EDITORIAL BOARD Editor in chief Support Editors Prof. Dr. Jay N Shah Calvin Ghimire Carmina Shrestha Managing Editor Jashmin Joshi Dr. Ashis Shrestha Jeetendra Bhandari Executive Editors Rakshya Sharma Dr. Amit Joshi Roja Khanal Dr. Angel Magar International Editors Dr. Arun Neopane Dr. Allister Appelby - US Dr. Ganesh Dangal Dr. Bai-yong Shen - China Dr. Nabees Man Singh Pradhan Dr. Bingya LIU - China Dr. Ram Krishna Dulal Dr. Birendra Prashad Shah – China, NRN Dr. Sumana Bajracharya Dr. Chanchai Panthingwiriyakul - Thailand Editors Dr. Darren Nichols - Canada Dr. Alka Singh Dr. Dingjianquinc - China Dr. Arbin Joshi Dr. Dominic Allen - Canada Mrs. Ira Shrestha Dr. Fortunato Cristobal - Phillipines Dr. Nabin Rayamajhi Dr. Francisco Lamus Lemus - Colombia Dr. Pukar Maskey Dr. Fredrik Theodoor Bosman - Netherlands Sr. Rachana Shakya Dr. Ganesh Acharya - Norway, NRN Dr. Ranjan Devbhandari Dr. Hue Morgan - Canada Mr. Shital Bhandary Dr. John F Smith - New Zealand Dr. Vivek Todi Dr. Juliana Linnette D’Sa - India Dr. Karl Stobbe - Canada Advisory Editors Dr. Kim Solez - Canada Dr. Ajit Raymajhi Dr. Minhua Zheng - China Dr. Buddha Basnyat Dr. Pattapung Kessomboon - Thailand Dr. Buddhi Poudyal Dr. Paul S. Auerbach - US Dr. Imran Ansari Dr. Peng Cheng-hong - China Dr. Kedar Baral Dr. Pierre Echaubard - France Dr. Paban Sharma Dr. Sanjayzopdpey - India Dr. Ravi Shakya Dr. Supat Sinawat - Thailand Dr. Shrijana Shrestha Dr. Surapoi Virasiri - Thailand Dr. Sitaram Shrestha Dr. S.V Mahadevan - US Dr. Shafik Dharmisi - India Dr. Yin Lu – China Prof. Yukimfumi Nawa, Japan Dr. Zhoujun SHEN - China

Editorial Support Mrs. Archana Shrestha Miss Sushila Rai

Online support Mr. Pramod Jnawali

CONTENTS

TITLE PAGE NO

EDITORIAL Author and Authorship in Scientific Journal 1 Jay N Shah

GENERAL SECTION Original Articles Extracorporeal Shock Wave Lithotripsy in Management of Urolithiasis 4 Bhairab Kumar Hamal, Bharat Bahadur Bhandari, Narayan Thapa

Comparative Study of Tweed Triangle in Angle Class II Division I Malocclusion Between 8 Nepalese and Chinese Population Bishnu Parsad Sharma, Chang Xin, Jagan Nath Sharma

Follow Up Study of Mortality after Clinical Protocol Based Intervention at Emergency 13 of Patan Hospital Sumana Bajrachraya, Ashis Shrestha

Misoprostol for Termination of Second Trimester Pregnancy 16 Sharda Duwal Shrestha, Alka Singh, Laxmi RC, Binita Pradhan, WuFei Shah, Reena Shrestha

Outbreak of Extended Spectrum Beta Lactamase Producing Klebsiella Species Causing 20 Neonatal Sepsis at Patan Hospital In Nepal Puja Amatya, Suchita Joshi, Shrijana Shrestha

Hepatitis B and HIV In Pregnant Ladies at Patan Hospital 26 Imran Ansari

Conversion from Laparoscopic to Open Cholecystectomy 30 Samir Shrestha, Surendra Shah, Sanjay Poudyal, Jay N Shah, Vijay Kumar Jaiswal

Spirometry findings in Patient with Chronic Obstructive Pulmonary Disease 33 Ashis Shrestha, Sumana Bajrachraya

Review Articles Incretin System: Recent Advances in Glucagon Like Peptide – I and Dipeptidyl 36 Peptidase – 4 Inhibitors Rameshwor Mahaseth

Case Reports Perforated Jejunal Diverticulum – An Unusual Presentation 43 Kamal Koirala, Mahesh Khakurel, Reetu Barai

Rupture Uterus Requiring Emergency Hysterectomy for Saving Mother 46 Binita Pradhan, Anagha Pradhan

Perspectives Clinical Skill Lab: A Need in Nepalese Medical School 49 Ajay Kumar Dhakal, Sanjay Dhakal CONTENTS

TITLE PAGE NO

STUDENT’S SECTION Perspective Traditional Healing Practice in Rural Nepal 52 Richa Baniya

Reflection on PEER Assisted Learning at Patan Academy of Health Sciences 54 Anil KC

NURSING SECTION Original Articles Impact of Educational Intervention on Knowledge and Practice of Universal Precaution 57 Among Nurses Indira Shrestha

Perspectives Nursing Posting and Medical Students 61 Jay N Shah, Ashis Shrestha

MEDICAL EDUCATION Original Article Student’s Perception and Preference of Problem Based Learning During Introductory 64 Course of Nepalese Medical School Satish Raj Ghimire, Shital Bhandary

Patan Academy of Health Sciences (PAHS) POBox : 26500, Kathmandu Tel : +977-1-5545112, 5545153 Fax : +977-1-5545114, 5534198 Email : [email protected] Web : www.pahs.edu.np www.jpahs.edu.np Jay N Shah: ‘Author andEDITORIAL Authorship’ in Scientific Journals

‘Author and Authorship’ in Scientific Journals Jay N Shah

Editor In Chief, Journal of Patan Academy of Health Sciences

Broadly ‘author’ is a person who originated or gave existence to anything and takes responsibility for that’, as defined in the ‘medical-dictionary. thefreedictionary.com’.

ISSN: 2091-2749 (Print) Science relies on new developments. Validation and accurate documentation 2091-2757 (Online) of scientific research findings is important. Author has the responsibility of integrity of research, the findings and its publication. Clear guidelines for ‘author and authorship’ are necessary to distinguish among authors, coauthors and guarantor in order to be responsible for the integrity of the research publication. The publication in the peer reviewed scientific journal Correspondence serves to communicate and validate such findings and so author needs to Prof. Dr. Jay N Shah have substantive intellectual contributions for the work. Editor in Chief Journal of Patan Academy of Health There is important and significant credit attached to author and authorship. Sciences Being listed as author in research publication has advantages of ‘respect from Email: [email protected], [email protected] the peers, progress in career and status’ in all aspects of ‘academic, social, and financial’ issues. Sharing authorship bounds us to take responsibility of all published information. All listed authors are accountable in case of fraud or misconduct. Authorship is the ‘collective’ responsibility of research and its publication. Authors need to take responsibility for their own specific contribution plus overall work and be familiar with all listed authors to minimize the possible misconduct of plagiarism, fabrication and falsification.

The question arises just how much one has to contribute in orderto qualify to be listed as an author! Also there is a question of ‘amount’ and ‘quality’ of work to distinguish authors from other contributors involved in the work and its publication. Acquiring funds, general supervision or tedious secretarial work is not sufficient for authorship. Only those who have sufficient participation and can take responsibility of the work and its publication can qualify for authorship. International Committee of Medical Journal Editors (ICMJE)’ recommendation is now accepted by most biomedical journals and editors. ICMJE guidelines include, 1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work, 2) Drafting the workor revising it critically for important intellectual content, 3) Final approval of the version to be published, 4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

In case of multi-authored work it is further complicated and difficult to judge ‘how much’ responsibility is needed to justify the listing and order

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):1-3 1 Jay N Shah: ‘Author and Authorship’ in Scientific Journals of the authorship. There is lack of appropriate rule to All authors should be able to identify co-authors list multiple authors in a particular order. Style of listing responsibility for their portions of the content to ensure order varies between fields of research, the organization integrity of the work. Journals take measures to minimize and the journals. The degree of involvement is the most misconduct and require authors to provide ‘ethical straightforward with significant and active contributors approval’ for the work and declare ‘conflict of interest’. listed first. However, placing principal investigator in This is author’s responsibility to get consent before last is seen in science and engineering publications and acknowledging persons or group for their important also there is listing in alphabetical order. The electronic contributions who do not qualify for authorship. indexing systems usually ‘cite’ first (primary) and Acknowledgement should explain clearly, for e.g., ‘helped secondary (co-authors) as searchable. The tradition in acquisition of fund, provided general supervision, of important place of ‘first author’ remains important language editing, proofreading, data collection’ etc. because of demand from most of the ‘academic’ and ‘funding’ organization. Corresponding author is a responsible person to communicate with the journal and public and relate Listing and order of authorship should be discussed well contents of such communication to all other authors. before the research begins and not at the time of writing, Thus, it is not always wise to nominate one of the certainly not at the time of manuscript submission. All junior authors thinking this is just a secretarial work of listed authors are required to sign authorship agreement corresponding between stakeholders. It is more suitable letter to journal for their contribution. All authors are to name the principal author or guarantor take the role of required to agree in writing for any change in the order corresponding author and be available to answer queries and to add or remove author from the list. In case of before and after the publication, especially when there conflict, the institution is responsible to investigate is conflict about the research work itself or reporting of and provide information to the journal about the work findings. and involvement. Instead of 1st, 2nd and so on, simply listing authors by their specific work may reduce this Appropriate authorship is important to maintain the confusion of ‘listing and order’ and importantly avoid the value and integrity of science. There is no alternative to misconduct of ‘guest, gift, honorary or ghost’ authorship. honest, transparent and fair authorship. We all need to work together to improve ‘authorship’ by adhering to the Gift authorship, guest authorship or honorary authorship guidelines for authors, institutions, editors, reviewers refers to misconduct when co-authorship is granted and publishers. to someone without significant contribution to the work. Senior co-workers or head of the department or REFERENCES institution with power over junior researcher or influence in securing fund or publication in journal are some of the 1. The free online dictionary [Online]. 2002 [cited 2014 reasons for gift, guest, or honorary authorship. Number February 12]; Available from: URL:http://medical- of publications is often seen as reputation and important dictionary.thefreedictionary.com/authorship motivation behind practice of such misconduct. Most 2. Defining the Role of Authors and Contributors [Online]. journals now demand ‘authorship letter’ with details 2004 [cited 2014 February 12]; Available from: of specific contribution and responsibility of authors to URL:http://www.icmje.org/recommendations/browse/ reduce such misconduct and also to identify such author roles-and-responsibilities/defining-the-role-ofauthors- in a case of fraud. The competition to secure fund and and-contributors.html publication as a measure of performance provide space 3. Author Responsibilities—Conflicts of Interest for ‘influential’ persons to get listed as (honorary) author [Online].2002 [cited 2014 February 28]; Available from: to increase citation and obtain more funds; and the URL:http://www.icmje.org/recommendations/browse/ vicious cycle of misconduct continues. roles-and-responsibilities/author-responsibilities-- conflicts-of-interest.html Ghost authors are individuals who meet authorship criteria 4. Uniform Requirements for Manuscripts Submitted to but are not listed as an author. This is seen in partnerships Biomedical Journals: Manuscript Preparation [Online]. between industry and higher education. Pharmaceutical 2007 [cited2014 January 3]; Available from: URL:http:// industries pay medical writing companies to prepare www.icmje.org/recommendations/browse/manuscript- manuscripts, and then recruit academically affiliated preparation researchers to pose as the authors. 5. Authorship issues [Online]. 2001 [cited 2014 January 29]; Available from: URL:http://www.wame.org/resources/ All listed authors need to understand and support the policies#authorship published findings as all are responsible and liable to be accused in case of fraud or fake research.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):1-3 2 Jay N Shah: ‘Author and Authorship’ in Scientific Journals

6. World Association of Medical Editors (WAME) [Online]. 9. Council of Science Editors (CSE) [Online]. 1957 [cited 1995 [cited on 2014 March 23]; Available from: 2014 March 12]; Available from: URL:http://www. URL:http://wame.org/ councilscienceeditors.org/ 7. Committee on publication ethics (COPE) [Online]. 1997 10. Academic authorship [Online]. 2012 Apr 27 [cited on 2014 [cited on 2014 March 23]; Available from: URl:http:// January 29]; Available from: URL:http://en.wikipedia.org/ publicationethics.org/ wiki/Academic_authorship 8. The European Association of Science Editors (EASE) Guidelines for Authors and Translators of Scientific Articles to be Published in English [Online]. 2000 [cited on 2014 February 7]; Available from: URL:http://www.ease. org.uk/publications/author-guidelines

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):1-3 3 GENERAL SECTION Bhairam Kumar Hamal: Extracorporeal Shock Wave Lithotripsy in Urolithiasis ORGINAL ARTICLE

Extracorporeal Shock Wave Lithotripsy in Management of Urolithiasis Bhairab Kumar Hamal,1 Bharat Bahadur Bhandari,2 Narayan Thapa3

1Senior Consultant Surgeon and Professor, 2Consultant Surgeon, 3Junior Consultant Surgeon Department of Surgery, Shree Birendra Hospital and Nepalese Army Institute of Health Sciences, Kathmandu, Nepal

ISSN: 2091-2749 (Print) 2091-2757 (Online) ABSTRACT

Introductions: Since 1980, when Chaussy in West Germany first demonstrated the efficacy of Dornier prototype lithotripsy HM1, extra corporeal shock wave Correspondence lithotripsy has become a convenient, noninvasive, outpatient procedure used Brigadier General Dr. Bhairab Kumar to fragment urinary stones. It is a standard internationally accepted first line Hamal preferred option for the management of renal stone less than 2.5 cm size. Professor, Department of surgery Shree Birendra Hospital and Methods: A cross sectional study was conducted in the department of surgery Nepalese Army Institute of Health of Shree Birendra Hospital on outpatient department basis during the period Sciences, Kathmandu, Nepal of March 2002 to February 2012. All consecutive patients presenting with renal Email: [email protected] and upper ureteric stones detected either on X-ray or ultrasound of the Kidney- Phone no: 9851037756 Ureter-Bladder who were treated with extra corporeal shock wave lithotripsy. Peer Reviewed by: Descriptive analysis included age, sex, stone location, need of total session, use Dr. Jay N Shah of double J stent and complications. Patan Academy of Health Sciences Email: [email protected] Results: Total 710 diagnosed cases of urolithiasis were taken for the study. The youngest age was 16 years and oldest 69 years of age. Overall stone clearance Dr. Nabees Man Singh Pradhan rate was 73.52%. The stone free rate for upper, middle, and lower calyx were Patan Academy of Health Sciences 85.94%, 90.20% and 50.52% respectively. Email: [email protected] Conclusions: Extracorporeal shock wave lithotripsy was successful in the management of the stones smaller than 2.5 cm in all caliceal locations and minimal morbidity.

Keywords: ESWL, steinstrasse, urolithiasis

Plain Language Summary ESWL with new generation Lithotripter was safe and effective in adult out patients with urolithiasis less than 2.5 cm in functioning kidney without distal obstruction or urine infection. Stone clearance was 70%. DJ stenting was done in stone larger than 2 cm.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):4-7 4 Bhairam Kumar Hamal: Extracorporeal Shock Wave Lithotripsy in Urolithiasis

INTRODUCTIONS of total session, use of double J stent (DJ stent) and any complication. Approval for study was taken from hospital Since 1980, when Chaussy in West Germany first authority. demonstrated the efficacy of Dornier prototype lithotripsy HM1, shock wave lithotripsy (SWL) has ESWL was performed in all patients with the Edap become a convenient, noninvasive, outpatient procedure Technomed Sonolith Parktis Version lithotripter. Stones used to fragment most urinary stones.1 It is a standard were localized using fluoroscope and ultrasonography. internationally accepted first line preferred option for All patients were treated in supine position. The stones the management of renal stone less than 2.5 cm size.2 treated were predominantly radio opaque. Patients did After the introduction of the original electro-hydraulic not undergo any special bowel preparation prior to the Dornier HM-3 and its high power delivery, lithotripters procedure except for overnight fast. A double J stent have been developed with new sources for generation of was placed in patients with stone size greater than 2 shock waves, such as electromagnetic and piezoelectric cm before subjecting to ESWL. Treatment was initiated sources.3 with 14 kV and adjusted from 11 to 22 kV depending on the tolerance of the patient, location of the stone and Beside Extracorporel Shockwave Litotrapsy (ESWL), the nature of the stone. Maximum of 3000 shocks were other minimally invasive surgical options revolutionized delivered in one. the treatment of urolithiasis and now open surgery is performed only in cases of contraindication or where All patients received Ciprofloxacin 500 mg twice a day and facility is not available. Shree Birendra Hospital (SBH), Diclofenac 50 mg thrice a day following the procedure for Kathmandu Nepal introduced ESWL in 1987. a period of 5 days. Patients were followed every month for a period of three months to make a final evaluation. Various studies have been published regarding the Successful results were defined as complete stone outcome of ESWL, but there is lack of data from local clearance by ultrasound or KUB X-ray at three months. institutes in Nepal where the prevalence of urolithiasis is still high. RESULTS

METHODS Total 710 diagnosed cases of urolithiasis (renal and upper ureteric stone) were included in the study. The youngest This was a cross sectional study conducted in the was 16 years and oldest 69 years of age. The size of stone Department of Surgery of SBH, the teaching hospital ranged from 5.6 mm to 23 mm. Overall stone clearance of Nepalese Army Institute of Health Sciences (NAIHS), rate was 73.52% (522 out of 710). during the period of March 2002 to February 2012. All consecutive patients older than 16 years of age, Table 1. Characteristic of stones in 710 (M: 380, F: 330) urolithiasis presenting with renal and upper ureteric stones who patients who underwent ESWL underwent ESWL on outpatient department (OPD) basis 1 Mean age of the patients 41.5 years were included in the study. All patients were evaluated 2 No. of Male patients 380 (53.52%) with complete haemogram, coagulation tests, blood urea, serum creatinine, urine for routine and culture 3 No. of Female patients 330 (46.47%) sensitivity, X-ray KUB and ultrasound abdomen - pelvis and 4 Maximum no. of stones size (10-15mm size) 411 (57.88%) intravenous urogram (IVU) or computerize tomography 5 No. of cases with single stone 467 (65.77%) (CT) scan before subjecting them to shock wave treatment. Patient with renal an upper ureteric stones 6 No. of cases with multiple stones 243 (34.22%) more than 5 mm and less than 2.5 cm, with normal renal 7 Patient with right side stone 364 (51.26%) function in non obstructed kidney were included in this 8 Patient with left side stone 346 (48.73%) study. The size of the stone was calculated by ultrasound and X-ray in all cases. Patient with active urinary tract Regarding the location of the stone and stone free infection, renal failure, uncorrected distal obstruction, rate for upper, middle and lower calyxes were 85.94%, gross hydronephrosis, pregnancy, abdominal and renal 90.20% and 50.52% respectively. The stone free rate artery aneurysm, coagulation disorder, obesity and for the bilateral kidney, PUJ stone and upper ureter was cardiac problem were excluded from the study. Patients 68.42%, 61.29% and 53.85% respectively. Stone free rate who developed complication during study period or in a single session was 75.67%, 71.13% and 30.2% of refused to complete study were also excluded from patients in the upper, middle and lower caliceal system study. Data was analyzed age, sex, stone location, need respectively.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):4-7 5 Bhairam Kumar Hamal: Extracorporeal Shock Wave Lithotripsy in Urolithiasis

Table 2. Location of stone and stone clearance rate 70-90% success rate.7 European treatment guidelines Location of the Total no of cases Total stone clearance no recommends ESWL treatment for all stones larger than S.N. stone (n=710) (n=522) 5 mm.8 1 Upper calyx 185 (26%) 159 (85.94%) Our lithotripsy, Sonolith Practice of Edap Technomed 2 Middle calyx 194 (27.32%) 175 (90.20%) features an electro hydraulic generator, which 3 Lower calyx 192 (27.04%) 97 (50.52%) incorporates a conductive medium in which sparks 4 PUJ 31 (4.3%) 19 (61.29%) are created. The electrode itself is located within the 5 Upper ureter 13 (1.83%) 7 (53.84%) ellipsoidal reflector, which has been designed to reduce 6 Bilateral 95 (13.38%) 65 (68.42%) pain without compromising efficacy. Voltage may be Total 710 522 (73.52%) continuously set from 10 to 22 KV. Coupling between patient and water is assured by a membrane covered Out of 710 only 37 (5.21%) patients with stones size more with ultrasound conductive gel. The lithotripsy has a than 2 cm had DJ stent before ESWL. double localization system. The major advantage of second generation lithotripter is anaesthesia free shock Table 3. Outcome of the study wave lithotripsy treatment. 1 Mean no. of shock wave and energy 2345 and 16.3kV 2 Total no of stone clearance in 1st session 403 (56.76%) In theory, extracorporeal lithotripsy is based on the 3 Spontaneously stone passage noted within 24 hours 431 (60.70%) fragmentation of urinary stones into smaller fragments (that can pass spontaneously through the ureter) by 4 Mean duration of procedure 43.5 minutes shockwaves generated outside the body and focally 5 Total no. of patient with major complication (Steinstrasse) 51 (7.1%) transmitted to the stone. Fragmentation is achieved by 6 No. of cases needed DJ stent before procedure 37 (5.21%) direct shearing force, erosion or cavitations.9 Shockwaves pass through the tissues with virtually no loss of strength, Skin bruise, nausea, minor pain and early haematuria but at the liquid-stone interface they induce a powerful were noted in most of the cases. Steinstrasse with colicky energy discharge due to the high variation of density and developed in 51 (7.1%) patients, of which 31 needed small impact surface. DJ stent and ureterescopic intervention. The surgical treatment after failure included pyelolithotomy and Lithotripters have four basic components: shockwave ureteroscopy with intracorporeal lithotripsy. generation system, focalization system, coupling mechanism and stone localization system. The shockwaves can be generated in three different ways: DISCUSSIONS electro-hydraulic, spark-gap or electromagnetic. Third The management of urinary stone disease has changed generation electromagnetic lithotripters provide a wide with the advances in technology. Until the introduction range of improvements such as high shockwave accuracy of minimally invasive treatments, the majority of the that in turn allows the procedure to be performed urinary stones with no spontaneous passage were usually with little or no analgesia as well as electromagnetic managed by open surgery. Nowadays the rate of open shockwave stability (due to the cylindrical source), wide surgical procedures for the urinary stone disease is below wave energy range and the possibility of continuous 10 5%. Modern therapies such as ESWL, Ureteroscopy, therapy supervision and energy adjustment. Percutaneous Nephrolithotomy (PCNL) and Retrograde Extracorporeal lithotripsy treatment outcome depends Intra Renal Surgery (RIRS) have replaced open procedures on several factors which include the type of lithotripter, and open surgery is performed only in cases of failure stone (size, location, composition and number), the and contraindication for minimal invasive methods.4 anatomy and kidney function.11 Stones larger than 15 mm ESWL treatment for urolithiasis started on February and calcium oxalate monohydrate usually require several 7, 1980 in Munich using a Dornier HM-1 lithotripter sessions of ESWL for clearance. Uric acid, calcium oxalate (the device was designed by the aero-spatial company dihydrate as well as struvite stones are easier disintegrate. Dornier and was initially intended for testing supersonic ESWL has better result with stone in upper and middle planes components). Stone localization can be done by pole of the kidney, but poor outcome for stones located 8 ultrasound and X-ray fluoroscopy.5 Newer lithotripters in the lower pole (stone free rate is 40-70%. Some of the have a double guiding system (ultrasound and X-ray).6 studies have questioned the use of lithotripsy in lower Extracorporeal shock wave lithotripsy has gradually pole kidney stone, but many have suggested as a primary 12 become the first line of treatment for upper urinary treatment modality for the stone size less than 2 cm. tract stones diseases worldwide. It is the least invasive For the optimum treatment, a good patient assistance is procedure compared to other methods and has achieved required without analgesia. This is even more important

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):4-7 6 Bhairam Kumar Hamal: Extracorporeal Shock Wave Lithotripsy in Urolithiasis after the procedure when the patient compliance with the medical recommendations is expected (fluid intake, medication, scheduled follow-up).

