- and post test analysis on the various components of written and oral examinations. A two and half days long training was conducted having 9 hours of teaching interactive sessions, 6 hours of group exercises, daily evaluation and 3 hours of presentation by participants. There was high degree of agreement with most topics of the assessment training. RESULTS: There was a significant gain in knowledge (p < 0.001) by the participants. All the participants (100%) agreed upon the training being informative and learned new things about assessment. More practice session with longer duration with invited resource persons were also suggested for an effective session. CONCLUSION: Thereis an immense opportunity for a better and comprehensive training in evaluation techniques in medical education..

Preparing tutors for problem-based learning: an experience from B. P. Koirala Institute of Health Sciences, Nepal.

BACKGROUND: Problem based learning (PBL) has made major impact on curricular designing and practice in medical education for the last forty years. Incorporation of PBL approach in medical education has been a challenge and opportunity for both educationists on how to impart change and medical teachers on how to internalise the change. OBJECTIVES: This paper aimed to investigate experiences, achievement and responses of medical teachers at B. P. Koirala Institute of Health Sciences (BPKIHS), Nepal. MATERIALS AND METHODS: There were 25 heterogeneous groups of teachers, majority of them were entry level. Pre- and Post-test question were taken from various topics relevant to PBL such as learning strategy and principles of adult learning, PBL practice at BPKIHS, tutorial session and role of a tutor, making resource session interactive, designing PBL problems, planning educational objectives in PBL, formulation of problem for PBL. In addition to it participants' perception on development and dissemination of PBL manual and effectiveness of workshop were also included in the questionnaire. RESULTS: There was significant gain in knowledge following the workshop (p<0.001). The perception of the teacher found quite relevant and useful for adopting new role as tutor. The respondent teachers noted that skills they learned during the training will be applicable to their job situation. They stressed for an additional training for reinforcement and update with new trends and tools in PBL. CONCLUSION: Therefore, such trainings for faculty development would be highly beneficial to inculcate new competencies in PBL.

Nerve conduction study in healthy individuals: a preliminary age based study.

BACKGROUND: Nerve conduction study assesses peripheral nerve functions and has clinical implication. OBJECTIVES: To study the effect of age on nerve conduction study variables in healthy adults. METHODS: Cross sectional study was done from Jan 2006 to Dec 2006 in department of Physiology, BP Koirala Institute of Health Sciences, Dharan, Nepal. The study was done in 34 (younger, n= 18, 17 to 29 years; older, n= 16, 30 to 57 years) consenting healthy adults of either sex. The compound muscle action potential and sensory nerve action potential were recorded using standard technique. Due to the non-normal distribution of data, the effect of age on nerve conduction study variables was analyzed using Mann Whitney U test. RESULTS: Younger vs. older individuals: older had lower Compound Muscle action potential amplitude (mV) in all motor nerves except radial and left ulnar nerves. Compound Muscle action potential duration (ms) was shorter in older (p less than 0.05) in ulnar, tibial, right median and left common peroneal motor nerves than the younger: right median (6.92±1.3 vs. 8.5±1.88), right ulnar (7.09±1.54vs. 8.2±1.31), left ulnar (10.56±1.44 vs. 12.06±1.5), right tibial (6.28±0.81vs. 7.28±1.12), and left tibial (9.58±1.52vs.10.78±1.71). Sensory nerve actional potential amplitude (µV) was smaller in older as compared to younger: right median (19.01±7.83 vs. 26.97±10.63), right ulnar (10.9±3.44 vs.16.09±5.85) and right radial (14.31±4.34 vs.19.72±6.47). SNAP duration (ms) was longer in older: right ulnar (1.34±0.17 vs.1.26± 0.18), left ulnar (1.46±0.14 vs. 1.29±0.26), and left median (1.11± 0.14 vs. 1± 0.14). CONCLUSIONS: Age has definite effects on amplitude and duration of motor and sensory nerves. Different nerves have different timing of aging. Without adjustment for age, the sensitivity and specificity of nerve conduction study will decrease whenusing the same reference data in patients with different age.

