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.

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.

Clinical profile and outcome of children presenting with poisoning or intoxication: a hospital based study.

Poisoning is a common preventable cause of morbidity and mortality in children. Most of the poisoning in children less than 5 years of age is accidental. Objective of the study was to study the clinical profile and outcome of childhood poisoning and intoxication. This was a retrospective study done in patients who were admitted in pediatric wards and pediatric intensive care unit (PICU) of BP Koirala Institute of Health Sciences with history of ingestion of poison or intoxication or envenomation firom January 2005 to June 2008. The data collected were analyzed with SPSS 12.0 software. There were 122 children enrolled in study. Male: female ratio was 1.4:1. The mean age of presentation was 5.8 years. Among 122 patients, 43.4% received pre-referral treatment in the form of gastric lavage, atropine etc. Organophosphorus poisoning was the commonest poisoning seen in 55 (45.1%) patients followed by hydrocarbon 12 (9.8%), mushroom 10 (8.2%) and organochlorine 10 (8.2%) poisoning. During treatment, 50.0% received antidotes. 55.7% received antibiotics, gastric lavage and anticonvulsants were required in 43.4% and 13.9% respectively. Overall survival was 87.4%. The time interval between intoxication and presentation to hospital, mean Glasgow Coma Scale (GCS) and presence of coma (GCS <8) were significantly different between survivors and expired cases. In conclusion, organophosphorus is the commonest agent involved in childhood poisoning. Overall, the outcome is good with 87.4% survival in our hospital. The time gap between the poisoning and presentation to hospital and presence of coma predict mortality.

Brain tumours in children.

A 10 years old, female patient presented with symptoms of abnormal movement of the body for 5 years, deviation of mouth to left side for 12 days and difficulty in walking for 12 days. We report a very rare case of Brain Stem gliomas. Clinical and imaging findings were suggestive of brain stem gliomas.

Incidence of congenital heart disease in tertiary care hospital.

AIMS AND OBJECTIVES: The present study was under taken to determine the spectrum, clinical profile and outcome of patients with congenital heart disease (CHD) admitted to a tertiary care hospital. MATERIALS AND METHODS: This is a retrospective, observational hospital based study conducted during January 2006 to December 2006. Out of 14461 admissions, 84 were cases of CHD. Only patients with echocardiographic proof of CHD were included in the study. Detailed clinical and laboratory findings and outcome of all cases were noted in pre-structured formats. Data were entered in MS-excel. Data was analyzed by software SPSS version 10. RESULTS: The incidence of CHD was 5.8 per 1000 hospitalized patients. Out of 84 CHD cases, 51 were males and 33 females; with a male to female ratio of 1.5:1. CHD presented more frequently during infancy (46 %). Acyanotic heart disease was detected in 58 (69 %) cases while cyanotic heart disease was detected in 26 (31%) cases. Among acyanotic heart disease, ventricular septal defect (VSD) was found in 49 (58.3%), atrial septal defect (ASD) in 4 patients (4.8%), endocardial cushion defect (ECD) in 2 patients (2.4%) and dextrocardia was found in 3 patients (3.6%). Among cyanotic heart disease, Tetralogy of Fallot (TOF) accounted for 13.1%, total anomalous pulmonary venous connection (TAPVC) 3.6%, transposition of great arteries (TGA) with VSD 1.2% and unspecified cases of heart disease was found in 13.1%. VSD and TOF were the most common lesions while other CHD like ASD, dextrocardia, TAPVC, ECD, TGA with VSD were encountered less frequently. The most common clinical presentations were failure to thrive (FTT) and developmental delay (86.9%), breathlessness (69%), lower respiratory tract infection (LRTI) (52%), congestive cardiac failure (CCF) (46%), cyanosis (20.2%), cyanotic spell (9.5%) and infective endocarditis (9.5%). The mortality rate was 20 %. CONCLUSION: The incidence of CHD was 5.8 per thousand hospitalized children. VSD, TOF were the most common congenital cardiac lesion. VSD was observed either isolated or associated with other lesions like TGA. The mortality rate was 20 %. The mortality usually occurred in those patients complicated with congestive cardiac failure, lower respiratory tract infection and infective endocarditis.

Acid base and electrolyte disturbance in diarrhoea.