The overall stone free rate in our study was 73.52% (in 522 patients). The stone free rate for upper, middle, and lower calyx was 85.94%, 90.20% and 50.52% respectively. The stone free rate for the bilateral kidney, PUJ stone and upper ureter was 68.42%, 61.29% and 53.85% respectively. This result is comparable to most of the Figure 3. Stone fragments passed by patients after Lithotripsy study published in the literature.

Auxiliary procedures were used before treatment in CONCLUSIONS some patients which included DJ stent placed in patient with stones size more than 2 cm. Only 37 (5.21%) Extracorporeal shock wave lithotripsy is successful in the patients needed DJ stent before the procedure. The stone management of the kidney stones smaller than 2.5 cm clearance rate is 56.75% (21) in stone size more than 2 in all caliceal locations and is safe modality with minimal cm in this study. The maximum numbers of stone size morbidity with better stone clearance for upper and were 10 to 15 mm (57.88%), where the stone clearance middle calyx. rate was 76.15%. References Our patient did not have any serious complications such as perirenal hematoma or urosepsis. Most case of 1. Chaussy C, Schmiedt E, Jocham D, Brendel W, Steinstrasse were treated with analgesics, antibiotics Forssmann B, Walther W. First clinical experience with and antispasmodics and extra water consumption with extracorporeally induced destruction of kidney stones by favorable outcome but a few cases required ureteroscopic shockwaves. J Urol. 1982;127:417–20. removal of stone (URSL) and double J stent placement. 2. Walsh PC, Retik AB, Vaughan D, Wein AJ, editors. Minor post procedural complication noticed in majority Campbell’s Urology. 8th ed. USA: Saunders Elsevier; 2002. of the cases was haematuria which was insignificant 3. Micali S, Sighinolfi MC, Grande M, Rivalta M, Stefani and rarely lasted for more than 24 hours. Other minor SD, Bianchi G. Dornier Lithotripter S 220 F EMSE: complications observed were skin bruise, nausea and The First Report of Over 1000 Treatments. Urology. colicky pain, very similar to other studies. 2012;74(6):1211-4. 4. Tomescu P, Pănuş A, Mitroi G,Drăgoescu O, Stoica L, Dena S, et al. Assessment of Extracorporeal Shock Wave Lithotripsy (ESWL) Therapeutic Efficiency in Urolithiasis. Curr Health Sci J. 2009 Jan-Mar;35(1):40–3. 5. Argyropoulus AN, Tolley DA. Optimizing Shock Wave Lithotripsy in the 21st Century. European Urology. 2007; 52(1):344-54. 6. Grasso M, Hsu J, Spaliviero M. Extracorporeal Shockwave Lithotripsy [Internet]. 2008 [updated 2008; cited 2014 Jan 12]. Available from: http://emedicine.medscape.com/ article/444554-overview 7. Tiselius HG, Ackermann D, Alken P, Buck C, Conort P, Figure 1. X-ray KUB before Lithotripsy Gallucci M. Guidelines on urolithiasis. Eur Urol. 2001 Oct;40(4):362-71. 8. Mobley TB, Myers DA, Grine WB, Jenkins JM, Jordan WR. Low energy lithotripsy with the Lithostar: treatment results with 19,962 renal and ureteral calculi. J Urol. 1993 Jun;149(6):1419-24. 9. Obek C, Onal B, Kantay K, Kalkan M, Yalçin V, Oner A, et al. The efficacy of extracorporeal shock wave lithotripsy for isolated lower pole calculi compared with isolated middle and upper caliceal calculi. J Urol. 2001 Dec;166(6):2081-4. 10. May DJ, Chandhoke PS. Efficacy and cost-effectiveness of extracorporeal shock wave lithotripsy for solitary lower Figure 1. X-ray KUB after Lithotripsy pole renal calculi. J Urol. 1998 Jan;159(1):24-7.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):4-7 7 GENERAL SECTION Bishnu Prasad Sharma: Comparative Study of Tweed Triangle in Nepali and Chinese ORGINAL ARTICLE

Comparative Study of Tweed Triangle in Angle Class II Division 1 Malocclusion between Nepalese and Chinese Students Bishnu Prasad Sharma,1 Chang Xin,2 Jagan Nath Sharma3

1Assistant Professor, Department of Dentistry, Patan Academy of Health Sciences, Lalitpur, Nepal 2Professor, Department of Orthodontics, Dalian Medical University, Dalian, China ISSN: 2091-2749 (Print) 3Associate Professor, Department of Orthodontics, B. P Koirala Institue of Health 2091-2757 (Online) Sciences, Dharan, Nepal

ABSTRACT Correspondence Dr. Bishnu Parsad Sharma Introductions: The establishment of specific cephalometric norms for specific Assistant Professor, Department of race or ethnic group has been documented in literatures. The aim of the Dentistry present study was to compare the Tweed triangle for Nepalese and Chinese Patan Academy of Health Sciences, subjects with Angle Class II division 1 malocclusion. Lalitpur, Nepal Email: [email protected] Methods: The cephalometric radiographs of 52 Nepalese and 52 Chinese students age between 14 to 18 years, Class II division 1 malocclusion with Point Peer Reviewed by A-Nasion-Point B angle larger than 4 degrees were analyzed for 9 parameters. Mr. Shital Bhandary Patan Academy of Health Sciences Results: Mean age of Nepalese participants was 14.28 years and that of Email: [email protected]. Chinese 14.09. The comparative variables of Nepalese and Chinese population np were: Y axis (61.39 and 67.52), Sella Nasion Point A angle (83.69 and 81.14), Sella Nasion Point B angle (76.87 and 74.62), Occlusal plane angle (19.0 and Dr. Ashis Shrestha Patan Academy of Health Sciences 23.12), Frankfort Mandibular plane angle (28.13 and 32.87) and Lower Incisior Email: [email protected] to Frankfort Horizontal plane Angle (54.77 and 48.23). Conclusions: The Class II skeletal pattern, well positioned maxillas and retrusive mandibles were present in both samples. The Chinese showed more protruded maxilla, more buccal inclination of lower incisors and longer face than Nepalese.

Keywords: angle class II division 1, cephalometry, tweed triangle

Plain Language Summary The study was done to identify the Tweed triangle for a sample of Nepalese and Chinese subjects with Angle Class II division 1 malocclusion . The study found that the both samples showed Class II skeletal pattern, well positioned maxillas and retrusive mandibles but the Chinese had more protruded maxilla, more buccal inclination of lower incisors and longer face than Nepalese. It showed the importance of ethnic role as Nepalese have distinct cephalometric features, which should be used as a reference while treating the Nepalese orthodontic patients.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):8-12 8 Bishnu Prasad Sharma: Comparative Study of Tweed Triangle in Nepali and Chinese

INTRODUCTIONS incisor to mandibular plane angle); Ls (Labrale superius); MP (Mandibular plane); N (Nasion); NA (Nasion-Point A Angle Class II Division 1 malocclusion is characterized plane); NB (Nasion-Point B plane); OP (Occlusal plane); by a distal relation of the lower teeth to the upper. OP-SN (Occlusal Plane Angle); Or (Orbitale); Pg1 (Soft The extension of lower teeth being more than one- tissue pogonion); Po (Porion); S (Sella); SN (Sella-Nasion half the width of one cusp and the protusive maxillary plane); SNA (Sella-Nasion-Point A Angle); SNB (Sella- 1 incisors. This can be related to a retrognathic mandible, Nasion - Point B Angle) prognathic maxilla, or a combination of both.2,3 The most common characteristics are the retrognathic mandible, maxillary prognathism and reduce vertical skeletal jaw relationship.4

Tweed analysis5 consists of the Tweed triangle formed by ‘Frankfort horizontal plane, the mandibular plane and the long axis of lower incisor’. In 1954 Tweed6 stated that “The lower incisor to Frankfort horizontal plane angle (FMIA) of 65 degree works beautifully but occasional patients require 75 degree.”

The purpose of the present study was to compare tweed triangle of Nepalese and Chinese subjects with Angle Class II division 1 malocclusion.

METHODS Figure 1. Points, planes and angles This cross sectional descriptive study was done in the Department of Orthodontics, B.P. Koirala Institute of Health Sciences, Nepal and the Department of Orthodontics, Dalian Medical University, China. The purposive sampling done with standardized lateral cephalometric radiographs of 52 Nepalese and 52 Chinese students with equal number of male and female in both groups (Male=26 and Female=26). Written consent was obtained from all participants after explaining the nature and purpose of the radiograph.

The inclusion criteria were natural-born ethnic Nepalese and Chinese, age 12 to 18 years. Angle class II division 1 malocclusion, A-Nasion-Point B (ANB) angle larger than 4 degrees, no craniofacial deformities, no previous orthodontic treatment or maxillofacial surgery or plastic Figure 2. Tweeted traingle surgery.

The descriptive analysis and independent student t-test were performed using Statistical Package for the Social RESULTS Sciences (SPSS version 11.5). Results were considered to be statistically significant when p≤0.05. All subjects participating in the study were students. Mean age of Nepalese participants was 14.28 years Different points and angles described in figure areas and that of Chinese participants was 14.09. Craniofacial follows: features on cephalometric parameters between Nepalese and Chinese population (Table-1) and cephalometric A (Point A); ANB (Point A-Nasion-Point B Angle); B (Point parameters for Nepalese and Chinese Male (Table-2) and B); FH (Frankfort Horizontal Plane); FMA (Frankfort female (Table-3) were compared. The gender difference Mandibular plane angle); FMIA (Lower incisor to Frankfort in FMIA angle amongst Chinese population was not horizontal plane angle); Gn (Gnathion); IMPA (Lower statistically significant. (Table 4) (Table-5).

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):8-12 9 Bishnu Prasad Sharma: Comparative Study of Tweed Triangle in Nepali and Chinese

Table 1. Comparison of mean values between Nepalese and Chinese Table 4. Comparison of hard and soft tissue mean values between subjects with Class II division 1 malocclusion Nepalese genders with Class II division 1 malocclusion Nepalese (n=52) Chinese (n=52) Nepalese Males (n =26) Nepalese Females (n =26) Variables t P Variables t p Mean SD Mean Mean SD Mean SD SD Y-axis 61.39 4.866 67.52 4.336 -6.776 .000* Y-axis 61.13 2.830 61.65 6.337 -.381 .704 SNA Angle 83.69 4.820 81.14 3.637 3.043 .003* SNA Angle 83.88 6.049 83.50 3.277 .285 .777 SNB Angle 76.87 4.753 74.62 2.978 2.893 .005* SNB Angle 76.88 5.324 76.85 4.211 .029 .977 ANB Angle 6.83 2.580 6.53 1.946 .665 .507 ANB Angle 7.00 2.498 6.65 2.697 .480 .633 OP-SN 20.69 8.592 17.31 4.798 1.754 .086 OP-SN 19.00 7.099 23.12 4.685 -3.489 .001* FMA 29.50 14.417 26.77 8.401 .834 .408 FMA 28.13 11.764 32.87 6.256 -2.560 .012* FMIA 58.62 15.562 50.92 7.944 2.245 .029* FMIA 54.77 12.835 48.23 8.113 3.105 .002* IMPA 97.65 14.727 102.31 4.994 -1.526 .133 IMPA 99.98 11.138 98.96 6.739 .565 .574 Z Angle 61.77 3.050 62.12 6.458 -.247 .806 Z Angle 61.94 5.004 63.08 6.296 -1.017 .311 Table 5. Comparison of mean values between Chinese genders with Table 2. Comparison of mean values between Nepalese and Chinese Class II division 1 malocclusion Male subjects with Class II division 1 malocclusion Chinese Males (n =26) Chinese Females (n =26) Nepalese Males (n=26) Chinese Males (n=26) Variables t P Variables t P Mean SD Mean SD Mean SD Mean SD Y-axis 68.85 3.728 66.19 4.561 2.297 .026* Y-axis 61.13 2.830 68.85 3.728 -8.401 .000* SNA Angle 80.94 4.208 81.35 3.032 -.397 .693 SNA Angle 83.88 6.049 80.94 4.208 2.036 .047* SNB Angle 74.62 3.488 74.62 2.434 .000 1.000 SNB Angle 76.88 5.324 74.62 3.488 1.818 .075 ANB Angle 6.33 1.918 6.73 1.991 -.745 .460

ANB Angle 7.00 2.498 6.33 1.918 1.090 .281 OP-SN 24.35 4.335 21.88 4.778 1.946 .057

OP-SN 20.69 8.592 24.35 4.335 -1.936 .059 FMA 35.42 6.300 30.31 5.152 3.205 .002* FMIA 46.88 8.539 49.58 7.590 -1.202 .235 FMA 29.50 14.417 35.42 6.300 -1.920 .061 IMPA 97.73 7.805 100.19 5.344 -1.327 .191 FMIA 58.62 15.562 46.88 8.539 3.370 .001* Z Angle 62.15 5.767 64.00 6.771 -1.058 .295 IMPA 97.65 14.727 97.73 7.805 -.024 .981 Z Angle 61.77 3.050 62.15 5.767 -.301 .765 DiscussionS Table 3. Comparison of mean values between Nepalese and Chinese female subjects with Class II division 1 malocclusion We observed significant differences in cephalometric mean values of Angles Class II division 1 malocclusion Nepalese Females (n =26) Chinese Females (n =26) Variables t P of the Nepalese and Chinese subjects: Y axis (61.39 Mean SD Mean SD and 67.52), Sella Nasion Point A (SNA) angle (83.69 and Y-axis 61.65 6.337 66.19 4.561 -2.964 .005* 81.14), Sella Nasion Point B (SNB) angle (76.87 and 74.62), Occlusal plane (OP-SN) angle (19.0 and 23.12), Frankfort SNA Angle 83.50 3.277 81.35 3.032 2.460 .017* Mandibular plane angle (FMA) (28.13 and 32.87), Lower SNB Angle 76.85 4.211 74.62 2.434 2.338 .023* Incisior to Frankfort Horizontal plane Angle (FMIA) (54.77 and 48.23). ANB Angle 6.65 2.697 6.73 1.991 -.117 .907 OP-SN 17.31 4.798 21.88 4.778 -3.447 .001* In both groups the mean value of SNA angle (Nepalese 83.69 and Chinese 81.14 degrees) for SNA angle suggests FMA 26.77 8.401 30.31 5.152 -1.831 .073 a well-positioned maxilla in relation to the cranial base FMIA 50.92 7.944 49.58 7.590 .625 .535 like previous studies.2,7,8 This suggests more protruded maxilla in Nepalese compared to Chinese. J.W.P. Lau and IMPA 102.31 4.994 100.19 5.344 1.475 .147 U. Hagg 9 in their study in Chinese class II division 1 found Z Angle 62.12 6.458 64.00 6.771 -1.027 .309 higher SNA mean value of 83.1 degree.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):8-12 10 Bishnu Prasad Sharma: Comparative Study of Tweed Triangle in Nepali and Chinese

The SNB angles (Nepalese 76.87 and Chinese 74.62 difference in Y-axis, SNA angle and FMIA between degrees) represents retracted mandible (retrognathic) in Nepalese and Chinese males. The mean value of Y-axis relation to the cranial base. Similarly Freitas et al7 from were larger in Chinese males (68.85 degrees) than Brazil found SNB mean value of 75.39 degrees, similar to Nepalese males (61.13 degrees) suggesting the position other researchers among other cranial structures.8,10-14 of the chin is more downward, rearward relation to the upper face in Chinese males. The SNA angle showed The maxillomandibular relationship determined by ANB Nepalese males have high mean value (83.88 degrees) angle showed Class II skeletal pattern, similar to the than Chinese males (80.94 degrees) which suggests more findings of ANB of 6.0 degree in Chinese class II division 1 protruded maxilla in Nepalese males when compared 9 by J.W.P. Lau and U. Hagg. The decrease in the ANB angle with Chinese males. The FMIA mean value were 58.62 15 happens with the treatment. degrees in Nepalese males and 46.88 degrees in Chinese males, suggesting more buccal inclination of the lower The Y-axis mean value was significantly higher in Chinese incisors in Chinese males than Nepalese males. (67.52 degree) than in Nepalese (61.39 degree). This suggests the position of Chin is more down and rear ward Among female gender, there was statistically significant in relation to the upper face in Chinese when compared difference between Nepalese and Chinese females in with Nepalese. terms of Y-axis, SNA angle, SNB angle and occlusal plane angle. The mean value of Y-axis were larger in Chinese The occlusal plane angle was higher in both the groups females (66.19 degrees) than Nepalese females (61.65 (Nepalese 19.00 and Chinese 23.12 degrees), suggesting degrees) suggesting the position of the chin is more long face (Chinese having longer face than Nepalese) downward, rearward relation to the upper face in Chinese with skeletal open bite. females. The higher mean value of SNA angle in Nepalese Skeletal pattern of the face is represented by FMA and is females than Chinese females (83.50 v.s. 81.35 degrees) considered the most important angle of Tweed triangle.16 suggests more protruded maxilla in Nepalese females. The FMA mean values was significantly higher in Chinese Between Nepalese and Chinese females, the higher (32.87 degrees) than Nepalese (28.13 degrees) suggests mean value of occlusal plane angle in Chinese females long face or vertically growing in both samples. P (21.88 degrees) than Nepalese females (17.31 degrees) Bhattarai et al.17 found FMA mean value of 28 degrees in suggests longer face in Chinese females. Nepalese and P.C. Tukasan et al.16 found FMA mean value 26.66 degree on Brazilian subjects. CONCLUSIONS

The FMIA angle represents a more balanced face when In Chinese and Nepalese students with Tweed Triangle in 6 maintained at 65 to 75 degree. The present study showed Angle class II, division I malocclusion both groups showed statistically significant FMIA mean value, 54.77 degrees well positioned maxilla and retrusive mandible. Maxilla in Nepalese and 48.23 degrees in Chinese, which shows was more protruded in Nepalese. The Chinese showed retrusive mandible in both samples but more in Chinese. longer face and more buccal inclination of lower incisors. The IMPA and Z angle values also show statistically non- The female Nepalese showed more buccal inclination of significant. lower incisors than male. Chinese males have longer face than females. Comparison between genders showed the FMIA mean values were higher in Nepalese males than Nepalese females (58.62 degree v.s. 50.92 degree) suggesting ACKNOWLEDGEMENTS more buccal inclination of lower incisors in females. However a study conducted by Bhattarai P et al17 shows no I express my gratitude to Prof. Liu Qi gui, statistician of significant difference. The FMA mean values were 35.42 Dalian Medical University, China for his guidance in degrees in Chinese males and 30.31 degrees in Chinese statistical analysis. females, which suggests Chinese males have longer face than Chinese females. The Y-axis mean values were 68.85 References degrees in Chinese males and 66.19 degrees in Chinese females, which suggests that position of the chin is more 1. Drelich RC. A cephalometric study of untreated Class II, downward and rearward relation to the upper face in division I malocclusion. Angle Orthod. 1948;18:70-5. Chinese males when compared with Chinese females. 2. McNamara Jr JA. Components of Class II malocclusion in children 8-10 years of age. Angle Orthod. 1981;51(3):177- Comparison between same genders of Chinese and 202. Nepalese subjects showed statistically significant 3. Sassouni V. A classification of skeletal facial types. Am J Orthod. 1969;55(2):109-23.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):8-12 11 Bishnu Prasad Sharma: Comparative Study of Tweed Triangle in Nepali and Chinese

4. Sidlauskas A, Svalkauskiene V, Sidlauskas M. Assessment 11. Bishara SE, Cummins DM, Jakobsen JR. The morphologic of Skeletal and Dental Pattern of Class II Division 1 basis for the extraction decision in Class 11, Division Malocclusion with Relevance to Clinical Practice. 1 malocclusions: A comparative study. Am J Orthod Stomatologija, Baltic Dental and Maxillofacial Journal. Dentofacial Orthop. 1995;107(2):129-35. 2006;8(1):3-8. 12. Ishii N, Deguchi T, Hunt NP. Craniofacial morphology of 5. Singh G. Textbook of Orthodontics. 2nd ed. India:Jaypee Japanese girls with Class II division 1 malocclusion. J Brothers, Medical Publisher (P) Ltd. 2007. p.119. Orthod. 2001;28:211–15. 6. Tweed CH. The Frankfort- mandibular-incisal angle 13. Tukasan PC, Magnani MBBA, Nouer DF, Nouer PRA, (FMIA) in orthodontic diagnosis treatment planning and Pereira Neto JS, Garbui IU. Craniofacial analysis of prognosis. Angle Orthod. 1954; 24(3):121-69. the Tweed Foundation in Angle Class II, division 1 7. Freitas MR, Santos MAC, Freitas KMS, Janson G, Freitas malocclusion, Braz Oral Res. 2005;19(1):69-75. DS, Henriques JFC. Cephalometric characterization of 14. Kolokitha OG, Chatzigianni SS, Kavvadia-Tsatala S, skeletal Class II division 1 malocclusion in white Brazilian Nikolaos Topouzeli NTs. Cephalometric study of the subjects. J Appl Oral Sc. 2005;13(2):198-203. position and the size of the mandible in 10-12 years old 8. Sayzn MO, Turkkahramana H. Cephalometric Evaluation children with Class II, division 1 malocclusion. Hell Orthod of Nongrowing Females with Skeletal and Dental Class II, Rev. 2007;10(1):41-52. division 1 Malocclusion. Angle Orthod. 2005;75(4):656– 15. Bishara SE, Jakobsen JR, Vorhies B, Bayati P. Changes in 60. dentofacial structures in untreated Class II division 1 and 9. Lau JWP, Hägg U. Cephalometric morphology of Chinese normal subjects: A longitudinal study. Angle Orthod. with Class II Division 1 malocclusion. British Dental 1997;67:55-66. Journal. 1999;186(4):188–90. 16. Tukasan PC, Magnani M, Nouer DF, Nouer PRA, Pereira 10. Harris J E, Kowalski C J, Walker G F. Discrimination between Neto JS, Garbui IU. Craniofacial analysis of the Tweed normal and Class II individuals using Steiner’s analysis. Angle Foundation in Angle Class II, division 1 malocclusion. Braz Orthodontist. 1972;42:212-20. Oral Res. 2005;19(1):69-75. 17. Bhattarai P, Shrestha RM. Tweeds analysis of Nepalese people. Nepal Med Coll J. 2011; 13(2):103-6.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):8-12 12 GENERAL SECTION Sumana Bajrachraya: Mortality After Clinical Protocol Based Intervention at Emergency ORGINAL ARTICLE

Follow-up Study of Mortality after Clinical Protocol Based Intervention at Emergency of Patan hospital Sumana Bajrachraya, Ashis Shrestha

Lecturers, Department of General Practice and Emergency Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal

ABSTRACT ISSN: 2091-2749 (Print) 2091-2757 (Online) Introductions: Decreasing the mortality of patients is one of the major concerns of emergency department. Mortality decreases after implementation of protocol based intervention. This follow up study has been done to see the benefit of protocol based approach.