High fat diet induces obesity in British Angora rabbit: a model for experimental obesity.

A reliable and cost-effective animal model for human obesity with its manifested disorders is yet to be established in the context of increased morbidity and mortality due to obesity and its related problems. Therefore, an attempt was made to produce obesity in locally available British Angora Rabbits (BAR) and examine the effect on metabolic and cardiovascular parameters. Adult male BARs weighing nearly 2 kg were randomly divided into two groups, one of the groups was fed with high fat diet (HFD) ad libitum for 10 weeks and the control group received standard normal rabbit chow for same period. Body weight, skinfold thickness, serum cholesterol, serum glucose and resting heart rate were measured before and after the dietary regimens. After 10 weeks, HFD group of rabbits demonstrated significant (P < 0.05) increase in body weight (+24%) and skinfold thickness (+37%). The gain in body weight was positively correlated to skinfold thickness (r = 0.61). Serum cholesterol, serum glucose and resting heart rate were also increased by 46%, 52% and 15%, respectively. Whereas no such increases in any of these parameters were observed in control group of rabbits. Our results suggest that obesity can be produced in BARs by feeding HFD. The obesity manifests with cardiovascular and metabolic changes. It is proposed that this may serve as a valid and reliable model of experimental obesity.

Obesity attenuates formalin-induced tonic pain in British Angora rabbits.

Obesity is known to alter various physiological parameters including the pain sensitivity. There are conflicting reports on the pain sensitivity in obesity. In this context, the present study was aimed to investigate the tonic pain response in obese rabbit model. To achieve this aim, two groups of adult male British Angora rabbits were used. One of the groups was fed with standard rabbit chow and served as control. The other group was fed high fat diet (HFD) for 10 weeks to produce obesity. The standard formalin test was performed at the start and after 10 weeks of dietary regimen in both the groups. Timed behavioral responses (limping, elevation of paw, licking, biting, grooming etc.) were categorized and quantified with the help of standard pain rating scale. The total average pain rating score decreased significantly from 2.01 +/- 0.02 to 1.47 +/- 0.08 (P < 0.05) in HFD group after 10 weeks of dietary regimen, whereas there was no change in the control group. A significant negative correlation was observed between body weight and pain rating score in HFD group of rabbits (P < 0.05, r = -0.62). Results suggest that obesity attenuates the tonic pain responses induced by formalin in British Angora rabbits.

Heart rate variability: Response to graded head up tilt in healthy men.

BACKGROUND: Heart rate variability is actually a misnomer for R to R variability in cardiac cycle. Variation in successive cycle length is called the heart rate variability (HRV). Head-up tilt is a model of studying cardiovascular haemodynamics, which reflects in heart rate variability (HRV). OBJECTIVES: To study the effect of 10 degrees and 70 degrees head-up tilt on HRV. MATERIALS AND METHODS: The study was done in the Department of Physiology using graded head up tilt (passive orthostatism). HRV measurement was done at 10 degrees and 70 degrees tilt and compared with supine using standardised methods on 30 consenting healthy males (age 25.37+/-3.89 years). The HRV variables across postures were compared by ANOVA and Bonferroni test. RESULTS: The heart rate increased at 70 degrees compared to 10 degrees and supine (70.48+/-8.17 Vs 70.22+/-8.67 and 88.51+/-12.84 bpm, p<0.001). The 70 degrees tilt decreased vagal HRV indicators compared to 10 degrees and supine: SDNN (31.13+/-8.12 Vs 38.07+/-11.29 and 38.13+/-10.89 ms, p<0.05), RMSSD (20.06 +/-8.47 Vs 34.23+/-14.22 and 36.16+/-12.22 ms, p<0.001), NN50 count (13.03+/-20.58 Vs 45.07+/-44.44 and 55.27+/-44.10, p<0.01), pNN50 (3.28+/-6.08 Vs 14.06+/-15.65 and 16.65+/-14.23, p<0.01), HF power (197.20+/-143.76 Vs 218.17+/-155.85 and 216.87+/-150.98 Hz, p<0.05), HFnu unit (24.28+/-14.16 Vs 45.48+/-16.34 and 47.67+/-19.89, p<0.001). The 70 degrees tilt increased LF power% (197.20+/-143.76 Vs 218.17+/-155.85 and 216.87+/-150.98, p<0.001). LFnu unit (75.72+/-14.76 Vs 54.52+/-16.34 and 52.32+/-19.89, p<0.001), LF: HF (4.96+/-4.08 Vs 1.53+/-1.138 and 1.69+/-1.67, p<0.001) compared to 10 degrees and supine. CONCLUSION: At 70 degrees tilt, HRV measures, reflecting vagal contribution to cardiac-cycle length, decreased with reciprocal increase in sympathetic activity compared to 10 degrees or supine leading to increase in sympathetic predominance. A 10 degrees tilt, which is almost equivalent to lying down with pillow, did not change HRV from supine. activity.