OBJECTIVE: The present study was undertaken to study the frequency of electrolyte imbalance in children with diarrhoea and the relationship between electrolyte abnormalities and mortality. MATERIALS AND METHODS: This is a retrospective, observational hospital based study. Fifty seven children admitted to paediatric ward with diarrhoea and dehydration was evaluated for electrolyte and acid base status at presentation. The variables were analyzed using chi-square and student t- test. RESULTS: Majority (70%) of patients were below 2 years of age. There were 37 (65%) males and 20(35%) females. Electrolyte disturbance was observed in 46 (80%) patients while acid base disturbance was observed in all (100%) where the estimations were done. The major electrolyte disturbances noted were hyponatremia (56%), which was either isolated (26%) or associated with hypokalemia (26%). The second common abnormality was hypokalemia (46%) which was again either isolated (14%) or associated with hyponatremia (26%). About 10% patient had hypernatremia and about 3% had hyperkalemia. Twenty one (37 %) patients had mixed electrolyte imbalance. ABG analysis was performed only in 16 patients. Arterial blood gas analysis could be performed only in 16 patients. Metabolic acidosis was present in 15 (94%) while one (6%) had metabolic alkalosis. Out of 57, five patients (8.7%) expired. All of them had electrolyte abnormalities. Out of five patients who died one had isolated hyponatremia, 2 had hyponatremia + hypokalemia, while one each had hypernatremia + hypokalemia and hypernatremia+ hyperkalemia. Statistically significant mortality was observed in patients presenting with either hyponatremia or hypokalemia as compared to the group with normal electrolytes. CONCLUSION: Hyponatremia, hypokalemia and metabolic acidosis are common electrolyte and acid-base abnormalities in children with diarrhoea and dehydration and often responsible for mortality.

Clinical and laboratory profile of dengue infection in children.

The present work is a prospective, observational, hospital based study on 100 sero positive cases of dengue infection, admitted to Dhaka Children Hospital, Dhaka, Bangladesh during the period 2000 -2001. The patients were in the age group 8 months to 14 years with a mean age of 8.3 years. The serological tests were performed by rapid strip test. Primary dengue infection (only Ig M positive) was observed in 15% cases while rest 85% were secondary dengue infection (either Ig G or both Ig M and Ig G positive). Classical dengue fever (DF) was noted in 11% patients and 89% children presented with dengue hemorrhagic fever / dengue shock syndrome (DHF / DSS). Common clinical presentations were fever, headache, retro- orbital pain, arthralgia / bone pain, vomiting, abdominal pain and bleeding manifestations. Other presentations were tachycardia, bradycardia, hypotension, hepatomegaly, splenomegaly, pleural effusion, ascites, thrombocytopenia and high hematocrit values. The incidences of tachycardia, hypotension, hepatomegaly, high hematocrit and thrombocytopenia were significantly higher in DHF / DSS cases. The tourniquet test was positive in significantly higher percentage of DF cases. The tourniquet test and thrombocytopenia did not correlate well with other bleeding manifestations suggesting alternate pathogenesis for bleeding. In an epidemic setting, if a child presents with fever, vomiting, musculoskeletal pain and bleeding along with hepatomegaly, low platelet count and high hematocrit, a strong possibility of DHF/ DSS should be kept.

Risk factors in early neonatal sepsis.

OBJECTIVE: To study the maternal and neonatal risk factors for neonatal sepsis. MATERIALS AND METHODS: This is prospective case control study, conducted on the neonates up to 7 days of life with a diagnosis of neonatal sepsis. There were 100 cases of neonatal sepsis and 100 control cases. The neonates in the case and control groups were evaluated for various maternal and neonatal risk factors. RESULTS: The factors which carried a significant risk for development of neonatal sepsis were premature rupture of membrane (PROM), meconium stained amniotic fluid (MSAF), foul smelling liquor, low birth weight, prematurity and low Apgar score at birth. The blood culture was positive in 22% of cases. The commonest organisms isolated were S. aureus and Klebsiella. The overall mortality was 11%. The incidence of risk factors was almost equal in culture positive and culture negative cases. CONCLUSION: The study identifies PROM, MSAF, foul smelling amniotic fluid, prematurity, low birth weight and low Apgar score at birth as strong risk factors for development of neonatal sepsis. In the presence of above factors, the neonate should be screened and observed for sepsis and considered for early institution of antibiotics.

Outcome of newborns with birth asphyxia.

Birth asphyxia is one of the common causes of mortality and morbidity in neonates and the incidence is 2-9 per 1,000 live borns. The present work is a retrospective hospital based observational study. Babies born at B.P. Koirala Institute of Health Sciences, Dharan, Nepal during the period from April 2002 to April 2003 with gestational age >or=37 weeks with Apgar score

The management of extensive penile fibrosis: a new technique of 'minimal scar-tissue excision'.

OBJECTIVE: To evaluate the results of excising minimal scar tissue in patients undergoing insertion of a penile prosthesis for extensive corporal fibrosis. PATIENTS AND METHODS: Twelve patients (mean age 58 years, range 44-73) with extensive corporal fibrosis who underwent the insertion of a penile prosthesis were evaluated. Eleven patients had a defect of varying extent after the insertion of the penile prosthesis, and a polytetrafluoroethylene graft was used to cover the area. RESULTS: All 12 patients tolerated the procedure well and currently have a functioning penile implant. CONCLUSIONS: Minimal excision of scar tissue provided better results and fewer complications when compared to other studies which used extensive excision.