Correspondence Methods: This was a cross sectional study conducted at emergency department Dr. Sumana Bajrachraya of Patan hospital from January 2013 to June 2013. All records of patient with Lecturer, Department of mortality were reviewed excluding those who were brought dead. General Practice and Emergency Medicine, Patan Academy of Results: Total mortality in six months was 31. Mortality rate was 1.7 per Health Sciences, Lalitpur, Nepal thousand emergency visits. Mean duration of stay at emergency was five Email: [email protected] hours, range 30 minutes to 25 hours. The common diagnoses at presentation were Pneumonia 12 (45.1%), Upper gastrointestinal tract bleeding 4 (13%), Peer Reviewed by Hypoglycaemia 3 (9.7%) followed by blunt abdominal trauma, penetrating neck Mrs Ira Shrestha injury, pneumothorax, spinal shock, head injury and zinc phosphide poisoning Patan Academy of Health 2 (6.5%) each. The most common causes of death were septic shock 9 (29%), Sciences hypovolaemic shock 7 (25.8%), respiratory failure 6 (19.4%), hypoglycaemia Email: [email protected] 3 (9.7%), cardiogenic shock, raised intracranial pressure and spinal shock 2 (6.5%) each. Dr. Ram Krishna Dulal Patan Academy of Health Conclusions: Protocol based management are important tools to decrease Sciences mortality but it is not the only factor that decreases the mortality. Email: [email protected] Keywords: clinical protocol, emergency, mortality

Plain Language Summary This study was done to see if implementing protocol based management improves mortality or not. This study highlighted the fact that protocol based management are important sufficient to decrease mortality.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):13-15 13 Sumana Bajrachraya: Mortality After Clinical Protocol Based Intervention at Emergency

IntroductionS Table 1. Duration of emergency stay in patients with different causes of mortality (n=31) Mortality indicates the quality of service we provide in Duration of stay any department of the hospital. After a mortality review Total Cause of death in 2011 at emergency department of Patan Hospital Number Less than 6-12 More than 6 hours hours 12 hours (PH), Patan Academy of Health Sciences (PAHS), a clinical protocol based approach was implemented to overcome Septic shock 9 7 0 2 three major causes of death which were respiratory Hypovolaemic shock 7 6 2 0 failure, sepsis and hypovolaemic shock.1 Respiratory failure 6 7 0 2 There is evidence suggesting that mortality decreases Hypoglycaemia 3 3 0 0 after an implementation of protocol based intervention Raised intracranial pressure 2 2 0 0 to the cause of mortality.2 So after finding out the major cause of mortality in emergency department a protocol Spinal shock 2 2 0 0 based management was carried out. This follow up Cardiogenic shock 2 2 0 0 study was then conducted with an intention to find Total (n) 31 25 2 4 out the causes of mortality and overall mortality rate in emergency department after implementation of Mortality rate was 1.7 per thousand emergency visits and protocol. This study has also explored the presenting 11.1 per thousand admissions. complaints and cause of mortality. The common diagnoses at presentation were Pneumonia 12 (45.1%), Upper gastrointestinal tract bleeding 4 (13%), METHODS Hypoglycaemia 3 (9.7%) followed by blunt abdominal This was a cross sectional, descriptive study reviewing trauma, penetrating neck injury, pneumothorax, spinal records of the patient having mortality at emergency shock, head injury and zinc phosphide poisoning which department, PAHS, Nepal, from 1st December 2012 to accounted for 2 (6.5%) each. The most common causes 30th May 2013. After reviewing mortality in 2011, an of death were septic shock 9 (29%) due to pneumonia emergency department protocol was developed to treat followed by hypovolaemic shock 7 (25.8%) due to three major causes of death; septic shock, respiratory upper gastrointestinal tract bleeding, blunt abdominal failure and hypovolaemic shock. The protocol for septic trauma and penetrating neck injury (4, 2 and 1 patients shock was based on “surviving sepsis guidelines”.3 respectively); respiratory failure 6 (19.4%) which was Hypovolaemic shock was based on “clinical review”4 due to pneumonia, pneumothorax and penetrating neck and expert opinion. Management of respiratory failure injury (3, 2 and 1 patients respectively); hypoglycaemia was based on “expert opinion”. All three protocols 3 (9.7%); cardiogenic shock due to zinc phosphide were internally validated through in the department. poisoning, raised intracranial pressure due to head injury One day training was conducted for all the nurses and and spinal shock due to trauma accounted 2 (6.5%) each doctors of emergency department in groups of 16 in a for mortality. session on communication skills, sepsis and respiratory On initial evaluation heart rate was recorded in 94.4%, distress protocol developed by the faculties. Mortality blood pressure on 72.2%, respiratory rate on 32.3% and records were reviewed for sex, age, duration of hospital temperature on 16.7% of cases. stay, cause of death, initial diagnosis and whether vital signs was recorded on initial assessment. Incompletely DISCUSSIONS documented cause of death and patients brought dead at emergency were excluded. Frequency analysis was We were able to decrease the mortality after done through SPSS 16.0. Ethical approval was taken from implementation of protocol on three major cause of institutional review board of PAHS. mortality. Mortality rate of 1.7 per thousand emergency visits after clinical protocol based intervention was lower than earlier figure of 2.1 during 2011 (unpolished hospital RESULTS data). However, it cannot be stated that this decrease was Out of 42 patients, 11 patients were excluded as they due to implementation of protocol only. A multicentre were brought dead. There was no incomplete record to be study published about weekly mortality on emergency excluded. Among, the rest of 31 who died in emergency, admission showed that mortality on weekdays was 5 male were 20 (64.5%) and female 11 (35.5%). Mean age 4.9% and 5.0% on weekends. In another study after the was 51.9 years (range 2 to 82 years). Mean duration of intervention, early mortality decreased from 47.6 to 37.9 2 stay was 5 hours, range 30 minutes to 25 hours. deaths per 1000 admissions.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):13-15 14 Sumana Bajrachraya: Mortality After Clinical Protocol Based Intervention at Emergency

In an earlier study in 2011 done in our department CONCLUSIONS had concluded that goal directed early treatment was effective and recommended protocol based approach.1 Implementing clinical based protocol for management of The study emphasized multiple approaches to reduce the patient is important to decrease mortality. mortality. In this study, the common causes of death were respiratory failure 18 (30%), raised intracranial REFERENCES pressure 7 (11.7%), septic shock 7 (11.7%), cardiogenic shock and hypovolemic shock 5 (8.3%).1 After protocol 1. Bajrachraya S. Analysis of presenting complaint and co based intervention in present study, the death due to morbidity of the mortality at Patan hospital emergency respiratory failure decreased from 30% to 19.4%. The department. JGPEMN. 2011;2(2):59-64. duration of stay did not change from earlier study and the 2. Russell JA. Management of sepsis. NEngl J Med. higher figures for death due to septic and hypovolemic 2006;355:1699-713. shock may be because of detection of these conditions 3. Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J. et al. Surviving sepsis campaign guideline for after introduction of protocol. management of severe sepsis and septic shock. Crit Care Med. 2004;32(3):858-71. Present study showed that the vital sign recording should 4. Guteirrez G, Reines DH, Guterirrez W. Clinical review: be improved as the evidence suggests it is as a predictor Hemorrhagic shock. Crit Care Med. 2004;8:373-81. 6 of mortality. 5. Aylin P, Yunus A, Bottle A, Majeed A, Bell D. Weekend mortality for emergency admissions. A large, multicentre The interventions aimed at increasing emergency care study. Qual Saf Health Care. 2010;19:213-7. are effective but requires rigorous evaluation before 6. Shapiro NI, Wolfe RE, Moore RB, Smith E, Burdick E, Bates implementation.7 The clinical protocol based intervention DW. Mortality in emergency department sepsis (MEDS) was useful in present study but should not be seen as the scores: a prospectively derived and validated clinical only factor that decreased mortality. prediction rule. Crit Care Med. 2003;31(3):670-5. 7. Mateo GF, Violan-Fors C, Santisteve CP, Peiro S, Argimon This study did not evaluate the patients who were JM. Effectiveness of organizational interventions to successfully resuscitated for respiratory distress and reduce emergency department utilization: a systematic septic shock. Further study could explore this and other review. Plos one. 2012;e7:e35903. possible factors that may decrease the mortality.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):13-15 15 GENERAL SECTION Sarada Duwal Shrestha: Misoprostol for Termination of Second Trimester Pregnancy ORGINAL ARTICLE

Misoprostol for Termination of Second Trimester Pregnancy Sarada Duwal Shrestha,1 Alka Singh,2 Laxmi RC,1 Binita Pradhan,1 WuFei Shah,3 Reena Shrestha1

1Lecturer, 2Associate Professor, 3Senior Registrar Department of Obstetrics and Gynecology, Patan Academy of Health Sciences, Lalitpur, Nepal

ISSN: 2091-2749 (Print) ABSTRACT 2091-2757 (Online) Introductions: The termination of second trimester pregnancy is challenging due unfavorable cervix. This study evaluate the efficacy and maternal side effects of intravaginal misoprostol for termination of second trimester pregnancy. Correspondence Dr. Sarada Duwal Shrestha Methods: During one year period from 15th June 2011 to 14th June 2012, Lecturer, Department of Obstetrics Department of Obstetrics and Gynaecology of Patan Hospital, women admitted & Gynaecology for second trimester termination of pregnancy for fetal congenital anomalies Patan Academy of Health Sciences, and intrauterine fetal demise were studied using the International Federation Lalitpur, Nepal Email: [email protected] of Gynaecology and Obstetrics recommended doses of vaginal misoprostol. For congenital anomalies, 400 mcg 3 hourly to a maximum of 5 doses were Peer Reviewed by used. For fetal demise, gestational age of 13-17 weeks received 200 mcg every Mrs. Ira Shrestha 6 hourly to a maximum of 4 doses, and 18-26 weeks dose was adjusted to Patan Academy of Health Sciences 100 mcg. Main outcome measures included success rate of abortion within 48 Email: [email protected] hours, induction to delivery interval and maternal side effects.

Dr. Jay N Shah Results: There were 40 patients during study period. Success rate for termination Patan Academy of Health Sciences of 2nd trimester pregnancy within 48 hours was 88.8% for congenital anomalies. Email: [email protected] For fetal demise, success of termination was 90.9% at 13-17 weeks and 100% at 18-26 weeks. Median time from induction to delivery was 26.8 hours for congenital anomalies. For fetal demise, it was 18 hours for 13-17 weeks was and 24 hours at 18 to 26 weeks respectively. Abdominal pain was seen in all doses of misoprostol.

Conclusions: Vaginal misoprostol is an effective method for termination of second trimester pregnancy.

Keywords: misoprostol, pregnancy, second trimester termination

Plain Language Summary The study was conducted to see the effectiveness of vaginal misoprostol for termination of second trimester pregnancy. The success rate of termination for congenital abnormality and fetal demise was high. Vaginal misoprostol was an effective method for termination of second trimester pregnancy.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):16-19 16 Sarada Duwal Shrestha: Misoprostol for Termination of Second Trimester Pregnancy

IntroductionS and confirmed by ultrasound when last menstrual period (LMP) was not confirmed. Routine investigations were The termination of second trimester pregnancy is risky done including blood grouping, hematocrit, platelets because of its complications and psychological trauma to and random blood sugar. Exclusion criteria were known patients. It constitutes 10-15% of all induced abortions hypersensitivity to prostaglandins, previous caesarean usually done for intrauterine fetal demise (IUFD), fetal section or any surgical intervention in uterus, gravidity congenital anomalies and medical disorders associated more than five, intrauterine contraceptive device in situ, with pregnancy.1 Early detection of lethal structural and low lying placenta, hydatidiform mole, ectopic pregnancy, chromosomal abnormalities, and IUFD has increased adnexal mass, cardiac disease and coagulopathy. the demand of rapid second trimester termination.2 The termination of second trimester pregnancy is a significant We followed vaginal misoprostol as per FIGO protocol.11 problem in the presence of unfavorable cervix and is The misoprostol tablets were placed in the posterior 3 often prolonged and tedious. vaginal fornix. Cervical status was assessed by vaginal examination before insertion of next dose or at the Among various methods of second trimester termination, onset of uterine contraction. Pethidine hydrochloride evacuation and curettage induces risk of bleeding, 50 mg intramuscularly was given for abdominal pain. infection, uterine perforation and cervical trauma.4 The acetaminophen 500mg oral for fever (temperature ≥ introduction of misoprostol, a synthetic prostaglandin 100.4o F), and metoclopramide (10 mg) intravenous for E analog (PGE ) has become an important for cervical 1 1 vomiting. ripening and uterotonic action.5 It is economic, stable at room temperature and is associated with few side Treatment success was defined as expulsion of the 6-12 effects such as fever, vomiting and diarrhea. There fetus within 48 hours after the insertion of initial dose is still debate about doses, routes and regimes of PGE1 of misoprostol. Induction to delivery interval was 7 for termination of pregnancy during second. Studies defined as the time from the initial dose of misoprostol have demonstrated greater efficacy with vaginal to the expulsion of fetus. Maternal side effects such as 8-10 misoprostol than oral misoprostol. The Federation of abdominal pain, fever (temperature ≥ 100.4o F), nausea, International of Gynecologists and Obstetricians (FIGO) vomiting, diarrhea and excessive bleeding requiring blood recommendation for second trimester termination with transfusion based on clinical examination and hematocrit vaginal misoprostol states “400 mcg at 3 hours interval less than 23% were recorded. Completion of termination to a maximum of 5 doses for induction of congenital was assessed by visual examination of abortus, bleeding, anomalies and for IUFD, the doses are adjusted to pain, and vaginal examination to see the status of cervical gestational age: 13-17 weeks 200 mcg every 6 hours to os. Uterine curettage was performed if retained product a maximum of 4 doses, and for 18-26 weeks 100 mcg of conception was detected on vaginal examination after 11 every 6 hours to a maximum of 4 doses”. The aim of this expulsion of fetus and placenta. All women who did not study was to assess the efficacy and maternal side effects abort within 48 hours of misoprostol induction, depending of misoprostol as per FIGO guidelines for termination of on their cervical status and amniotic membrane integrity second trimester pregnancy. received a transcervical Foley catheter 18 Fr, balloon inflated with 50 ml of distilled water and kept in situ for Methods 24 hours or intravenous oxytocin infusion.

This was a cross sectional study of one year period from Statistical Package for Social Sciences (SPSS) version 13 15th June, 2011 to 14th June 2012 in the Department was used for descriptive analysis. of Obstetrics and Gynecology, Patan Hospital. Forty The study was approved by the institutional review pregnant women with fetal congenital anomalies and committee of PAHS. intrauterine fetal demise (IUFD) admitted for second trimester (13-26 weeks) termination were included. Counseling was done regarding the procedure, Results advantages and disadvantages and possible side effects. Informed consent were obtained. The gestational age There were forty women, 31 with IUFD and nine was determined by menstrual history, pelvic examination congenital anomalies for termination of pregnancy during the second trimester of 13-26 weeks.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):16-19 17 Sarada Duwal Shrestha: Misoprostol for Termination of Second Trimester Pregnancy

Table 1. Characteristics of patient undergoing second trimester Abdomen pain was seen at all doses and nausea vomiting abortion (n= 40) at high dose of misoprostol Characteristics Table 3. Maternal complications of vaginal Misoprostol induction in Mean Age ± SD (years) 26.30 ± 5.04 patient undergoing second trimester abortion (n=40)

Mean GA ± SD (weeks) 20.32 ± 4.05 400 mcg (N=9) 200 mcg (N=11) 100 mcg (N = 20) Side Effects Mean Gravidity ± SD 1.88 ± 1.04 N % N % N %

Primigravida 19 (47.50%) Abdominal pain 4 44.44 6 54.54 5 25 0 Multigravida 21 (52.50%) Pyrexia (>100.4 F) 1 11.11 0 0 0 0 Nausea vomiting 2 22.22 0 0 0 0 Congenital Anomalies 9 (22.50%)

IUFD 31 (77.50%) None of our patient required transfusion for excessive Note: n = Total number of patients, SD = Standard Deviation, GA = Gestational Age, bleeding. There was no mortality in this series. IUFD= intrauterine fetal demise

Of 31 fetal IUFD, 11 (35.49%) were of gestational age 13- DISCUSSIONS 17 weeks and 20 (64.51%) of 18-26 weeks. In this study the success rate within 48 hours of At 48 hours, the successful termination in 31 IUFD was misoprostol induction was 88.8% (8 of 9) for congenital 90.9% (10 of 11) at 13 to 17 weeks and 100% (20 0f 20) anomalies which is comparable to 90.5%.12 For IUFD, the at 18-26 weeks. The success rate was 88.8% (8 of 9) for success rate was 90.9% (10 of 11 cases of 13 to 17 weeks) congenital anomalies. Median induction to delivery time and 100% (20 0f 20 cases of 18-26 weeks), higher than was 26.8 hours with 400 mcg Misoprostol for congenital 87.2% reported by Jain et al.5 anomalies. For IUFD, it was 18 hours with 200 mcg at 13 to 17 weeks and 24 hours with 100 mcg at 18 to 26 weeks The required amount of misoprostol not only decreases with increasing gestational age, but has also been found Table 2. Vaginal Misoprostol induction to delivery time in patient to be lower in women with a dead fetus. This may be due undergoing second trimester abortion (n=40) to intrinsic changes in the uterus and cervix that make Total the myometrial cells sensitive to stimulant and cervical Number of Induction Vaginal Mean doses 12 Number patients with to delivery tissues favorable to ripening agent after fetal death. dose of gestational required of induction to time (hrs) The cervix of pregnant women with dead fetus tends to misoprostol age ± SD (number patients delivery time Median (mcg) (weeks) of patient; efface more readily and dilate when compared with that (q1*,q3*) %) <48 hrs >48 hrs of the live fetus.12 J. Srisomboon and S. Pongpisuttinun 5 (8; 88.9) 7 1 have also concluded that intrauterine fetal death had 26.8 400 9 20.36 ± 3.44 higher success rate and aborted earlier than those with a (20, 41.5) 4 (1; 11.1) 1 0 live fetus by comparing the efficacy and safety of 200 mcg 2 (3; 27.3) 3 0 of intravaginal misoprostol administered every 12 hours 18 200 11 15.90 ± 1.81 17 (12, 26) between live and dead fetuses in second trimester. 4 (8; 72.7) 7 1

1 (2; 10) 2 0 In this study, the median induction to delivery interval was 26.8 hours (Q1, Q3: 20, 41.5 hours) in 400 mcg for 2 (3; 15) 3 0 24 congenital anomalies whereas 18 hours (Q1, Q3: 12, 26 100 20 22.73 ± 3.09 (14, 26) 3 (1; 5) 1 0 hours) in 200 mcg for IUFD at 13 to 17 weeks and 24 hours (Q1, Q3: 14, 26 hours) in 100 mcg for IUFD at 18 to 4 (14; 70) 14 0 26 weeks respectively. Q= quartile Several studies have evaluated the use of misoprostol for 1-3 For women who did not abort within 48 hours of induction of labour in the second trimester. There are misoprostol induction, 11.2% (1 of 9) for congenital different regimes for the use of misoprostol in termination 13 anomalies received trans-cervical Foley catheter whereas of second trimester pregnancy. In this study, we used 9.1% (1 of 11) for IUFD at 13 to 17 weeks received the protocol recommended by the FIGO for second intravenous oxytocin infusion. All of them expelled the trimester termination with vaginal misoprostol: 400 mcg fetus successfully. at every 3 hours interval to a maximum of 5 doses for induction of congenital anomalies. For IUFD, doses were