Can homemade alcohol (Raksi) be useful for preserving dead bodies? An experiment on wistar albino rats.

INTRODUCTION: Embalming is the through disinfection and art of preserving bodies after death using chemical substances. It keeps a body life like in appearance during the time it lies in a state prior to funeral. OBJECTIVE: This study was undertaken to investigate the effectiveness of Raksi in sacrificed rats in arresting postmortem changes and establishing scientific fact whether Raksi can be an alternative to standard embalming constituent if it is not available. MATERIAL AND METHODS: 50 albino rats were systematically randomized into control and experiment groups. Raksi and distilled water were injected for embalming purpose intraventricularly in experiment and control groups of rats respectively and kept for 48 to 96 hours for observation for postmortem changes. RESULT: Observations made at 48 and 72 hours of embalming revealed that Raksi can arrest postmortem changes in the rats up to 72 hours (3rd day) successfully in the experimental group whereas moderate to severe postmortem changes were seen in the control group. The experimental group showed mild degree of putrefactive changes, liberation of gases and liquefaction of tissues only at 96 hours (4th day) of embalming. DISCUSSION: The Raksi used in this experiment contained 34% of alcohol, which was determined by an alcohol hydrometer. Experiment clearly demonstrated from its result that raksi can be utilised temporarily for embalming since it contains alcohol and has preservative, bactericidal and disinfectant properties. CONCLUSION: It is concluded from the study that this knowledge if applied to dead human subjects, may preserve dead bodies temporarily allowing delayed funeral.

Autonomic studies in hypertensive patient with unusual sexual dysfunction: response to reserpine.

The authors examined a 48-year-old man with a history of hypertension (6 years) and a history of erection and ejaculation during cold exposure and confrontation with fear (20 years). Exposing the foot to cold water induced ejaculation in 10 seconds. A variety of antihypertensive medications resulted in control of hypertension, without improvement in ejaculatory dysfunction. Similarly, prazosin controlled the blood pressure, but not the episodes of ejaculation. Treatment with reserpine resulted in gradual reduction in blood pressure and an improvement in ejaculatory dysfunction.

Effect of graded head-up tilt on parasympathetic reactivity.

Thirteen healthy subjects were tested for parasympathetic reactivity during head-up tilt and reversal of the tilt. Head-up tilt (70 degrees) resulted in significant increase in baseline heart rate and diastolic blood pressure. Head-up tilt also led to increased parasympathetic reactivity as measured by Valsalva manoeuvre and hand grip test. Heart rate response to deep breathing test did not change. The reversal of the tilt led to returning of heart responses to original values. Responses indicate towards enhanced parasympathetic reactivity during head-up tilt position.