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):16-19 18 Sarada Duwal Shrestha: Misoprostol for Termination of Second Trimester Pregnancy adjusted to gestational age: between 13-17 weeks 200 7. Eslamian L, Gosili R, Jamal A, Alyassin A. A prospective mcg every 6 hours interval to a maximum of 4 doses, and randomized controlled trial of two regimens of vaginal between 18-26 weeks 100 mcg every 6 hours interval to misoprostol in second trimester termination of pregnancy. a maximum of 4 doses.11 Acta Medica Iranica. 2007;45(6):497-500. 8. Akoury HA, Hannah ME, Chitayat D, Thomas M, Winsor E, The most common maternal side effects observed in this Ferris LE, et al. Randomized controlled trial of misoprostol study were abdominal pain followed by nausea, vomiting for second-trimester termination associated with fetal and pyrexia. Symptomatic management was successful. malformation. Am J Obstet Gynecol. 2004 Mar;190:755- Other authors have observed fever as the most frequent 62. side effects.13-17 9. Dickinson JE, Evans SF. A comparison of oral misoprostol with vaginal misoprostol administration in second trimester pregnancy termination for fetal abnormality. CONCLUSIONS Obstet Gynecol. 2003 Jun;101:1294-9. 10. Guix C, Palacio M, Figueras F, Bennasar M, Zamora L, Coll Vaginal misoprostol was effective with minimal side O, et al. Efficacy of two regimens of misoprostol for early effects for termination of second trimester pregnancy for second-trimester pregnancy termination. Fetal Diagn fetal congenital anomalies and intrauterine fetal demise. Ther. 2005 Nov-Dec;20:544-8. 11. Weeks A, Faundes A. Misoprostol in obstetrics and gynecology. Int J Gynaecol Obstet 2007;99 Suppl 2:S156- REFERENCES 9. 12. Elati A, Weeks AD. The use of misoprostol in obstetrics and 1. Ramin KD, Ogburn PL, Danilenko DR, Ramsey PS. High gynaecology. BJOG. 2009 Oct;116:61-9. dose oral misoprostol for midtrimester pregnancy 13. Wong KS, Ngai CS, Yeo EL, Tang LC, Ho PC. A comparison interruption. Gynecol Obster Invest. 2002;54(3):176-9. of two regimens of intravaginal misoprostol for 2. Haleemi M. Therapeutic termination of second trimester termination of second rimester pregnancy: a randomized pregnancy: a comparison of extra amniotic foley’s comparative trial. Hum Reprod. 2000 Mar;15(3):709-12. Catheter balloon and extra amniotic instillation of F2 14. Dickinson JE, Evans SF. The optimisation of intravaginal alpha. J Postgrad Med Inst. 2004;18:408-18. misoprostol dosing schedules in second-trimester 3. Pongsatha S, Tongsong T. Therapeutic termination of pregnancy termination. Am J Obstetrics Gynecol. second trimester pregnancies with intrauterine death 2002;186:470–4. with 400 microgram of oral misoprostol. J Obstet 15. Tang OS, Lau WN, Chan CC, Ho PC. A prospective Gynaecol Res. 2004 Jun;30:217-20. randomised comparison of sublingual and vaginal 4. Liaqat NF, Javed I, Shuja S, Shoaib T, Bano K, Waheed misoprostol in second trimester termination of pregnancy. S, et al. Therapeutic termination of second trimester BJOG. 2004 Sep;111(9):1001–5. pregnancies with low dose misoprostol. J Coll Physicians 16. Jain JK, Kou J, Mishell DR Jr. A comparison of two Surg Pak. 2006 Jul;16(7):464-7. dosing regimens of intravaginal misoprostol for second- 5. Natthinee P, Kusol R, Dittakarn B. Success Rate of Second- trimester pregnancy termination. Obstet Gynecol. 1999 Trimester Termination of Pregnancy Using Misoprostol. J Apr;93(4):571-5. Med Assoc Thai. 2006;89(8):1115-9. 17. Srisomboon J, Pongpisuttinun S. Efficacy of 6. Nagaria T, Sirmor N. Intravaginal misoprostol for Intracevicovaginal Misoprostol in Second-Trimester termination of second trimester pregnancy. J Obstet Pregnancy Termination: A Comparison between Live and Gynecol India. 2007;57(5):435-8. Dead Fetuses. J Obstet Gynaecol Res. 1998;24(1):1-5.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):16-19 19 GENERAL SECTION Puja Amatya: Outbreak of Neonatal Sepsis ORGINAL ARTICLE

Outbreak of Extended Spectrum Beta Lactamase Producing Klebsiella Species Causing Neonatal Sepsis at Patan Hospital in Nepal Puja Amatya,1 Suchita Joshi,2 Shrijana Shrestha3

1Lecturer, 2Assistant Professor, 3Professor, Department of Pediatircs, Patan Academy of Health Sciences, Lalitpur, Nepal

ISSN: 2091-2749 (Print) 2091-2757 (Online) ABSTRACT Introductions: Klebsiella sepsis is the most important nosocomial infection in neonates. The objectives of this study were to review an outbreak in a neonatal unit caused by Klebsiella species, to identify the source of the infections, and Correspondence to identify infection control measures for eradication and prevention of these Dr. Puja Amatya infections. Department of Pediatrics Patan Academy of aHealth Sciences, Methods: The case notes and investigation reports of all sepsis cases admitted Lalitpur, Nepal in neonatal units of Patan hospital from July to December 2011 caused by Email: [email protected] Klebsiella species were retrospectively reviewed. The demographic profile, risk factors along with clinical features and management of sepsis were reviewed. Peer Reviewed by Dr. Ashis Shrestha Results: Twenty three out of 37 neonatal blood cultures grew Klebsiella species. Patan Academy of Health Sciences Email: [email protected] Thirty one were K. pneumoniae and six K. oxytoca. Seventeen of the 31 (55%) K. pneumoniae isolates were multidrug resistant and extended spectrum beta Dr. Sumana Bajrachraya lactamase producers. Eighteen of 23 (78%) neonates with Klebsiella sepsis died. Patan Academy of Health Sciences After extensive cleaning methods and identifying an intermittently leaking roof Email: sumanabajrachraya@pahs. in one of the nurseries below a vescicovaginal fistula room of gynecological edu.np ward above, the infection outbreak was finally controlled.

Conclusions: Infections with extended spectrum beta lactamase producing Klebsiella spp. are a threat in neonatal units because of limited treatment options for these multidrug resistant organisms. Identification of the source and control of the outbreak can be a challenge.

Keywords: extended spectrum beta lacatamase, Klebsiella, multi drug resistant, neonates

Plain Language Summary The study was done to review an outbreak caused by Klebsiella species, to identify the source of the infections along with infection control measures for eradication and prevention of these infections in neonate unit. Identification of the source and eradication of the outbreak of Klebsiella species can be a challenge. Hand washing remains one of the most important methods to prevent cross infections and nosocomial infections.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):20-25 20 Puja Amatya: Outbreak of Neonatal Sepsis

INTRODUCTIONS for any source of infection such as leaking roofs, damp walls and plumbing defects. Klebsiella pneumoniae is the most common pathogen among the Klebsiella species,1 and there has been an Klebsiella isolates from cases not responding to increase in the incidence of nosocomial infections caused antimicrobial therapy reported as susceptible were also by K. pneumoniae strains producing extended-spectrum sent to the Microbiology Unit at Canterbury Health beta-lactamases (ESBL).2-4 The widespread use of broad- Laboratories (CHL), Christchurch, New Zealand. spectrum antibiotic in intensive care units (ICU) favors development of multidrug resistant (MDR) organism.5,6 The isolates were also screened for the production of ESBL by the double disk diffusion procedure. The presence of There was an outbreak of ESBL producing MDR Klebsiella Klebsiella producing carbapenamases (KPC) and metallo- species in a neonatal unit of Patan hospital. All the β-lactamase (MBL) enzymes were tested by the inhibition neonates infected with ESBL Klebsiella had similar signs of the enzyme using boronic acid for KPC and dipicolinic and symptoms. The retrospective review of charts was acid for MBL.7 The presence of a carbapenemase was done to identify the source of infections, measures to confirmed using a multiplex8 PCR and DNA sequencing control and prevent such incident. on a representation of each K. pneumonia antibiogram pattern; four patterns were seen. Microsoft excel 2010 was used fro descriptive analysis. Methods

This cross sectional, descriptive study was performed in RESULTS three sites of neonatal units: nurseries (clean and septic), neonatal intensive care unit (NICU) and pediatric intensive Twenty three neonates were included. All 23 neonates care unit (PICU) of Patan Hospital, a tertiary care teaching had hypotension, respiratory failure, acute renal failure, hospital of Patan Academy of Health Sciences. Approval and disseminated intravascular coagulation with was taken from Institutional Review Committee. Neonates Multiorgan Dysfunction Syndrome (MODS). without any risk factors for sepsis are admitted to the clean nursery, while neonates with risk factors for sepsis, and those Eighteen out of 23 neonates (78%) died. Out of 23 who have positive blood, urine or stool cultures, diarrhoea, neonates, sixteen (70%) were males and seven (30%) conjunctivitis or skin infections are kept in a ‘septic nursery’. were females. Twenty out of 23 (87%) were premature Among the neonates requiring ICU care, the inborn babies and low birth weight. (delivered in Patan Hospital) are admitted to NICU while Fifteen out of 23 (65%) neonates were delivered by the outborn neonates (born outside Patan Hospital) are normal vaginal delivery and eight out of 23 (35 %) were admitted to PICU. The case notes of all babies infected with born through caesarean section. Of the twenty-three Klebsiella during the six month duration (July to December babies, 15 were admitted in NICU, five in PICU, two in 2011) were reviewed. Clinical and demographic data for the septic nursery and one in the clean nursery. Out of each patient were recorded. The maternal case-notes 23 neonates, ten (44%) neonates acquired Klebsiella were reviewed to evaluate maternal risk factors for the infection in NICU, seven (30%) in septic nursery, five infection like history of premature rupture of membrane, (22%) in PICU and one (4%) acquired in clean nursery. foul smelling liquor and maternal fever. Out of 23 neonates, 18 needed mechanical ventilation While reviewing the maternal case-notes, we looked and only two survived. Eight infants had umbilical venous for antenatal risk factors such as history of premature catheter and five had umbilical arterial catheter inserted. rupture of membrane (PROM), maternal fever, number Out of thirteen umbilical catheters, eleven were kept of per vaginum examination and use of antepartum for more than three days. Meningitis was present in five antibiotics. neonates and Klebsiella pneumoniae was isolated from cerebrospinal fluid (CSF) in one. The environmental sampling included laryngoscope blades, ventilator, stethoscopes, equipment trolleys, There were no associated maternal risk factors for incubators, central lines, tip of endotracheal tubes, neonatal sepsis in these babies The first blood culture suction tubes, tap water, floor and door handles. These taken within 72 hours of birth were negative in all environmental cultures were obtained fortnightly and neonates. sent to microbiology laboratory of Patan hospital. Hand Out of thirty-seven Klebsiella isolates, 23 were from swabs and rectal swabs from all the staffs working in the blood, eight were from the endotracheal tube-tip, three neonatal units, culture of purified water and disinfectants, from urine, two from umbilical catheters and one from and swabs from the air conditioning unit were also sent. CSF. All neonatal nurseries and ICUs were inspected in detail

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):20-25 21 Puja Amatya: Outbreak of Neonatal Sepsis

Figure 1. Frequency distribution of neonates with sepsis across different Figure 2. Frequency distribution of neonates with sepsis across different gestational age (n=23) birth weights (n=23)

Table 1. Culture and sensitivity pattern of Klebsiella isolates in twenty-three neonates Antibiotics 1 2 3 4 5 6. 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Augmentin. ------R - - - R - - - R R R R R - Ampicillin. R R R R R R R R R R R R R R R R R R R R R R R Amikacin S S I S R R S R S R R S S R S R R R R R R R R Cefepime. - - - - - R - - - R - S S R - - - R R R R R - C-S - - I S R R R R R R R S R R - R R R R R R R R Cefoxitin. - - - I - R - - - R - - - R - - R R R R R - Cefotaxim R R R R R S R R R R R S S R R R R R R R R R R Ceftriaxone. ------R - - - R - - - R R R R R - Chloram R R R S R S S S S R R S S R S R R R R R R R S Cefuroxime. ------R - - - R - - - R R R R R - Cipro. R R R R R S R R R R R S S R R R R R R R R R R CTZ. R R R R R R R R R R R S S R S R R R R R R R R Colistin. - - - - - S - - - S - S S S S S S S R S S S S Etrapenem. - - - - - R - - - R - - - R - - - R R R R R - Gentamicin. R S I S R S R R R R R S S R R R R R R R R R R Imipenem. S S S S R R S R S I R S S I R S R R I I I I S Meropenem. S S S S S S S S S I S S S R S S S R I I I I S Nalidixic acid R R R R R S R R R R R R R R R R R R R R R R R Nitro S R R R R R R R R R R R R R R R R R R R R R R Ofloxacin S R R R R S S S S R R S S R R R R R R R R R S Pip/Taz - - R S R R R R - R R R R R - R R R R R R R R Tazocin. - - - - - R - - - R - - - R - - - R R R R R - Tobramycin. - - - - - R - - - R - - - R - - - R R R R R - Species KPNE KPNE KPNE KPNE KPNE KPNE KPNE KPNE KPNE KPNE KPNE KOXY KOXY KPNE KOXY KPNE KPNE KPNE KPNE KPNE KPNE KPNE KPNE ESBL screen - - - - P - - - - P P - - P - P P P P P P P - MBL PCR NDM- NDM-1 NDM-1 NDM- - NDM- 1 1 1 Specimen Urine Blood Blood Blood Blood Blood Blood Blood Blood Blood Blood Blood Blood Blood Blood Blood CSF Blood Blood Blood Blood Blood Blood ET ET Urine UVC ET ET Urine ET UVC

Out of twenty-three Klebsiella isolates in blood, two Thirty-one were identified asK. pneumoniae and six were neonates had repeated positive blood cultures; out of K. oxytoca. Infection with K. pneumoniae was associated which four were from one neonate and two from another with disseminated intravascular coagulation (DIC) and neonate. Out of eight Klebsiella isolates in endotracheal refractory hypotension. Seventeen out of 18 neonates tube-tip, in two neonates, it was isolated on two different who died had K. pneumoniae, and one had K. oxytoca. occasions. In those who had positive isolates in urine, umbilical catheter and endotracheal tube-tip, the same Seventeen out of 37 K. pneumoniae isolates were organisms were also isolated in blood cultures. The infant MDR and ESBL producers. They were resistant to all who had positive CSF culture for Klebsiella had negative the first line, ampicillin and amikacin and second line blood cultures. drugs, cefotaxim/chloramphenicol and ofloxacin, and

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):20-25 22 Puja Amatya: Outbreak of Neonatal Sepsis some were resistant to third line drugs, meropenem/ and hospitalized patients. Bacteremia and meningitis imipenem/piperacillin-tazobactum/cefoperazone- are common in pediatric patients, especially those in sulbactum and colistin used in our neonatal units. NICUs.13,14 These infections are frequently caused by Twentythree isolates were sent to CHL, New Zealand multidrug-resistant strains and have a high mortality for microbiological confirmation and subtyping. Nine rate.15 Low birth weight, mechanical ventilation, out of eleven isolates were confirmed as K. pneumoniae prolonged hospitalization, use of third-generation and two as K. oxytoca. All nine K. pneumoniae isolates cephalosporins, and invasive procedures are important were confirmed as MDR and ESBL producers. The K. risk factors for the emergence of nosocomial infections pneumoniae isolates showed intermediate resistance to in intensive care units and for high mortality.16,17 More meropenem and imipenem except in one which showed than 50% of the neonates affected in this study had low complete resistance to meropenem. These Klebsiella birth weights and were premature. Out of twenty-three, isolates were only sensitive to colistin. Out of these nine, 18 required mechanical ventilation and eight had central seven Klebsiella pneumoniae isolates were reported (umbilical) venous or arterial catheters. Klebsiella was sensitive to carbapenems in Patan Hospital. Out of the isolated in eight out of 18 endotracheal tube-tip cultures five neonates who survived, three had received colistin. and six out of eight neonates died who grew Klebsiella in The details of culture and sensitivity patterns along with their endotracheal tip. Two out of 13 umbilical lines grew subtyping of Klebsiella isolates in twenty three neonates Klebsiella and both neonates died. Klebsiella infections are shown in Table 1. may spread rapidly from medical devices, soap and disinfectants, blood products, and the hands of hospital The subtyping of Klebsiella isolates were done at CHL, staff.13,18 New Zealand and the strain was found to be NDM-1 (New Delhi Metallo-beta-lactamase) strain in five neonates In view of Klebsiella outbreak of from contaminated which was resistant to all beta lactams. disinfectant in a neonatal and pediatric intensive-care unit,13 we tested all disinfectant solutions which were Klebsiella was isolated in various environmental cultures used in our neonatal units. All the disinfectants were such as laryngoscope blades, suction jar, jar containing equally effective for Klebsiella. ESBL Klebsiella has also purified water, tap water, and a hand of health care been liked to artificial nails.19 Melek Ayan et al20 reported worker. Additionally, swab from the air conditioner also Klebsiella outbreaks in premature neonates with grew Klebsiella species. None of these environmental intravenous catheters, mechanical ventilation or both, isolates were MDR or ESBL. Rectal swab of all health care and high mortality rate (76.7%) was noted. In this study, workers in our neonatal units were found to be negative more than half of the patients had low birth weight, for ESBL producing Klebsiella species. were premature, or underwent mechanical ventilation. Approximately three-fourths of the patients died. In our An intermittent leaking roof with a toilet drain pipe series, 87% of the babies with Klebsiella sepsis were was noted in one of the nurseries situated below the premature and low birth weight while the mortality rate vescicovaginal fistula (VVF) room of Gynecology ward. of 78% is almost comparable to the Melek Ayan’s study. Further investigation revealed that MDR Klebsiella were More than half of the strains in the study by Melek Ayan isolated in the urine specimens of patients in the VVF were resistant to many beta-lactam antibiotics, amikacin, room and in the surface cultures of the room. and trimethoprim/sulfamethoxazole. Resistance to multiple antibiotics, mainly to broad-spectrum beta- DiscussionS lactam antibiotics was observed, particularly in Klebsiella pneumoniae isolates. Similarly, resistance to expanded- Eighteen out of 23 neonates died in this study. Thirty- spectrum cephalosporins is reported for most of the seven Klebsiella species were isolated in six months outbreak strains of Klebsiella species.9,15,21 In our study, duration. Out of 37 isolates, 17 were extended spectrum Klebsiella pneumoniae isolates were resistant to all the beta lactamase producers and multidrug resistant beta lactams. Klebsiella which were resistant to all first and second line antibiotics. There is increasing evidence of the emergence of carbapenem resistant isolates.22,23 In the study by Several outbreaks of infection caused by K. pneumoniae Hanna Sidjabat et al24 carbapenem resistance in isolates that are simultaneously resistant to broad- Klebsiella pneumoniae due to NDM-1 beta lactamase spectrum cephalosporins and aminoglycosides have been was demonstrated. Similarly, study done by Dongeun widely reported.9-12 Klebsiella can cause serious infections Young et al24 also characterized NDM-1 gene and a such as bacteremia, pneumonia, and urinary tract and novel erythromycin esterase gene on a unique genetic soft tissue infections, particularly in immunosuppressed structure in Klebsiella pneumoniae sequence type 14

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):20-25 23 Puja Amatya: Outbreak of Neonatal Sepsis from India. Comparing our study with them, six out of limitation of our study is that, this being a retrospective eleven patients who were ESBL K. pneumoniae were study, some of the information were missing on the intermediate, two were resistant and the rest were medical notes especially information regarding the risk sensitive to meropenem. Regarding imipenem, six were factors for sepsis. intermediate, four were resistant and only one was sensitive. Carbapenem resistant organisms were of NDM- Conclusions 1 strain. Timothy R Walsh et al25 found the dissemination of NDM-1 positive bacteria in New Delhi environment Infections with ESBL Klebsiella pneumoniae was a major (water supply and sewage effluent samples). Similarly, cause of morbidiry and mortality among neonates in 26 Mariana Castanheira et al found early dissemination Patan Hospital during the outbreak with the limited of NDM-1 producing enterobacteriaceae in Indian treatment options for MDR organisms. The emergence hospitals. Although we cannot extrapolate these data for of ESBL and carbapanem resistant Klebsiella pneumonia our country, with emerging carbapenem resistant NDM-1 pose a great challenge for clinicians. strain Klebsiella pneumoniae, there is a need for a broad environmental survey. AKNOWLEDGEMENTS In addition to surveillance cultures, various infection control strategies were implemented. Revised cleaning We would like to thank Dr. Abhilasha Karkey and Mr. policy was added to our infection control protocol. 1% Krishna G. Prajapati, Department of microbiology, Patan virkon was used for cleaning equipments after testing its hospital, who helped us in culture and sensitivity of efficacy to inhibit Klebsiella species in-vitro. After each Klebsiella and sending these isolates to New Zealand for new MDR Klebsiella infection, surface cleaning, high confirmation. dusting, and fumigation of neonatal units were done. The routine chlorination of water sources was inspected. REFERENCES Purified water was used in humidifiers of ventilators. Disposable paper-towels were used instead of cloth 1. Sirot J. Detection of extended-spectrum plasmid- towels in all neonatal units. Staffs and visitor gowns were mediated ß-lactamases by disk diffusion. Clin Microbiol changed every morning. All visitors were advised to use Infect. 1996;2:35-9. gowns hung in the designated pegs. All visitors were 2. Gniadkowski M, Hryniewicz W. Outbreak of ceftazidime- informed about hand washing policy. Air conditioner resistant Klebsiella pneumonia in a pediatric hospital in was cleaned. Disposable tubings for ventilators were Warsaw, Poland: clonal spread of the TEM-47 extended used. Discarding of infected equipments was done. spectrum ß-lactamase (ESBL)-producing strain and transfer of a plasmid carrying the SHV-5-like ESBLencoding Cleaning protocols for ventilators were implemented. gene. Antimicrob Agents Chemother. 1998;42:3079-85. The importance of hand washing was emphasized to all 3. Siu LK, Lu PL, Hsueh PR, Lin FM, Chang SC, Luh KT, et the staffs working in neonatal units. Bedside cleansing al. Bacteremia due to extended-spectrum ß-lactamase solution Microshield (chlorhexidine) was used in all producing Escherichia coli and Klebsiella pneumoniae neonatal units. Universal decontamination using daily in a pediatric oncology ward: clinical features and chlorhexidine bath for all neonates was implemented. identification of different plasmids carrying both SHV-5 The nursery with the leaking roof was eventually closed and TEM-1 genes. J Clin Microbiol. 1999 Dec;37(12):4020- and was shifted to another room. 7. 4. Peña C, Pujol M, Ardanuy C, Ricart A, Pallares R, Linares After implementation of these infection control measures, J, et al. Epidemiology and successful control of a large we have now reduced the infection with MDR and ESBL outbreak due to Klebsiella pneumoniae producing Klebsiella species. Hence, we need to do prospective extended spectrum ß-lactamases. Antimicrob Agents Chemother. 1998 Jan;42(1):53-8. studies to conclude that how useful these measures are 5. Waggoner LA, Donowitz LG. Infection in newborns. In: to prevent the outbreak. Wenzel RP, editor. Prevention and control of nosocomial infections. 3rd ed. Baltimore: Williams & Wilkins; According to our hospital policy, the microbiology 1997.p.1019-38. laboratory does test the antimicrobial sensitivity on 6. Tenover FC, Hughes JM. The challenge of emerging surface swabs culture. Therefore, we were unable to infectious diseases. Development and spread of multiply- prove that the leaking roof was indeed the source of resistant bacterial pathogens. JAMA. 1996 Jan 24- the outbreak. However, closing this nursery below the 31;275(4):300-4. VVF room finally eradicated the infection outbreak. In 7. Giske CG, Gezelius L, Samuelsen Ø, Warner M, Sundsfjord addition, some patients who were admitted in the VVF A, Woodford N. A sensitive and specific phenotypic room also had similar Klebsiella infection to the infants in assay for detection of metallo-β-lactamases and KPC in the nursery, which strengthens the speculation. The main Klebsiella pneumoniae using meropenem discs supplied

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):20-25 24 Puja Amatya: Outbreak of Neonatal Sepsis

with boronic acid, dipicolinic acid and cloxacillin. Clin resistant Klebsiella from a pediatric ICU. Chest. Microbiol and Infect. 2011 Apr;17(4):552-6. 2001;119:862-6. 8. Poirela L, Walsh TR, Cuvillier V, Nordmann P. Multiplex 18. Reiss I, Borkhardt A, Füssle R, Sziegoleit A, Gortner L. PCR for detection of acquired carbapenemase genes. Disinfectant contaminated with Klebsiella oxytoca source Diagn Microbiol and Infect Dis. 2011 May;70(1):119-23. of sepsis in babies. The Lancet. 2000 Jul22:310. Reiss I, 9. French GL, Shannon KP, Simmons N. Hospital outbreak Borkhardt A, Füssle R, Sziegoleit A, Gortner L. Disinfectant of Klebsiella pneumoniae resistant to broad-spectrum contaminated with klebsiella oxytoca as a source of sepsis cephalosporins and β-lactam-β-lactamase inhibitor in babies. The lancet 2000 Jul 22;356:310. combinations by hyperproduction of SHV-5 β-lactamase. J 19. Gupta A, Della-Latta P, Todd B, San Gabriel P, Haas J, Wu Clin Microbiol. 1996;34:358–63. F, et al. Outbreak of extended-spectrum beta-lactamase- 10. Gniadkowski M, Palucha A, Grzesiowski P, Hryniewicz W. producing klebsiella pneumonia in a neonatal intensive Outbreak of ceftazidime-resistant Klebsiella pneumoniae care unit linked to artificial nails. Infection Control and in a pediatric hospital in Warsaw, Poland: clonal spread Hospital Epidemilogy. 2004;25:210-5. of the TEM-47 extended-spectrum β-lactamase (ESBL)- 20. Ayan M, Kuzucu C, Durmaz R, Aktas E, Gizmeci Z. Analysis producing strain and transfer of a plasmid carrying the of three outbreaks due to klebsiella species in a neonatal SHV-5-like ESBL-encoding gene. Antimicrob Agents intensive care unit. Infection Control and Hospital Chemother. 1998;42:3079–85. Epidemilogy. 2003;24:495-500. 11. Pena C, Pujol M, Ardanuy C, Ricart A, Pallares R, Linares 21. Ariffin H, Navaratnam P, Mohamed M, Arasu A, Abdullah J, et al. Epidemiology and successful control of a large WA, Lec CL, et al. Ceftazidime-resistant Klebsiella outbreak due to Klebsiella pneumoniae producing pneumoniae bloodstream infection in children with extended-spectrum β-lactamases. Antimicrob Agents febrile neutropenia. Int J Infect Dis. 2000;4:21-5. Chemother. 1998 Jan;42(1):53-8. 22. Khan E, Ejaz M, Zafar A, Inayat R, Zafar A, Jabeen K, 12. Rice LB, Eckstein EC, DeVente J, Shlaes DM. Ceftazidime et al. Increased isolation of ESBL producing Klebsiella resistant Klebsiella pneumoniae isolates recovered at the pneumoniae with emergence of carbapenem resistant Cleveland Department of Veterans Affairs Medical Center. isolates in Pakistan: Report from a tertiary care hospital. J Clin Infect Dis. 1996;23:118–24. Pak Med Assoc. 2010;60:186-90. 13. Podschun R, Ullmann U. Klebsiella spp. as nosocomial 23. Sidjabat H, Nimmo GR, Walsh TR, Binotto E, Htin A, pathogens: epidemiology, taxonomy, typing methods, and Hayashi Y, et al. Carbapenem Resistance in Klebsiella pathogenicity factors. Clin Microbiol Rev. 1998;11:589- pneumoniae Due to the New Delhi Metallo-β-lactamase. 603. Clin Infect Dis. 2011;52: 481-4. 14. Patterson JE, Hardin TC, Kelly CA, Garcia RC, Jorgensen JH. 24. Yong D, Toleman MA, Giske CG, Cho HS, Sundman K, Lec Association of antibiotic utilization measures and control K, et al. Characterization of a new metallo-beta-lactamase of multipledrug resistance in Klebsiella pneumoniae. gene, bla(NDM-1), and a novel erythromycin esterase Infect Control Hosp Epidemiol. 2000;2:455-8. gene carried on a unique genetic structure in Klebsiella 15. Silva J, Gatica R, Aguilar C, Becerra Z Garza-Ramos pneumoniae sequence type 14 from India. Antimicrob U, Velazquez M, et al. Outbreak of infection with Agents and Chemother. 2009;53(12):5046–54. extendedspectrum beta-lactamase-producing Klebsiella 25. Walsh TR, Weeks J, Livermore DM, Toleman MA. pneumoniae in a Mexican hospital. J Clin Microbiol. Dissemination of NDM-1 positive bacteria in the New 2001;39:3193-6. Delhi environment and its implications for human health: 16. Parasakthi N, Vadivelu J, Ariffin H, Iyer L, an environmental point prevalence study. Lancet Infect Palasubramaniam S. Arasu mitted multidrug resistant Dis. 2011;11: 355–62. Klebsiella pneumoniae. Int J Infect Dis. 2000;4:123-8. 26. Castanheira M, Deshpande LM, Mathai D, Bell JM, 17. Petros AJ, O’Connell M, Roberts C, Wade P, Hendrick Jones RN, Mandes RE. Early Dissemination of NDM- K, Sacne V. Systemic antibiotics fail to clear multidrug- 1- and OXA-181-Producing Enterobacteriaceae in Indian Hospitals: Report from the SENTRY Antimicrobial Surveillance Program, 2006-2007. Antibicrobial Agents and Chemotherapy. 2011;55:1274–78.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):20-25 25 GENERAL SECTION Imran Ansari: Hepatitis B and HIV in Children and Pregnant Ladies ORGINAL ARTICLE

Hepatitis B and HIV in Children and Pregnant Ladies at Patan Hospital Imran Ansari

Associate Professor, Department of Pediatircs, Patan Academy of Health Sciences, Lalitpur, Nepal

ABSTRACT

ISSN: 2091-2749 (Print) Introductions: The primary objective of this study was to find the prevalence 2091-2757 (Online) of Hepatitis B and HIV infections in children and pregnant ladies visiting Patan Hospital. The secondary objective wasto investigate how these individuals may have got infected, the clinical presentation and outcome.

Methods: Laboratory records of all individuals tested for Hepatitis B and HIV Correspondence between 2006 July to 2011 Aug were included. The charts were reviewed for Dr. Imran Ansari history and clinical findings Associate Professor, Department of Pediatrics Results: Out of 44,958 individuals who were tested, 229 were positive. The Patan Academy of Health Sciences, prevalence of HIV was 0.2% and HBV 0.3% and both was 0.01% (5). The numbers Lalitpur, Nepal of children under age of 15 and of pregnant ladies were 13 and 32 respectively. Email: [email protected] Risk factors identified in 40 adult patients were: intravenous drug use, multiple Peer Reviewed by: sex partners, working abroad and long distance drivers. Twenty-seven patients Dr. Nabees Man Singh Pradhan died, all with HIV. Of the 32 pregnant ladies 31 were discovered by routine Patan Academy of Health Sciences testing. All the babies born were healthy. Fever, cough and breathing difficulty Email: [email protected]. were the most common presenting features. Ten were treated for pneumonia np and 3 for TB. Parents of 5 HIV-infected infants also had the same infection themselves. There was no death among children. Dr. Jay N Shah Patan Academy of Health Sciences Conclusions: The prevalence of HBV and HIV was low. HBV was a ‘hidden’ Email: [email protected] infection, discovered on routine testing of asymptomatic pregnant ladies. Almost all children got these infections through vertical transmission.

Keywords: HVB, HIV, infection, seroprevalence

Plain Language Summary This study was conducted to see prevalence of Hepatitis B and HIV in pregnant ladies and children at Patan Hospital, Nepal. Charts were reviewed. Prevalence of both was found to be very low.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):26-29 26 Imran Ansari: Hepatitis B and HIV in Children and Pregnant Ladies

IntroductionS Table 2. Racial distribution of HBsAg and HIV positive cases Race Number positive % of total Viruses responsible for Hepatitis B and HIV infections are transmitted through sexual intercourse, blood Mongolian 71 31.0 transfusion and vertically from mother to fetus. Health Newar 44 19.3 personals may get infected if universal precautions are not practiced. Chhetri 32 14.0

An estimated 75,000 (16,262 confirmed) people are living Dalit 27 11.8 1 with HIV/AIDS in Nepal. There is lack of data about the Brahmin 25 10.9 magnitude of this problem among patients visiting Patan Hospital. Data and knowledge on this issue will motivate Tharu 6 2.6 health professionals to comply with institutional plans Madheshi 6 2.6 and policy of universal precaution. Muslim 6 2.6 This aim of this study was to find out overall HIV and Others 12 5.2 HBV infections in patients coming to Patan Hospital, their clinical presentation, and outcome and to investigate Total 229 100 how they may have got infected.

Methods Diarrhea

It was a hospital based cross sectional, descriptive study. GI bleed Laboratory records of all individuals tested for Hepatitis Weight Loss B and HIV infections between July 2006 to Jul 2011 were included in the study. Hospital numbers of all the Anorexia positive results were noted to retrieve patient files from the record section of the hospital. Relevant findings, like Edema presenting complaint, risk behavior, physical findings and Pregnancy outcome were studied. Approval for the study was taken from hospital authority. Cough

Fever Results Figure 1. Presenting com[plaints of patients with Hepatitis B and HIV A total of 44,958 individuals were tested for both *Many patients had more than one of the stated symptoms, so the sum Hepatitis B and HIV in the five year study period. Of them of the numbers shown in this diagram exceeds total number of patients. 229 (0.51%) were positive; 136 (0.3%) for Hepatitis B, 88 for HIV and 5 (0.01%) for both. Overall, fever in 74 (32.3)%, cough in 58 (25.3%) were common presenting complaints (Figure 1) and 48 Table 1. Individual and co-infection of Hepatitis B and HIV in male and (21.8%) patients had both of these symptoms. In 32 female patients (14%) pregnant ladies the infections were discovered Male Female Total during routine ante-natal investigation. Tuberculosis was HBsAg 76 58 134 detected in 61 (28%) patients. Among 14 children, fever HIV 56 34 90 in 10 (71.4 %), cough in 8 (57.1%) and breathing difficulty in 5 (35.7%) were the common complaints. Ten were HBsAg & HIV 3 2 5 treated for pneumonia and three for disseminated TB. Total 135 94 229 Three children had oral thrush.

Out of total infected individuals 153 (66.8%) were in the Risk factors could be identified in only 40 (17.5%) cases active age group of 26 to 49 years. Infected children up and among these, intravenous drug use was 16 (40%) and to 14 years of age were 13 (5.7%); 11 HIV and two HBsAg patients with multiple sex partners, working or worked positive. There was no co-infection in the pediatric abroad, and long distance drivers were each 8 (20%). population. Pregnant ladies were 32 (14%); 29 HBsAg, two HIV and one both. In order to find the source or spread, spouses of adult and parents of children were screened. Total of 16 instances of

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):26-29 27 Imran Ansari: Hepatitis B and HIV in Children and Pregnant Ladies spouse-testing were documented, 12 in patients infected 13 (6%) children under 15 years of age were victims of with HIV and 4 in those with the HBsAg. Half of those mother to child transmission (MTCT). tested were positive (7 HIV, 1 HBsAg). Eleven patients had other members of the family (sibs, parents) also infected The people of Mongolian race constituted one third (71; with same virus as the index case (10 HBsAg, 1 HIV). 31%) of the infected in our study, which could be due to Mothers of two and both parents of one HIV infected more male members of this race are in security jobs in infant tested positive. Both parents of another child had India and other countries, being away from family for died of AIDS. Father of one child worked abroad as driver long periods, and engaging in unsafe sexual activities may in a hotel and that of another was getting antiretroviral increase the risk of infections. A WHO document of 2010 treatment from Shaheed Shukra Raj Tropical Hospital, has also reported high prevalence of these infections in 6 Teku, Nepal. One mother of an HIV infected child refused the tribal population of India. to undergo screening test. Most common reasons for the patients to seek medical During study period 48 (21%) patients improved and were advice was cough in 74 (32%), fever in 58 (25% ) and both discharged, 20 (9%) left against medical advice. There in 48 (21%). These findings are similar to those of Siddiqui 7 were 27 (12%) mortality, all were HIV infected which MH who found fever (59.6%) and cough (28.8%) as amounts to 30.7% (27 of 88) case fatality for HIV. Thirty major presenting complaints in their patients in Karachi, one patients with HIV were referred to Teku Hospital for Pakistan. Also, 64 (28%) of them had tuberculosis is further management. There was no death in the HBsAg significant finding due to compromised immune defenses goup. in HIV patients.

Of the 32 pregnant ladies who were HBsAg positive, 23 In 40 cases there were identifiable risk factors; intravenous (72%) delivered by vaginal route, six underwent caesarian drug use (16), multiple sex partners (8), working abroad section (one had twin) and three went to deliver at (8) and long distance drivers (8). All of these behaviors/ some other facility. All the babies born to these infected professions are well known for their relationship with the mothers were healthy and weighed between 2850 g and two infections under study. The reason for the majority 3900 g. There was no fetal loss in the present pregnancy of the cases with no known risk factor may be due to but 2 of them had history of abortions in the past. the sensitive nature of and the social stigma attached to these conditions.

DiscussionS Since HBV and HIV can spread to the sex partner, only 16 instances of spouses agreed for testing of whom 8 Overall sero-prevalence in 44958 patients tested was 229 were positive. It can be assumed that more would have (0.5%); of which 136 (0.3%) were Hepatitis B positive, 88 been discovered had there been wider coverage of (0.2% ) HIV and 5 (0.011% ) both is comparable with the investigations. Other family members (siblings, parents) findings four years ago in 2009 in Kathmandu in which were found to have infected in 11 instances, possibly 21,716 units of blood donated for transfusion were from the common source, i.e. parent. Eight of the 13 found infected with HBsAg in 0.47% and 0.21% with HIV.2 children tested positive had direct or indirect evidence Another study from medical college in Western Nepal of MTCT. had high sero-prevalence of 3.4% of HIV3 which could be due to higher risk factors in that areas and needs in- The overall mortality rate of 12% and HIV case fatality depth research. The co-infection rate of HBV and HBsAg rate of 29% in this series is higher than 4.3% mortality 8 (0.011%) in our study is lower than what Ghimire P et al4 reported by Paudel BN from Seti Zonal Hospital Nepal found (0.033%) in their research in ‘blood donors’. This is which could be due to more serious or critical pool of an important finding for further analysis to see whether patients coming to Patan Hospital for tertiary level care. the donors were individuals donating blood to full fill The study may have missed the infections in window their financial need for high-risk life style. period.

Males 135 (59%) were affected more than females in CONCLUSIONS this study similar to findings of Ashish et al2, in contrast 5 to Paudel BN who observed a female predominance The overall sero-prevalence of 0.2% HIV, 0.3% HBV and probably due to different target group. 0.01% both in individuals tested at Patan Hospital is low. This study reveals hidden infections in unsuspected Similar to other studies,2,5 two-thirds (153) of the sero- pregnant women an importance of universal precautions. positive patients in present study were sexually and All children in this series had infections from their economically active age groups of 25 to 49 years old. All mothers through vertical transmission.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):26-29 28 Imran Ansari: Hepatitis B and HIV in Children and Pregnant Ladies

References 5. Paudel BN, Sharma S, Singh GB, Dhungana GP, Paudel P. Socio-Demographic Profile of HIV Patients at Seti Zonal 1. National Centre for AIDS and STD Control [Nepal]. Hospital.J Nepal Health Res Counc.2008Oct;6(13):107-10. Factsheet: Cumulative HIV Situation of Nepal, as of 6. World Health Organization South-East Asia Region. Viral Shravan 2067: 2010 [document on the Internet]. c2012 hepatitis in the context of HIV in South-East Asia Region. [cited 2013 Nov 9]. Available from:http://www.ncasc. Report of an informal consultation; 2010 June 7–9; New gov.np/uploaded/facts_n_figure/EP_Fact_sheet_2010/ Delhi, India. Available from:http://apps.searo.who.int/ Factsheet_2_HIV_Cases_November_2010.pdf. pds_docs/B4596.pdf. 2. Shrestha AC, Ghimire P, Tiwari BR, Rajkarnikar M. 7. Siddiqui MH. Demographic profile and clinical features of Transfusion-transmissible infections among blood admitted HIV patients in a tertiary care teaching hospital donors in Kathmandu, Nepal. J Infect Dev Ctries. of Karachi, Pakistan. Pak J Med Sci. 2009;25(5):861-64. 2009Dec15;3(10):794-7. 8. Paudel BN, Dhungana GP. Scenario of HIV/AIDS Patients 3. Chander A, Pahawa VK. Sero-Prevalence of HIV-1/HIV- in a Government Hospital of Nepal. J Nepal Health Res 2 Infection in Bhairahawa, Western Nepal - A Hospital Counc. 2010Oct;8(17):103-6. Based Study.J Nepal Health Res Counc.2004Apr;2(1):1-4. 4. Ghimire P, Thapa D, Rajkarnikar M, Tiwari BR. HIV and Hepatitis B Co-infection among Volunteer Blood Donors.J Nepal Health Res Counc. 2004Apr;4(1):26-8.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):26-29 29 GENERAL SECTION Samir Shrestha: Conversion from Laparoscopic to Open Cholecystectomy ORGINAL ARTICLE

Conversion from Laparoscopic to Open Cholecystectomy Samir Shrestha,1 Surendra Shah S,2 Sanjay Poudyal,3 Jay N Shah,4 Vijay Kumar Jaiswal4

1Assistant Professor, 2Lecturer, 3Associate Professor, 4Professor, Department of Surgery, Patan Academy of Health Sciences, Lalitpur, Nepal

ABSTRACT

Introductions: With the advent of newer technology, the era of open surgery for gall bladder diseases has been preferably taken over by laparoscopic ISSN: 2091-2749 (Print) 2091-2757 (Online) cholecystectomy. However, certain cases still require conversion to open surgery. In this review we aim to analyze the reason for conversion.

Methods: This retrospective study was conducted at Patan Hospital, Patan Acdemy of Health Sciences, Nepal. All patients who underwent laparoscopic Correspondence cholecystectomy from February 2009 to July 2012 were included in the study. Dr. Samir Shrestha File numbers of all the patients were obtained from operation room register. Department of Surgery The patient files were analyzed for age, sex, duration of symptoms, liver Patan Academy Of Health Sciences, function tests, ultrasound findings and the description in operation note for Lalitpur, Nepal reason for conversion. Email: samir_shrestha99@yahoo. com Results: The age ranged from 12 to 81 years with mean age of patients 32.76 years and male to female ratio 1:2.9. The mean operating time was 65 minutes Peer Reviewed by and average post operative hospital stay was 1.61 days. Out of 305 patients, 34 Dr. Sumana Bajrachraya Patan Academy of Health Sciences (11.14%) required open conversion. Factors responsible for open conversion Email: sumanabajrachraya@pahs. were dense fibrosis at Calots in 11 (3.6%), adhesions due to previous abdominal edu.np surgery in 6 (1.9%), uncontrollable bleeding in 5 (1.6%), bile duct injury in 4 (1.3%) cholecystoenteric fistula in 3 (0.9%), Mirizzi’s syndrome 2(0.6%). Dr. Ashis Shrestha Patan Academy of Health Sciences Conclusions: Adhesions at the calot’s triangle was the common reason for Email: [email protected] conversion from laparoscopic to open cholecystectomy.

Keywords: adhesions, conversion, gallstone, laparoscopic cholecystectomy

Plain Language Summary This study was conducted to determine the predictive factors for conversion of laparoscopic cholecystectomy. The study found that dense adhesion around calot’s triangle and adhesions pertaining to previous abdominal surgery were the main reasons for conversion to open surgery. So, before embarking on laparoscopic cholecystectomy, it is essential to take detail history and examination, to rule out the probable cause of conversion beforehand and minimize; morbidity, duration of surgery and cost.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):30-32 30 Samir Shrestha: Conversion from Laparoscopic to Open Cholecystectomy

IntroductionS

Since its introduction in 1987 by Philip Mouret, 0.3 laparoscopic cholecystectomy (LC) as minimally invasive procedure has become the gold standard. However, for 0.6 various reasons there are conditions to convert to open 0.6 cholecystectomy (OC). Inability to correctly identify the 3.6 anatomy of the Calot’s triangle due to inflammation, adhesion, or anatomical variations are some common conditions for coversion. This study was conducted to analyze the conversion cause and rate for conversion to 1.6 open surgery in patients who underwent laparoscopic 1.9 cholecystectomy at Patan Hospital (PH).

Methods Figure 1. Causes for rate of conversion from laproscopic to open cholecystectomy This retrospective cross sectional, descriptive study was conducted at Patan Hospital, Patan Acdemy of Health post operative day, 21 (6.88%) on rd3 post operative day Sciences, Nepal. All patientswho underwent laparoscopic as patient preference. Six (1.96%) patients developed cholecystectomy or conversion to open surgery from postoperative fever, three each had chest infection February 2009 to July 2012 were included in the study. and urinary tract infection. All patients with fever were File numbers were obtained from operation room register managed conservatively and discharged within 6th post and patient files retrieved from record section. Patients operative day. Eight (2.62%) patients had postoperative age, sex, duration of symptoms of gallstones (acute or bile leak recovered after conservative management chronic cholecystitis), liver function tests (LFTs including and were discharged on 7th (3 patient), th 8 (2 patient), serum alanine transaminase, aspartate transaminase, 12th (1 patient), 17th(1 patient) and th 18 (1 patient) day alkaline phosphatase and bilirubin), ultrasound findings, respectively. There was no mortality in this series. types of anesthesia and the operation notes (for number of ports, anatomy of Callot’s triangle, size of common bile duct(CBD)) were analyzed for reason of conversion DiscussionS from laparoscopic to open surgery and mortality. Ethical approval was taken from ethical review committee of The conversion rate in our study was 11.14% (34 of 305), Patan Acacdemy of Health Sciences (PAHS). which compares well with the incidence reported in the literature, which varies from 2% to 15%. In developed countries less than 20% of total cholecystectomies are Results performed by open method. In developing countries the open method is still common due to lack of skill and There were 305 patients charts available (out of total apparatus. 316 patients registered in operation theater record book, 11 files were not found in record section) for analysis. We had 11 patients with unclear Calots triangle There were 70 (22.95%) males and 235 (77.05%) females, anatomy and six had adhesions associated with previous age 12 to 81 years (mean 32.76 years), chronic calculus abdominal surgery. Among five uncontrolled bleeding, cholecystitis in 276 (90.5%), acute calculus cholecystitis majority (three) were due to cystic artery injury, and one in 17 (5.6%), gall bladder polyp in 12 (3.9%). Thirty four each because of hepatic artery bleed and liver bed bleed. (11.14%) patients required conversion to open method. We noticed bile duct injury in two patients who required Of them 22 (64.70%) were male and 12 (35.30%) female. conversion. Similar findings of difficulty dissection of Calot’s triangle, adhesions, bleeding and bile duct injury The most common reason for conversion was fibrosis as cause of conversion has been described. Precise around calot’s triangle (figure 1), four (1.3%) had bile identification of cystic duct junction with gall bladder at duct injury- two due to diathermy injury in CBD, and one end and CBD at other end before and avoiding blind two CBD injury during dissection) and five (1.6%) had use of cautery and clips are useful to prevent bileduct bleeding (one each from cystic artery and hepatic artery injury. and three from gallbladder bed). Post operative hospital stay ranged from 1 to 18 days (mean 1.61 days) as per our In our study, we had no difficulty in creation of existing policy. 205 (67.21%) patients were discharged pneumoperitoneum. Situations, where difficulty in on 1st postoperative day. Remaining 65 (21.31%) on 2nd gallbladder extraction or instrument failure necessitated

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):30-32 31 Samir Shrestha: Conversion from Laparoscopic to Open Cholecystectomy conversion did not arise. There were no deaths References reported. The limitation of our study was, we have not quantified the thickness of the gallbladder wall asthe 1. Soper NJ, Stockmann PT, Dunnegan DL, Ashley ultrasound data available were incomplete. Many other SW. Laparoscopic cholecystectomy. The new ‘gold standard’? Arch Surg. 1992;127:917–21. parameters such as obesity; diabetes mellitus; body 2. Cuschieri A, Dubois F, Mouiel J, Mouret P, Becker H, Buess mass index and preoperative Endoscope retrograde G, et al. The European experience with laparoscopic cholangiopancreatography (ERCP), which have been cholecystectomy. Am J Surg. 1991;161:385–7. studied in other studies, could not be included in this 3. Iqbal J, Ahmed B, Iqbal Q. Laparoscopic VS open study because of retrospective nature of data collection. cholecystectomy: morbidity comparision. The Professional med J. 2002;9(3):226-34. Several possible factors responsible for conversion have 4. Abbasi SA, Azami R Haleem A. Tariq GR, Iqbal A, Almas been studied. In particular, prediction of conversion D, et al. An audit of laparoscopic cholecystectomy through the analysis of preoperative factors responsible performed at PNS Shifa. Pak Armed Forces Med Journ. for conversion has been studied. These include age; sex; 2003;53(1):51-8. obesity; diabetes mellitus; body mass index; duration of 5. Livingston EH, Rege RV. A nationwide study of conversion symptoms; total leukocyte count; LFT; ultrasound; acute from laparoscopic to open cholecystectomy. Am J Surg. 2004;188:205–11. cholecystitis; history of biliary diseases such as jaundice, 6. The Southern Surgeons Club A prospective analysis of cholangitis, history of pancreatitis and preoperative 1518 laparoscopic cholecystectomies. N Engl J Med. 5,6 endoscopic retrograde cholangiopancreatography. 1991;324:1073–8.

Conclusions

The most common cause of conversion of LC to OC was adhesion at calot’s triangle which results difficulty in delineating biliary anatomy. Though, conversion rate in our study is comparable, we can minimize intraoperative complication with low threshold for conversion.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):30-32 32 GENERAL SECTION Ashis Shrestha: Spirometry Findings in COPD ORGINAL ARTICLE

Spirometry Findings in Patients with Chronic Obstructive Pulmonary Disease Ashis Shrestha, Sumana Bajrachraya

Lecturers, Department of General Practice and Emergency, Patan Academy of Health Sciences, Lalitpur, Nepal

ABSTRACT ISSN: 2091-2749 (Print) 2091-2757 (Online) Introductions: Clinical diagnosis of chronic obstructive pulmonary disease is often not accurate and treated for prolong duration. This study explores the use of pulmonary function test to confirm the diagnosis and further management of such patients.

Correspondence Methods: This was a cross sectional study conducted at Patan Hospital, Patan Dr. Ashis Shrestha Academy of Health Sciences, Nepal. All patients coming for spirometry between Lecturer, Department of General June 2012 and May 2013 with the clinical diagnosis of chronic obstructive Practice and Emergency Medicine pulmonary disease were enrolled in the study. Patan Academy of Health Sciences, Lalitpur, Nepal Results: Out of 338 patients with clinical diagnosis of chronic obstructive Email: [email protected] pulmonary disease that underwent spirometry, 80 (23.7%) patients had ratio of forced expiratory volume in one second and forced vital capacity less than 70%. Peer Reviewed by Dr. Vivek Todi Out of these 80 patients, 50 (14.8%) had irreversible airway obstruction and Patan Academy of Health Sciences 30 (8.9%) had reversible airway obstruction. Patient with normal spirometry Email: [email protected] findings was 258(76.3%).

Dr. Jay N Shah Conclusions: Clinically diagnosed chronic obstructive pulmonary disease is Patan Academy of Health Sciences best confirmed by spirometry for optimum management. Email: [email protected] Keywords: chronic obstructive pulmonary disease, pulmonary function, spirometry

Plain Language Summary The study was done to see whether the clinical diagnosis of COPD is accurate of not. The study found that most of the patient diagnosed as COPD did not have the disease on spirometry. So, diagnosis of COPD should always be aided by spirometry before starting long term treatment.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):33-35 33 Ashis Shrestha: Spirometry Findings in COPD

INTRODUCTIONS

According to 2008 Global initiative for chronic lung disease update, clinical diagnosis of Chronic Obstructive Pulmonary Disease (COPD) should be considered in any patient who has dyspnoea, chronic cough or sputum production, or a history of smoking. The diagnosis of COPD should be confirmed by spirometry.1 A cohort in 20052 and 20063 showed that almost half of the patients diagnosed to be COPD clinically did not have the disease.

This study was designed to see the pulmonary function by spirometry for patients diagnosed clinically with COPD.

Figure 1. Frequency distribution in different age group in clinically METHODS diagnosed COPD patients (n=338)

This was a descriptive cross sectional study evaluating obstruction. Mean FEV1/FVC, FEV1 and FVC of patients records of patients with COPD coming for spirometry at with irreversible airway obstruction was 59.7%, 41.4% pulmonary function test unit of Patan Hospital, Patan 70.0% respectively of predicted values, those with Academy of Health Sciences (PAHS), Nepal between reversible airway obstruction had 59.7%, 55.04%, 65.3% June 2012 and May 2013. These patients were clinically respectively of predicted values and those who did not diagnosed as COPD in outpatient department of general require bronchodilator had 94.2%, 59.1% and 63.1% practice and medical department. Ethical approval respectively of predicted values. The differences observed was taken from the institutional review committee of in these three groups were statistically significant for PAHS. Records of all patients consecutively registered FEV1/FVC (p<0.05), FEV1 (p<0.05) and insignificant for at pulmonary function test unit were analyzed. FVC (p=0.1). Similarly in male mean FEV1/FVC, FEV1 and Spriometry diagnosis of COPD was defined as ratio of FVC were 86.02%, 50.6%, 59.7% respectively of predicted forced expiratory volume in one second and forced vital and in female 86.1%, 59.7% and 71.1% of respectively capacity (FEV1/FVC) less than 0.70 and reversibility as of predicted values. The difference in values for male post bronchodilator change in forced expiratory volume and female was statistically not significant for FEV1/FVC in one second (FEV1) more than 0.20 of predicted. (p<=0.9), FVC (p=0.9) and significant for FEV1 (p=0.02). Microsoft Access 2007 was used to record data and On evaluation with non smoking status the values were statistical analysis was done using SPSS 16.0. Student’s 98.4%, 62.1%, 65.04% respectively of predicted values t-test and chi square test were used, p value < 0.05 was and with smoker it was 84.07%, 53.8% and 66.3% taken as statistically significant. respectively of predicted values. The difference in smoker and nonsmoker was statistically significant for FEV1/FVC RESULTS (p<0.05), FEV1 (p=0.02) and insignificant for FVC (p=0.9). Table 1. Difference in spirometry results in clinically diagnosed COPD Out of 409 patients referred for spirometry, 338 patients patients (n=338) in relation to gender with clinical diagnosis of COPD were evaluated while 69 patients with other diagnoses like bronchial asthma, Gender PFT Diagnosis FEV1/FVC % * FEV1 % † FVC % ‡ pneumonia were excluded from the study. Out of 338 Irreversible airway obstruction 59.5 37.7 69.9 study patients, 174 (51.5%) were male and 164 (41.5%) Reversible airway obstruction 59.7 37.02 63.3 female. Mean age was 62.7 years, range 37 to 88 years. Female Smokers were 291 (86.1%) and non smokers 47 (39.9%). Normal § 93.6 54.4 58.6

Out of 338 clinically diagnosed COPD patients, 80 Irreversible airway obstruction 59.8 44.5 75.3 (23.7%) had FEV1/FVC ratio less than 70% while 258 Male Reversible airway obstruction 94.8 64.3 68.1 (76.3%) patients had FEV1/FVC ratio more than 70%. Normal § 94.8 64.3 68.1 Out of these 80 patients, 50 (14.8%) had irreversible airway obstruction and 30 (8.9%) had reversible airway * p<0.9; † p<0.05; ‡ p<0.05; § Reversibility not checked

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):33-35 34 Ashis Shrestha: Spirometry Findings in COPD

Table 2. Difference in spirometry results in clinically diagnosed COPD another cohort study, 184 of the 597 participants had a patients (n=338) in relation to smoking clinical diagnosis of chronic bronchitis or emphysema; 89 Smoking FEV1/FVC FEV1 FVC (48%) of the 184 were confirmed as having COPD with PFT Diagnosis status % * % † % ‡ spirometry, while 95 (52%) did not meet the criteria for Irreversible airway obstruction 59.7 41.0 69.4 COPD.3 This shows that not only in our study but in other Smoker Reversible airway obstruction 59.0 43.7 78.2 parts of the world also many COPD patients are sent for Normal* 92.6 58.0 62.8 spirometry unnecessarily. Irreversible airway obstruction 85.7 50.9 59.3 Non Our study also highlighted the statistically significant Reversible airway obstruction 51.7 28.1 66.0 Smoker difference between FEV1/FVC and FEV1 for normal, Normal* 65.0 65.08 102.5 reversible and irreversible obstruction after controlling * p<0.05; † p=0.02; ‡ p<0.09; § Reversibility not checked the possible confounders like age, sex and smoking status. So, spirometry can be used as a very good tool for Evaluation of different age group and pulmonary function diagnosis, grading and ongoing management of disease. test showed no statistically significant difference on age category with respect to pulmonary function test results (FEV1/FVC: p=0.3, FEV1: p=0.09 and FVC: p=0.9). CONCLUSIONS Clinical diagnosis of COPD needs to be confirmed by DISCUSSIONS spirometry for ongoing management. It should however not be used for screening purpose. Other better tools like Global initiative to prevent lung disease recommends COPD questionnaire should be evaluated for screening spirometry for the diagnosis of COPD.1 However, tool. spirometry is underutilized in many parts of the world. In a study done in US, it was found that spirometry use was 66% in pediatricians, 47% in family practitioners ACKNOWLEDGEMENTS and 60% in internal medicine.4 Another study in Nigeria stated that knowledge and practice of spirometry were We would like to acknowledge Mrs Sarala Shrestha for poor among hospital based Nigerian doctors because of performing pulmonary function test. unavailability of spirometry in most hospitals.5 We found that 258 (76.3%) patients with clinical diagnosis of COPD REFERENCES had normal pulmonary function test result. This shows mismatch between clinical diagnosis and spirometry 1. Global Initiative for Chronic Obstructive Lung Disease. findings. To minimize unnecessary load and misuse of Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. spirometry tests, these patients should be rigorously c2008 [updated 2008 November; cited 2009 June screened by proper clinical tool like COPD population 8]. Available from: URL: http://www.goldcopd.org/ screening questionnaire before sending for pulmonary GuidelinesResources. function test.6 In this line, US Preventive Services Task 2. Bolton CE, Lonescu AA, Edwards PH, Faulkner TA, Edwards Force recommends against screening adults for COPD SM, Shale DJ. Attaining a correct diagnosis of COPD in using spirometry following a systematic review of general practice. Respir Med. 2005;99(4):493-500. evidence of the benefits and harms and an assessment 3. Tinkelman DG, Price DB, Nordyke RJ, Halbert RJ. of the net benefit.7 Misdiagnosis of COPD and asthma in primary care patients 40 years of age and over. J Asthma. A 2005 prospective cohort study in the United Kingdom 2006;43(1):75–80. assessed 125 participants with a previous clinical 4. Blain EA, Craig TJ. The use of spirometry in a primary care setting. International Journal of General Medicine. diagnosis of COPD. When spirometry was used to confirm 2009;2:183-6. the COPD diagnosis, only 61 (49%) met diagnostic criteria. 5. Desalu OO, Busari OA, Onyedum CC, Salawu FK, Obateru Of the remaining participants, 25 (20%) had reversible OA, Nwogu KC, et al. Evaluation of current knowledge, airway obstruction, 5 (4% ) had restrictive obstruction, awareness and practice of spirometry among hospital and 34 (27%) had normal spirometry.2 In our study, out -based Nigerian doctors. BMC pulmonary medicine. of total clinically diagnosed COPD, only 80 (23.7%) had 2009;9:50-8. airway obstruction, of which 50 (14.8%) had irreversible 6. Calverley PM, Nordyke RJ, Halbert RJ, Isonaka S, Nonikov and 30 (8.9%) had reversible airway obstruction. The D. Development of a population-based screening number of patient with normal spirometry in our study questionnaire for COPD. COPD. 2005.2(2):225–32. was 258 (76.3%) in contrast to 34 (27%) in a cohort 7. U.S. Preventive Services Task Force. Screening for chronic obstructive pulmonary disease using spirometry: study mentioned above.2 This raises the possibility of U.S. Preventive Services Task Force Recommendation many patients having spirometry unnecessarily. In yet Statement. Ann Intern Med. 2008;148(7):529-34.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):33-35 35 GENERAL SECTIONRameshwar Mahaseth: Recent Advances in Glucagon Like Peptide-1 & Dipeptidyl Peptidase-4 Inhibitors REVIEW ARTICLE

Incretin System: Recent Advances in Glucagon Like Peptide-1 and Dipeptidyl Peptidase-4 Inhibitors Rameshwar Mahaseth

Department of Internal Medicine, Manmohan Memorial Medical College, Swoyambhu, Kathmandu, Nepal

Abstract ISSN: 2091-2749 (Print) 2091-2757 (Online) The endogenous incretins, glucose-dependent insulinotropic polypeptide and Glucagon-like peptide, are peptide hormones secreted from endocrine cells in the small intestine. Glucagon-like peptide-1 stimulates insulin and suppresses glucagon secretion, delays gastric emptying, and reduces Correspondence: appetite and food intake, which explains the positive effect of incretin Dr. Rameshwar Mahaseth mimetics on weight. The incretins have also been shown to have a sustained Department of Internal Medicine, improvement in glycemic control over three years. A wide range of Manmohan Memorial Medical cardiovascular benefits have also been claimed, such as lowering of blood College & Teaching Hospital pressure and postprandial lipids. Clinical trials with the incretin mimetic (MMTH), Swoyambhu, Kathmandu, exenatide and liraglutide show reductions in fasting and postprandial glucose Nepal concentrations, and haemoglobin A1c (1–2%), associated with weight loss Email: [email protected] (2–5 kg). The most common adverse event associated with Glucagon-like Phone: 9843076992 peptide-1 receptor agonists is nausea, which lessens over time. Orally administered Dipeptidyl Peptidase-4 inhibitors reduce hemoglobin A1c by Peer Reviewed By Dr. Buddhi Paudyal 0·5–1·0%, with few adverse effects and no weight gain. These new classes of Patan Academy of Health Sciences anti-diabetic agents also expand β-cell mass in preclinical studies. However, Email: [email protected] long-term clinical studies are still needed to determine the benefits of incretin for the treatment of type 2 diabetes. Dr. Ashis Shrestha Patan Academy of Health Sciences Keywords: dipeptidyl pedptidase-4 inhibitors, glucagon-like peptide-1 RA, Email: [email protected] glucose-dependent insulino tropic polypeptide, incretin

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):36-42 36 Rameshwar Mahaseth: Recent Advances in Glucagon Like Peptide-1 & Dipeptidyl Peptidase-4 Inhibitors

IntroductionS The metabolic effects of GIP include, in addition to increasing insulin secretion, the following: inhibiting In the 1960s, data suggested that oral glucose elicited a gastric acid secretion; bio-regulating fat metabolism in much greater secretion of insulin than a similar amount adipocytes; increasing glucagon secretion; increasing 1 of glucose administered intravenously and that this β-cell replication; and decreasing β-cell apoptosis.9,10 potentiating of insulin secretion by the gut maybe Under normal physiologic conditions, fasting plasma responsible for up to 70% of the insulin response to a glucose (FPG) is managed by tonic insulin and glucagon 2, 3 meal. This physiologic activity was subsequently secretion, but excursions of pat pran dialglucose are referred to as the intestinal secretion of insulin, or controlled by insulin and the incretin hormones.9 incretin effect. It was later found that two hormones and Several key pathologic abnormalities characteristic of glucagon-like peptide-1 are responsible for the incretin T2DM appear to be related to the biologic activities 3 effect. A key feature of glucagon-like peptide-1 action and functions of incretins. Patients with T2DM have is the glucose-dependent stimulation of insulin secretion impaired incretin function, impaired GLP-1 release, and concomitant suppression of glucagon. Thus, diminished insulinotropic response to GIP, glucoregulatory pharmacologic efforts to develop medications that mimic defects, and impaired glucose homeostasis.6,9 Table 1 the actions of GLP-1 have become a target for improving lists the effects of GLP-1 and GIP on defects in glucose or reversing chronic hyperglycemia. Dipeptidyl-like metabolism, pancreas function, and energy uptake in peptidase-4 inhibitors - sitagliptin and vildagliptin are the patients with T2DM.11 Importantly, the incretin effect in first agents in this class to have received FDA approval, in particular, postprandial production of GLP-1 is impaired addition to saxagliptin and linagliptin. in patients with T2DM. The insulin-secretory response, however, can be restored with pharmacologic doses of The Antidiabetic Actions of Incretin Hormones: As GLP-1.12 knowledge of the pathophysiologic mechanisms of diabetes mellitus has increased, clinical attention Table 1. Action of incretins GLP-1 and glucose dependent insulotrophic has shifted to the incretin system.6 Hormones polypeptide on pathophysiologic defects in patients with type 2 secreted from gastrointestinal endocrine cells play key diabetes mellitus. 11 roles in the control of energy balance by regulating Defects in Type 2 Diabetes Action of Incretins the assimilation, storage, and metabolic processing of 7 Impaired glucose stimulated Restoration of glucose dependent insulinotropic nutrients. Disruption of these endocrine cells disturbs insulin secretion and first phase effect and lack of postparandial biphasic the normal control of insulin production and body response response weight, contributing to the development of Diabetes Hypergluccagonemia Supression of glucagon secretion Mellihas Type 2. Two incretin hormones, GLP-1 and GIP, Defective hypoglycaemia counter Glucagon secretion and loss of insulinotropic are vital to the control of glucose homeostasis through regulation effect, when plasma glucose is low their ability to increase the β-cell insulin response to Increased synthesis of proinsulin, possible ingested glucose.6,7 These hormones are responsible Reduced beta cell mass and insulin increased beta cell mass or differentiation of content for more than 90% of the incretin effect observed after islet precursor cells into beta cells glucose ingestion.6 Possible inhibition of toxin induced beta cell Accelerated beta cell apoptosis apoptosis GLP-1 and GIP are released within minutes of glucose 8 Normal retarded or accelerated absorption to increase insulin secretion. GLP-1 is Slowing of gastric emptying gastric emptying synthesized in L-cells in small bowel and colon, whereas Supression of appetite/increase satiety, weight GIP is secreted by K-cells in the duodenum and proximal Hypercaloric energy intake, obesity jejunum. Both GLP-1 and GIP trigger insulin tropic actions loss by binding to β-cell receptors. GLP-1 receptors are primarily expressed on pancreatic glucagon-containing Incretin-Based Treatment Options: Glucagon-like α, β and δ cells, though they are also widely expressed peptide-1 is rapidly metabolized by the enzyme DPP-4, resulting in the generation of an inactive compound that in the central and peripheral nervous system, lung, 7 heart, and gastrointestinal tract.8,9 GLP -1 and GIP exert makes for a nonviable therapeutic agent. As a result, a multiple biological effects.10 The metabolic effects of number of of GLP-1 homologs (exenatide and lixisenatide) GLP-1 include: inhibiting glucose-dependent glucagon or analogs (liraglutide, dulaglutide, and albiglutide), and secretion from α cells; increasing β-cell proliferation and inhibitors of DPP-4(sitagliptin, vildagliptin, linaglutin and decreasing β-cell apoptosis; slowing gastric emptying; sexagliptin) have been developed as options for treating increasing CNS-mediated satiety leading to reduced patients with T2DM. GLP-1 receptor agonists can food intake; indirectly increasing insulin sensitivity and produce GLP-1 levels that are more than five times a patient’s physiologic levels, and DDP-4 inhibitors result in nutrient uptake in skeletal muscles and adipose tissue; 13 and exerting neuroprotective effects.9,10 an approximate two-fold increase in GLP-1 levels.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):36-42 37 Rameshwar Mahaseth: Recent Advances in Glucagon Like Peptide-1 & Dipeptidyl Peptidase-4 Inhibitors

GLP-1 Receptor Agonists Exenatide (synthetic exendin-4): and HbA1c after once weekly administrations of Its first incretin-related therapy available for patients with exenatide LAR for 15 weeks compared with exenatide type 2 diabetes. It is naturally occurring peptide from twice daily.24 A recent study comparing 2 mg preparation the saliva of the Gila monster and has an approximate of exenatide –LAR given once weekly with conventional 50% amino acid homology with GLP-1. It binds to GLP-1 exenatide 10 mcg given twice daily showed a greater receptors and mimics many properties of GLP-1. GLP-1 is reduction in HbA1c levels with exenatide –LAR and highly degraded within one to two minutes by DPP-IV within one effective with once weekly injection. However, nausea to two minutes of entering the circulation. But exenatide has been reported less frequently with once weekly is resistant to DPP-IV inactivation. Moreover, it is >1000 than with twice daily administration (26% versus 50%).25 times more potent than GLP-1 in circulation. It does not stimulate gastric acid secretion or trigger hepatic vagal Liraglutide: Liraglutide is a GLP-1analogue with 97% efferent. Following injection, it is measurably present sequence identity to the human hormone. Liraglutide in plasma for up to 10 hours and therefore suitable for contains a single amino acid substitution relative to twice a day administration by subcutaneous injection.14 endogenous GLP-1 and is linked to a fatty acid chain, Exenatide is excreted renally so, it is contraindicated in resulting in slow absorption into circulation, increased patients with decreased creatinine clearance (CrCl <30 reversible albumin binding, and reduced susceptibility mL/min) or with end-stage renal disease (ESRD).17 to DPP-4. These effects extend liraglutide’s benefits, Most recently, a multicenter placebo-controlled trial,15 increasing its plasma half-life to 11 to 15 hours.20,21 with evaluated the safety and efficacy of twice-daily exenatide maximal concentration after eight to twelve hours.22 in patients whose T2DM was uncontrolled with insulin Injected once daily, at any time of day, irrespective of glargine, with or without oral antihyperglycemic agents. meals, liraglutide reduced fasting blood glucose and Patients receiving exenatide (n=138) had a mean HbA1c glycemic excursions associated with all meals.14 reduction of 1.74%, compared to 1.04 % in patients In LEAD-1, LEAD-2, and LEAD-4, researchers tested the receiving placebo (n=123) (between-group difference, use of liraglutide combined with glimepiride, metformin, -0.69; 95% confidence interval (CI), -0.93% to -0.46%; or metformin and rosiglitazone, respectively. These p<.001). Body weight decreased by an average of combination regimens reduced mean HbA1c levels 1.8 kg with exenatide and increased by an average of by more than 1% over 26 weeks.27-29 In LEAD-5, once- 1.0 kg with placebo (between-group difference, -2.7 daily liraglutide was compared directly with insulin Kg; 95% CI, -3.7 Kg to -1.7 Kg; p<.001). The incidence glargine in patients receiving concomitant metformin of minor hypoglycemia was similar between the two and glimepiride.30 Liraglutide led to significantly lower groups. The rates of hypoglycemia observed in patients HbA1c levels compared with glargine (p=.0015). As is taking exenatide are largely dependent on the agents commonly observed following transition to insulin,31 with which it is combined. However, patients receiving patients starting glargine gained weight. Convercsely, exenatide experienced higher rates of gastrointestinal those administered liraglutide lost weight, with a adverse effects compared to those receiving placebo.15 difference of 3.5 kg at study’s end.30 The final LEAD study, Two clinical studies18,19 of exenatide (5 μg or 10 μg once LEAD-6, offers a head-to-head comparison between the daily) demonstrated mean increases in the homeostasis two GLP-1 receptor agonists.32 In this study, liraglutide model assessment–β-cell (HOMA-B) index, a commonly and exenatide both significantly reduced1c HbA levels used measure of β-cell function, of 19% at 24 weeks relative to baseline. However, the extent of this reduction and 32% at 30 weeks. In patients with T2DM, exenatide was significantly greater for liraglutide (p<0.0001). normalizes the loss of first-phase insulin secretion and Treatment-associated nausea declined with time for both glucagon hypersecretion from β cells, thereby reducing study arms but persisted longer in patients treated with hepatic glucose production in the postprandial state.16 exenatide. Analysis across the available LEAD studies Guidelines from both the National Institute for Health and shows a consistent improvement in HbA1c levels with Clinical Excellence (NICE) and the Scottish Intercollegiate liraglutide (1.0% to 1.6%), and a very low incidence of Guidelines Network (SIGN) have recommended using hypoglycemic episodes. In addition, liraglutide treatment exenatide and liraglutide as third-line agents in obese was associated with sustained weight loss, systolic blood (body mass index (BMI) >30 kg/m2) patients who do not pressure reduction, and improved β-cell function.29,30, 32 meet glycaemic targets on a combination of metformin There have been reports suggesting that both treatments and a sulphonylurea. with exenatide,33 and liraglutide,34 the most common GLP- Long Acting Exenatide: Preliminary experience with 1 receptor agonists, are associated with an increased risk exenatide LAR in 45 patients with type 2 diabetes indicates of pancreatitis. As chronic pancreatitis is also a known a much greater reduction in fasting glucose concentrations risk factor for pancreatic cancer through cytotoxicity

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):36-42 38 Rameshwar Mahaseth: Recent Advances in Glucagon Like Peptide-1 & Dipeptidyl Peptidase-4 Inhibitors of inflammatory cytokines, reactive oxygen species, undergoing dialysis. For patients with moderate renal and proliferation,35 there might be an increased risk of insufficiency (Crcl 30-50 ml/min), the sitagliptin dose pancreatic cancer as well. It has also been observed in should be reduced to 50 mg. For patients with severe preclinical studies that incidence of thyroid C- cell tumors renal insufficiency (Crcl <30 ml/min) or end-stage was increased in rodents treated with GLP-1 analogs.36 renal disease, a sitagliptin dose reduction to 25 mg is Therefore, monitoring f or thyroid cancer has been a indicated.44 Vildagliptin is not recommended for use in focus in the clinical development plans of all DPP-4 moderate renal failure. inhibitors and GLP-1 receptor agonists, but thus far the Saxagliptin: Saxagliptin is another DPP-4 inhibitor data have been reassuring. approved by FDA for the treatment of patients with Taspoglutide: Another extended release molecule works T2DM.45 It is a potent, reversible, competitive agent on a once weekly basis promising results in phase 2 that selectively inhibits DPP-4.46 As with sitagliptin, studies. Tapsoglutide has a 93% homology to endogenous saxagliptin exerts its glucoregulatory actions through GLP-1. The development of tapsoglutide was recently prevention of incretin degradation, leading to discontinued because of hypersensitivity concerns, potentiation of GLP-1 and GIP action.46 The efficacy of an effect that has not been seen with any of the other saxagliptin has been studied as monotherapy and in approved or experimental GLP-1 mimetics. combination with metformin, sulfonylureas, and TZDs. During 24 to 102 weeks of treatment with saxagliptin, Albiglutide: It is a human GLP-1 receptor agonists with glycemic efficacy has been demonstrated in patients two molecules of GLP-1 linked to albumin. The half life is with T2DM regardless of age, gender, race/ethnicity, or about five days making once weekly dosing possible. In body weight.46 When used as monotherapy, saxagliptin phase 2 trials, HbA1c reduction observed after 16 weeks 5 mg once daily produced mean HbA1c reductions of were similar for dosages 30 mg weekly, 50 mg bi-weekly 0.5% to 0.7%.46,47 When used in combination with and 100 mg monthly. traditional oral hyperglycemic agents, saxagliptin 5 mg DPP4 Inhibitors: Oral DPP4 inhibitors increase the once daily (as add-on therapy or as initial combination availability of endogenous GLP-1, thus enhancing glucose- therapy) provided clinically important reductions in induced insulin secretion and inhibiting glucagon release. HbA1c level.46 Saxagliptin, when used with metformin, These agents have no effect on gastric emptying,38, 39 and produced mean reductions in HbA1c levels of 0.7% do not affect body weight.37 to 2.5%,53,54 when used with a sulfonylurea, HbA1c mean reduction was 0.6% 60; and when used with a TZD, Sitagliptin and Vildagliptin: Sitagliptin and vildagliptin HbA1c mean reduction was 0.9%.48 are the first agents in this class to have received FDA approval. Sitagliptin is potent, highly selective, reversible The usual dose of saxagliptin is 2.5 or 5 mg once daily, and competitive inhibitor of DPP-4 enzyme and exerts its with 2.5 mg dose recommended for patients with anti-hyperglycemic effect by slowing the inactivation of moderate to severe kidney disease (CrCl <50 mL/min) incretin hormones. Sitagliptin has been associated with and for patients taking strong CYP3A4/5 inhibitors, an approximate two-fold increase in postprandial GLP-1 such as ketoconazole.46 The most common adverse plasma concentrations, compared to placebo in healthy events observed with saxagliptin are similar to those of human study participants and in patients with T2DM.40,41 sitagliptin, such as headache, nasopharyngitis, upper A comprehensive meta-analysis of trials of once-daily respiratory tract infections, and urinary tract infections.46 sitagliptin (available in Canada and elsewhere) or twice- Linagliptin: In May 2011, linagliptin became the latest daily vildagliptin (marketed in Europe) concluded that DPP-4 inhibitor to be approved by the FDA for the these agents were well tolerated,42 although infections treatment of patients with T2DM.49 Similar to sitagliptin including nasopharyngitis, upper respiratory tract and saxagliptin, linagliptin is a potent, highly selective, infections, and urinary tract infections, were significantly DPP-4 inhibitor.50 In approximately 4000 patients with increased with sitagliptin (relative risk 1.15 compared T2DM in clinical trials, linagliptin as monotherapy or in with placebo 95% confidence interval 1.02 to 1.31;p=.03). combination with other oral antihyperglycemic drugs They are indicated as monotherapy and in combination was generally well tolerated, with a low incidence of with metformin, thiazolidinedione (TZD) and insulin. hypoglycemia.50 The usual dose of linagliptin is 5 mg Headache was reported for both drugs but was more once daily. No dose adjustment is needed in patients common in patients taking vildagliptin.42 with renal or hepatic impairment. Inducers of CYP3A4 Because sitagliptin is cleared by the kidneys, dosage (eg Rifampin) may decrease the efficacy of linagliptin. adjustments are recommended in patients with Therefore, patients requiring such drugs should receive moderate to severe renal insufficiency and in patients an alternative to linagliptin.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):36-42 39 Rameshwar Mahaseth: Recent Advances in Glucagon Like Peptide-1 & Dipeptidyl Peptidase-4 Inhibitors

Table 2. Comparison of DPP-4 and GLP-1 RAs.52 agonists work in a glucose-dependent manner, they are DPP-4 likely to reduce hyperglycemia safely, without a marked Effects/parameters inhibitors GLP-1 receptor agonists fluctuation toward hypoglycemia. In the process of acutely restoring β-cell function, GLP-1 agonists may allow Route of administration Oral Subcutaneous injection patients to achieve 1cHbA <7%, without experiencing Dose/timing of Once or twice daily or once weight gain or hypoglycemia. These incretin-based administration Once daily weekly medications demonstrate improved efficacy and safety A1c reduction 0.5%-1.0% 0.6-1.9% relative to traditional agents, and they represent a major paradigm shift in the treatment of patients with diabetes Body weight Neutral Reduced mellitus and might be considered as first-line therapy Hypoglycemic Low incidence Low incidence after metformin, and insulin therapy (mainly long-acting Insulin secretion Enhanced Enhanced analogs) could be added if A1C is not at target, mainly when fasting or pre-prandial glucose levels are high. The Post prandial hyperglycemia Reduced Reduced safety of constant DPP-4 or GLP-1therapy over time is Glucagon secretion Suppressed Suppressed not yet fully clear. Presently, the benefits of using DPP- 4 inhibitors or GLP-1 receptor agonists for treatment of Appetite No effect Suppressed type 2 diabetes outweigh the risks. Nonetheless, their Gastric emptying No effect Slowed (Short acting agent) safety profile should be monitored and their indications should be widened cautiously. Gastrointestinal None Nausea, diarrhea, vomiting

GLP-1Receptor Agonists versus DPP-4 Inhibitors: Various Acknowledgments similarities and differences exist between GLP-1 receptor agonists and DPP-4 inhibitors.51,52 Among the differences I thank Prof Dr G.P. Acharya & Dr Nandita Acharya, MD- between these two drug classes, GLP-1 receptor agonists Dept of Internal Medicine, Manmohan Memorial Medical are administered via subcutaneous injection, while DPP- College and Dr Mahesh, DM- Dept of Endocrinology, CMC- 4 inhibitors are delivered as oral tablets. Glucagon-like Vellore, for their editorial assistance and contributing to peptide-1 receptor agonists are probably more effective the literature review. than DPP-4 inhibitors at reducing HbA1c levels (Table2).52 Glucagon-like peptide-1 receptor agonists help preserve References β cells, which are diminished with DPP-4 inhibitors; induce weight loss, unlike DPP-4 inhibitors; and have 1. Perley MJ, Kipnis DM. Plasma insulin responses to oral beneficial effects on blood pressure that, have not been and intravenous glucose: studies in normal and diabetic demonstrated with DPP-4 inhibitors.51,52 sujbjects. J Clin Invest. 1967 Dec;46(12):1954-62. 2. Nauck MA, Busing M, Orskov C, Siegel EG, Talartschik J, et al. Preserved incretin effect in type 1 diabetic patients Future developments with end-stage nephropathy treated by combined heterotopic pancreas and kidney transplantation. Acta Many new incretin-based agents are under investigation Diabetol. 1993;30:39–45. for the treatment of patients with T2DM. Albiglutide, 3. Holst JJ, Vilsboll T, Deacon CF. The incretin system and exenatide LAR, and lixisenatide are investigational GLP-1 its role in type 2 diabetes mellitus. Mol Cell Endocrinol. receptor agonists in late stages of clinical development.55 2009;297:127–36. Liraglutide and exenatide are first-generation GLP-1 4. Langley AK, Suffoletta TJ, Jennings HR. Dipep-tidyl receptor agonists, requiring once or twice daily parenteral peptidase IV inhibitors and the incretin system in type 2 administration, respectively. Much effort continues to be diabetes mellitus. Pharmacotherapy. 2007;27(6):1163- directed towards improvement of the pharmacokinetic 80. profile of GLP-1R agonists, to minimize peak levels of the 5. Pinkney J, Fox T, Ranganath L. Selecting GLP-1agonists drug and thus reduce the extent of nausea. Longer-acting in the management of type 2 diabetes: dif-ferential GLP-1R agonists should ideally provide more uniform pharmacology and the therapeutic benefits of liraglutide and sustained GLP-1R activation over a 24-h period, but and exenatide. Ther Clin Risk Manag. 2010;6:401-11. require less frequent administration. 6. Drucker DJ, Nauck MA. The incretin system: glucagon- like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors in type 2 diabetes. Lancet. ConclusionS 2006;368(9548):1696-705. 7. Freeman JS. Role of the incretin pathway in the The treatment of patients with T2DM remains complex pathogenesis of type 2 diabetes. Cleve Clin J Med. and challenging for physicians. Because GLP-1 receptor 2009;76(suppl 5):S12-S19.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):36-42 40 Rameshwar Mahaseth: Recent Advances in Glucagon Like Peptide-1 & Dipeptidyl Peptidase-4 Inhibitors

8. Baggio LL, Drucker DJ. Biology of incretins: GLP-1 and GIP. 22. Kim D, MacConnell L, Zhuang D, et al. Safety and efficacy Gastroenterology. 2007;132(6):2131-57. of a once-weekly, long-acting release formulation of 9. Khoo J, Rayner CK, Jones KL, Horowitz M. Incretin-based exenatide over 15 weeks in patients with type 2 diabetes. therapies: new treatments for type 2 diabetes in the new Diabetes. 2006;55(suppl 1):116. millennium. Ther Clin Risk Manag. 2009;5(3):683-98. 23. Chakraborti CK. Exenatide: A new promising antidiabetic 10. Drab SR. Incretin-based therapies for type 2 diabetes agent. Indian J Pharm Sci. 2010 Jan-Feb;72(1):1–11. mellitus: current status and future prospects. 24. Buse JB, Rosenstock J, Sesti G, et al. Liraglutide once a Pharmacotherapy. 2010;30(6):609-24. day versus exenatide twice a day for type 2 diabetes: a 11. Fonseca VA, Zinman B, Nauck MA, Goldfine AB, 26-week randomised, parallel-group, multinational, open- Plutzky J. Confronting the type 2 diabetes epidemic: the label trial (LEAD-6). Lancet. 2009;374:39–47. emerging role of incretin-based therapies. Am J Med. 25. Marre M, Shaw J, Brandel M, Bebakar WM, Kamaruddin 2010;123(7):S2-S10. NA, Strand J, et al. Liraglutide, a once-daily human GLP- 12. Paul ES, Lawrence AL, Subodh V. The incretin system 1 analogue, added to a sulphonylurea over 26 weeks and cardiometabolic disease. Can J Cardiol. Feb produces greater improvements in glycaemic and weight 2010;26(2):87–95. control compared with adding rosiglitazone or placebo in 13. Buse JB, Bergenstal RM, Glass LC, et al. Use of twice -daily subjects with type 2 diabetes (LEAD-1 SU). Diabet Med. exenatide in Basal insulin –treated patients with type 2009;26(3):268-78. 2 diabetes: a randomized, controlled. Ann Intern Med. 26. Nauck M, Frid A, Hermansen K, Shah NS, Tankova 2011;154(2):103-12. T, Mitha IH, et al. Efficacy and safety comparison of 14. Neumiller JJ. Differential chemistry (structure), liraglutide, glimepiride, and placebo, all in combination mechanism of action, and pharmacology of GLP-1 with metformin, in type 2 diabetes: the LEAD (Liraglutide receptor agonists and DPP-4 inhibitors. J Am Pharm Assoc. Effect and Action in Diabetes)-2 Study. Diabetes Care. 2009;49(suppl 1):S16-S29. 2009;32(1):84-90. 15. Drab SR. Incretin-based therapies for type 2 diabetes 27. Zinman B, Gerich J, Buse JB, Lewin A, Schwartz S, Raskin mellitus: current status and future prospects. P, et al. Efficacy and safety of the human GLP-1 analog Pharmacotherapy. 2010;30(6):609-24. liraglutide in combination with metformin and TZD in 16. Zinman B, Hoogwerf BJ, Duran Garcia S, et al. The patients with type 2 diabetes mellitus (LEAD-4 Met+TZD). effect of adding exenatide to a thiazolidinedione in Diabetes Care. 2009;32(7):1224-30. suboptimally controlled type 2 diabetes: a randomized 28. Russell-Jones D, Vaag A, Schmitz O, Sethi BK, Lalic N, trial. Ann Intern Med. 2007;146(7):477-85. Antic S, et al. Liraglutide vs insulin glargine and placebo in 17. Moretto TJ, Milton DR, Ridge TD, et al. Efficacy and combination with metformin and sulfonylurea therapy in tolerability of exenatide monotherapy over 24 weeks in type 2 diabetes mellitus (LEAD-5 met+SU): a randomised antidiabetic drug-naïve patients with type 2 diabetes: a controlled trial. Diabetologia. 2009;52(10):2046-55. randomized, double-blind, placebo-controlled, parallel- 29. Davies M, Lavalle-Gonzalez F, Storms F, Gomis R. Initiation group study. Clin Ther. 2008;30(8):1448-60. of insulin glargine therapy in type 2 diabetes subjects 18. Knudsen LB, Nielsen PF, Huusfeldt PO, Johansen NL, suboptimally controlled on oral antidiabetic agents: Madsen K, Pedersen FZ, et al. Potent derivatives of results from the AT.LANTUS trial. Diabetes Obes Metab. glucagon-like peptide-1 with pharmacokinetic properties 2008;10(5):387-99. suitable for once daily administration. J Med Chem. 30. Garber A, Henry R, Ratner R, Garcia-Hernandez PA, 2000;43(9):1664-9. Rodriguez-Pattzi H, Olvera-Alvarez I, et al. Liraglutide 19. Degn KB, Juhl CB, Sturis J, Brock B, Chandramouli V, versus glimepiride monotherapy for type 2 diabetes Rungby J, et al. One week’s treatment with the long- (LEAD-3 Mono): a randomised, 52-week, phase acting glucagon-like peptide 1 derivative liraglutide III, double-blind, parallel-treatment trial. Lancet. (NN2211) markedly improves 24-h glycemia and α- 2009;373(9662):473-81. and β-cell function and reduces endogenous glucose 31. Denker PS, Dimarco PE. Exenatide (exendin -4)-in duced release in patients with type 2 diabetes. Diabetes. pancrea titis: a case report. Diabetes Care. 2006;29:471. 2004;53(5):1187-94. 32. Buse JB , Rosenstock J, Sesti G, et al . LEAD -6 Study 20. Elbrønd B, Jakobsen G, Larsen S, Agersø H, Jensen LB, Group. Liraglutide once a day versus exenatide twice a Rolan P, et al. Pharmacokinetics, pharmacodynamics, day for type 2 diabetes: a 26 -week randomised, parallel safety, and tolerability of a single-dose of NN2211, a long- -group, multi-national, open -label trial (LEAD -6). Lancet. acting glucagon-like peptide 1 derivative, in healthy male 2009;374:39–47. subjects. Diabetes Care. 2002;25(8):1398-404. 33. Rebours V, Boutron -Ruault MC, Schnee M, et al. The 21. Garber A, Henry R, Ratner R, Garcia-Hernandez PA, natural history of hereditary pancreatitis: a national Rodriguez-Pattzi H, Olvera-Alvarez I, et al. Liraglutide series. Gut. 2009;58:97–103. versus glimepiride monotherapy for type 2 diabetes 34. Bjerre Knudsen L, Madsen LW, Andersen S, et al. GLP- 1 (LEAD-3 Mono): randomised, 52-week, phase receptor agonists activate rodent thyroid C-cells causing III, double-blind, parallel-treatment trial. Lancet. calcitonin release and C-cell proliferation. Endocrinology. 2009;373(9662):473-81. 2010;151:1473–86.

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35. Richter B, Bandeira-Echtler E, Bergerhoff K, Lerch CL. 47. Tradjenta (linagliptin) tablets [prescribing infor-mation]. Dipeptidyl peptidase-4 (DPP-4) inhibitors for type Ridgefield, CT: Boehringer Ingelheim; 2011. http: // hcp. 2 diabetes mellitus. Cochrane Database Syst Rev. trad jenta. com /prescribing information.jsp. Accessed 2008;(2):CD006739. May 18, 2011. 36. Ahrén B. Dipeptidyl peptidase-4 inhibitors: clinical data 48. Scott LJ. Linagliptin in type 2 diabetes mellitus. Drugs. and clinical implications. Diabetes Care 2007;30(6):1344- 2011;71(5):611-24. 50. 49. Drucker DJ, Sherman SI, Gorelick FS, Bergenstal RM, 37. Holst JJ, Deacon CF. Inhibition of the activity of dipeptidyl- Sherwin RS, Buse JB. Incretin-based therapies for the peptidase IV as a treatment for type 2 diabetes. Diabetes. treatment of type 2 diabetes: evaluation of the risks and 1998;47(11):1663-70. benefits. Diabetes Care. 2010;33(2):428-33. 38. Freeman JS. Role of the incretin pathway in the 50. Macconell L, Pencek R, Li Y, Maggs D, Porter L. Exenatide pathogenesis of type 2 diabetes. Cleve Clin J Med. once weekly: sustained improvement in gly- ycemic 2009;76(suppl 5):S12-S19. control and cardiometabolic measures through 3 years. 39. Herman GA, Stevens C, Van Dyck K, et al. Diabetes Metab Syndr Obes. 2013;6:31–41. Pharmacokinetics and pharmacodynamics of sitagliptin, 51. Nauck M, Frid A, Hermansen K, et al. LEAD-2 Study an inhibitor of dipeptidyl peptidase IV, in healthy Group. Efficacy and safety comparison of liraglutide, subjects: results from two randomized, double-blind, glimepiride, and placebo, all in combination with placebo-controlled studies with single oral doses. Clin metformin, in type 2 diabetes: the LEAD (liraglutide Pharmacol Ther. 2005;78(6):675-88. effect and action in diabetes)-2 study. Diabetes Care. 40. Richter B, Bandeira-Echtler E, Bergerhoff K, Lerch 2009;32(1):84-90. CL. Dipeptidyl peptidase-4(DPP-4) inhibitors for type 52. Jadzinsky M, Pfützner A, Paz-Pacheco E, Xu Z, Allen E, 2 diabetes mellitus. Cochrane Database Syst Rev. Chen R, et al. Saxagliptin given in combination with 2008;(2):CD006739. metformin as initial therapy improves glycemic control 41. Elashoff M, Matveyenko AV, Gier B, Elashoff R, in patients with type 2 diabetes compared with either Butler PC. Pancreatitis, pancreatic, and thyroid monotherapy: a randomized controlled trial. Diabetes cancer with glucagon-like peptide-1-based therapies. Obes Metab. 2009;11(6):611-22. Gastroenterology. 2011;141:150–6. 53. De Fronzo RA, Hissa M, Garber AJ, et al. Saxagliptin 42. Gallwitz B. The evolving place of incretin-based therapies 014 Study Group. The efficacy and safety of in type 2 diabetes. Pediatr Nephrol. 2010;25(7):1207- saxagliptin when added to metformin therapy in 17. patients with inadequately controlled type 2 diabetes 43. Onglyza (saxagliptin) tablets [prescribing information]. on metformin alone. Diabetes Care. 2009;32(9):1649-55. Princeton, NJ: Bristol-Myers Squibb; 2009. http:// 54. Search for clinical trials. US National Institutes of Health packageinserts.bms.com/pi/pi_onglyza.pdf. Accessed ClinicalTrials.gov Web site. http://clinical trials.gov/. March 15, 2011. Accessed July 1, 2011. 44. Kulasa K, Edelman S. Saxagliptin: the evidence for its place 55. Ban K, Hui S, Drucker DJ , Husain M. Cardiovascular in the treatment of type 2 diabetes mel-litus. Core Evid. consequences of drugs used for the treatment of 2010;5:23-37. diabetes: potential promise of incretin-based therapies. J 45. Rosenstock J, Aquilar-Salinas C, Klein E, Nepal S, List J, Am Soc Hypertens. 2009;3:245–59. Chen R. Effect of saxagliptin monotherapy in treatment- 56. Reid T. Diabetes. 2012;(30)1: 3-12; scheen AJ. Eur J Int naïve patients with type 2 diabetes. Curr Med Res Opin. Med. 2012;23(2):126-131; Rosenstok J, et al: Int J Clin 2009;25(10):2401-11. Pract Suppl. 2008;(159):15-23. 46. Hollander P, Li J, Allen E, Chen R. Saxagliptin added to a thiazolidine-dione improves glycemic control in patients with type 2 diabetes and inadequate control on thiazolidinedione alone . J Clin Endocrinol Metab. 2009;94(12):4810-9.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):36-42 42 GENERAL SECTION Kamal Koirala: Perforated jejunal diverticulum CASE REPORT

Perforated Jejunal Diverticulum - an Unusual Presentation Kamal Koirala,1 Mahesh Khakurel,1 Reetu Barai2

1Department of Surgery, 2Department of Pathology, KIST Medical College and Teaching Hospital, Lalitpur, Nepal

Abstract ISSN: 2091-2749 (Print) 2091-2757 (Online) Jejunal diverticula are rare and usually asymptomatic. Acute complications may include haemorrhage, diverticulitis, obstruction, abscess formation and perforation.

Here we report a case of 61 years lady who presented with generalized Correspondence: abdominal pain, vomiting and fever. There were features of acute peritonitis Dr. Kamal Koirala on examination. Exploratory laparotomy revealed a perforated jejunal Department of Surgery diverticulum. Resection of the jejunal segment containing the perforated KIST Medical College and Teaching diverticulum and primary anastomosis was done. Histopathological Hospital, Lalitpur, Nepal examination revealed jejunal diverticulum with pinhole perforation. Email: [email protected] Keywords: acute abdomen, diverticular perforation, jejunal diverticulum, Peer Reviewed By small bowel diverticular disease Dr. Vivek Todi Patan Academy of Health Sciences Email: [email protected]

Dr. Sumana Bajracharya Patan Academy of Health Sciences Email: sumanabajracharya@pahs. edu.np

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):43-45 43 Kamal Koirala: Perforated jejunal diverticulum

INTRODUCTIONS wall and are usually multiple, arising on the mesenteric border where the arteries enter the intestine, contrary 1 Jejunal diverticula are rare clinical entities. The majority to the true congenital Meckel’s diverticulum. Their of cases are asymptomatic. Only a few cases present size varies from a few millimetres to more than 10 with chronic non-specific abdominal symptoms and cm and they occur in greatest number in the oral part acute complications, including haemorrhage, intestinal of the small bowel and they also tend to be larger.6 In 2-5 obstruction, diverticulitis and perforation. Because of our case also, the diverticulum was originating on the the rarity of the disease and its complications, diagnosis mesenteric border of the jejunum and was 5 cm in size 6 is difficult and delayed. We are presenting a rare case of with perforation at tip. The predominance of diverticula perforated jejunal diverticulum. in the jejunum is attributed to the greater diameter of the penetrating jejunal arteries.1 CASE REPORT Acute complications like infection, haemorrhage, A 61 years lady with abdominal pain of three days and obstruction and perforation require prompt 2-5 two episodes of vomiting presented to the emergency management. Most frequent acute complication department of KIST Medical College, Kathamandu, of the jejunoileal diverticula is diverticulitis with or 1 Nepal. She was ill looking, dehydrated and febrile (1010F) without perforation, occurring in 2.3 % to 6.4 of cases. with heart rate of 110 bpm, blood pressure of 90/50 Complications or symptoms requiring surgery have been 1 mmHg. There was generalized abdominal tenderness, reported to occur in up to 10 %. Chronic symptoms more prominent at right iliac fossa. White cell count include abdominal pain, nausea, vomiting, flatulence and 4,7 was elevated (16 × 109/L) with neutrophils 87%. Other diarrhoea or malabsorption, but these are non-specific. laboratory tests were normal. Supine abdominal X-ray The incidence of jejuno-ileal diverticula is reported to be displayed multiple dilated loops of small bowel. Chest 0.5% to 2.3% in small-bowel contrast studies and 0.3% 3,4 X-ray revealed free gas under diaphragm. Ultrasonography to 4.5% in autopsy studies. Owing to their mesenteric of abdomen showed dilated small bowel with minimal location, they may frequently be overlooked at operation pelvic collection. Patient was resuscitated (intravenous and autopsy fluid, antibiotic Ceftriaxone and Metronidazole, Foley Jejunal diverticulosis, unlike colonic diverticulosis is catheterization) for emergency laparotomy with not associated with surrounding diverticulitis10 as we diagnosis of appendicular perforation. found intra-operatively (Figure 1) and was confirmed on Intra-operative findings revealed a solitary jejunal histopathological report (Figure 2). diverticulum of 5×52 cm with pinhole perforation The elderly woman in our case with rare disease of (Figure.1) at two feet from the duodeno-jejunal flexor, jejuno-ileal diverticula presented with acute perforation swollen appendix and minimal amount of pus in the peritonitis and was successfully managed with resection peritoneal cavity. Appendectomy, segmental resection anastomosis during emergency laparotomy. of the jejunum and primary jejuno-jejunal anastomosis were carried out. Peritoneal lavage was done with warm normal saline and abdomen was closed with tube drains in pelvis and in vicinity of anastomosis. Histopathology revealed the jejunal diverticulum with pinhole perforation (Figure.2). She made an uneventful recovery and was discharged on the 9th post operative day.

DISCUSSIONS

Our patient was diagnosed with perforated appendix and underwent laparotomy. Only during surgery we found perforated jejunal diverticulum. The diagnosis of complicated or uncomplicated jejunal diverticulitis is seldom made before exploratory laparotomy or diagnostic laparoscopy.7, 8 Small bowel diverticula are rare.1,4,9 These diverticula are classified as acquired diverticula.10 They are formed by herniation of mucosa Figure 1. Cut surface of surgical specimen showing jejunal diverticulum and submucosa through the muscular layer of the bowel with pinhole perforation

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):43-45 44 Kamal Koirala: Perforated jejunal diverticulum

3. Ross CB, Richards WO, Sharp KW, Bertram PD, Schaper PW. Diverticular disease of the jejunum and its complications. Am Surg. 1990;56:319–24. 4. Longo WE, Vernava AM 3rd. Clinical implications of jejunoileal diverticular disease. Dis Colon Rectum. 1992;35:381-8. 5. de Bree E, Grammatikakis J, Christodoulakis M, Tsiftsis D. The clinical significance of acquired jejunoileal diverticula. Am J Gastroenterol. 1998;93:2523–8. 6. Lempinen M, Salmela K, Kemppainen E. Jejunal diverticulosis: a potentially dangerous entity. Scand J Gastroenterol. 2004; 39: 905–9. 7. Chiu EJ, Shyr YM, Su CH, Wu CW, Lui WY. Diverticular disease of the small bowel. Hepatogastroenterology. 2000;47:181–4. 8. Cross MJ, Snyder SK. Laparoscopic-directed small bowel Figure 2. Histopathology of jejunal diverticulum resection for jejunal diverticulitis with perforation. J Laparoendosc Surg. 1993;3:47–9. References 9. Gross SA, Katz S. Small bowel diverticulosis: an overlooked entity. Curr Treat Options Gastroenterol. 2003;6:3–11. 1. Tsiotos GG, Farnell MB, Ilstrup DM. Nonmeckelian jejunal 10. Joseph S Butler, Christopher G Collins, Gerard P McEntee. or ileal diverticulosis: an analysis of 112 cases. Surgery. Perforated jejunal diverticula: a case report. Journal of 1994;116:726–32. Medical Case Reports. 2010;4:172. 2. Wilcox RD, Shatney CH. Massive rectal bleeding from jejunal diverticula. Surg Gynecol Obstet. 1987;165:425–8.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):43-45 45 GENERAL SECTION Binita Pradhan: Ruptured Uterus Requiring Emergency Hysterectomy CASE REPORT

Ruptured Uterus Requiring Emergency Hysterectomy for Saving Mother Binita Pradhan,1 Anagha Pradhan2

1Assistant Professor, 2Lecturer, Department of Gynecology and Obstetrics, Patan Academy of Health Sciences, Lalitpur, Nepal

ISSN: 2091-2749 (Print) Abstract 2091-2757 (Online) A 26 years woman with G3P2L0AO at 40 weeks and 6 days of gestation, but no antenatal clinic visit history presented to Gynecology and Obstetrics out patient clinic complaining decreased feeling of fetal movement since Correspondence: 2 days. Ultrasonography examination revealed fetal demise with amniotic Dr. Binita Pradhan fluid volume of 28 cm. Emergency lower segment caesarean section for ante Assistant Professor, Department of partum hemorrhage was done. A vertical rupture of the posterior aspect of Gynecology and Obstetrics the uterus from fundus upto the level of cervix with hemoperitoneum of Patan Academy of Health Sciences, two liters was detected. A macerated dead fetus weighing 3.5 Kg was lying Lalitpur, Nepal in the peritoneal cavity and the placenta was already partially separated. Email: [email protected] The mother after hysterectomy was treated in ICU for two days with antihyperglycemic agent additionally and discharged. Peer Reviewed by Dr. Ram Krishna Dulal Keywords: hemoperitoneum, hysterectomy, misoprostol, rupture uterus Patan Academy of Health Sciences Email: [email protected]

Dr. Jay N Shah Patan Academy of Health Sciences Email: [email protected]

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):46-48 46 Binita Pradhan: Ruptured Uterus Requiring Emergency Hysterectomy

IntroductionS Intraoperative findings revealed two litres of blood in peritoneal cavity and vertical rupture of the posterior A cesarean hysterectomy is very different from a non- aspect of the uterus from fundus down to cervix pregnant hysterectomy. It is uncommon emergency, extending laterally towards the right tuboovarian vessels. life-threatening conditions that are stressful to everyone A macerated male dead fetus weighing 3.5 Kg was 1 involved. lying in the peritoneal cavity with head still within the uterus with placenta partially separated. Due to active Uterine rupture (UR) during pregnancy is a rare bleeding, repair was not possible and the obstetrics obstetrics complication. Spontaneous rupture can occur team proceeded for hysterectomy after consent from in previously scared uterus following curettage, manual her husband. The left tube and ovary was conserved. removal of placenta, grandmultipara, congenital anomaly. Four pints of blood was transfused during the operation Iatrogenic rupture may occur with the use of oxytocin, due to blood loss. Then, the patient was treated in ICU. prostaglandins/misoprostol, forcible external version Hematocrit was 18%. Insulin was administered at 1 unit/ or trauma. Rupture of the uterus occurs in 1 per 15000 hour for 2 days while ICU stay. Blood sugar monitoring deliveries. Unscarred uterine rupture during pregnancy is was done six hourly. Then the patient was transferred 1 (0.0033%) per 30,764 deliveries .2 Overall incidence of to the general gynae/ obstetrics ward and treated with pregnancy related uterine rupture is 1 (0.07%) per 1,416 insulin 50:50 12 units before meals and metformin 500 pregnancies.3 mg orally twice daily.

Case Report Patient was discharged after 13 days with metformin 500 mg and advised to come for follow-up after one week. In June 2013, a 26 years woman presented to Gynecology But she didn’t come for follow-up. and Obstetrics out-patient clinic complaining decreased feeling of fetal movement since 2 days. Obstetric history DiscussionS was gravida 3 para 2 with no living issue and 40 weeks plus 6 days of gestation. She had no antenatal clinic visit Uterine rupture is a severe obstetric complication. history. Ultrasonography (USG) examination showed Rupture of the pregnant uterus is a major obstetric intrauterine fetal demise with amniotic fluid volume of complication that occurs often with no warning signs. 28 cc. Her general condition was fair and the vital signs Uterine rupture is a potential complication for patients were within normal limit. On examination per abdomen, with non-scarred uterus as well as scarred uterus.4 uterus was term size with cephalic presentation, head of the fetus was 4/5 palpable with no contraction. On vaginal The choice of surgical procedure depends upon the type, examination, the cervical os was 1.5 cm soft, posterior, extent and location of the rupture as well as the patient’s uneffaced, membrane intact, head of the fetus at -2. condition and desire to preserve her child bearing The patient and her husband were counseled regarding capacity. A retrospective study of uterus rupture, after fetal demise based on the USG report, explained the 28 weeks of pregnancy, for the period of 20 years from necessity of induce labor to prevent further risk to the 1985 to 2005 A.D. admitted in Prashuti Griha (Maternity mother. Induction of labor with misoprostol in two doses Hospital), Nepal was carried out, In 20 years review, of 25 ug per vaginal at 4 hours apart was given. During data indicated that 251 cases with ruptured uterus were reassessment, after 4 hours, cervical os was 3 cm, cervix admitted. Padhye repored that the total incidence of 50% effaced and planned to observe for further progress. RU in her study was 1:1100 deliveries (0.09%) in mostly unbooked (app. 73%) patients. On the total, 70% (n=175) However, in two hours, the patient was found drowsy was complete rupture, incomplete rupture (n=64) 25% with blood pressure 90/50 mmHg. Her random blood and “no mention” in 5% (n=12) cases.5 sugar was 812 mg/dl. On abdominal examination, the uterus was tensed-up with free head of the fetus. On The incidence of unscarred uterus was reported in vaginal examination, the cervix was posteriorly pulled up 1996 ref.. The rupture of unscarred uterus appear to and head of the fetus was felt high up. At the time, fresh occur more frequently in less developed countries due blood was coming out from the cervical os. Then, as to high parity, long labor. Uterine rupture due to use indicated, an emergency surgery was decided considering of misoprostol has been reported but incidence of this the case as ante partum hemorrhage with possibility type is reported. Diagnosis is made by non reassuring of placental abruption. Diabetic ketoacidosis was ruled fetal heart rate pattern, cessation of contractions, out and medical consultation was sought to involve loss of station, tenderness, vaginal bleeding, maternal physicians to manage high blood sugar and hypotension. tachycardia, shock.2 In this case, there was loss of station with vaginal bleeding. According to meta-analysis done

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):46-48 47 Binita Pradhan: Ruptured Uterus Requiring Emergency Hysterectomy from 25 studies from 1976-2012, the rate of spontaneous 3. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse rupture of unscarred uterin in developed countries was 1 DJ, Spong CY. Williams Obstetrics. 23rd ed. New York: per 8,434 pregnancies (0.012%).6 The rupture of uterus McGraw-Hill; c2010. p.574. and expulsion of fetus into the peritoneal cavity, perinatal 4. Yılmaz M, İsaoğlu Ü, Kadanalı S. The evaluation of uterine mortality rate was reported 74-92% and maternal rupture in 61 turkish pregnant women. Eur J Gen Med mortality rate 1-13%.7 Repair is mostly applicable where [Internet]. 2011 [cited 2013 Jan 4];8(3):194-9. Available the margins are clean and is done by excision of the from: URL:http://www.ejgm.org/upload/sayi/15/EJGM- fibrous tissue. Repair and tubal sterilization is mostly 398.pdf 5. Padhye SM. Rupture of the pregnant uterus – A 20 done with a clean-cut scar rupture with completed family year review. Kathmandu University Medical Journal history. In the case of complete rupture, 10-20% required 2005;3(1):234-8 hysterectomy for hemostasis.8 6. Thomas A, Jophy R, Maskhar A, Thomas RK. Uterine rupture in a primigravida with misoprostol used for REFERENCES induction of labour. BJOG. 2003;110(2):217-8. 7. Tang OS, Gemzell-Danielsson K, Ho PC. Misoprostol: 1. Avery DM, Hooper DE, Waits JB. Cesarean hysterectomy pharmacokinetic profiles, effects on the uterus and for family medicine physicians practicing obstetrics. Am J side-effects. International journal of gynaecology and Clin Med. 2009;6(2):68-71. obstetrics. 2007;99 Suppl 2:S160-7. 2. Bennett BB. Uterine rupture during induction of labor 8. Hofmeyr GJ, Say L, Gulmezoglu AM. WHO systematic at term with intravaginal misoprostol. Obstetrics and review of maternal mortality and morbidity: the gynecology. 1997;89(5):832-3. prevalence of uterine rupture. BJOG. 2005;112(9):1221-8.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):46-48 48 GENERAL SECTION Ajaya Kumar Dhakal: Clinical skills Lab: A Need in Nepalese Medical School PERSPECTIVE

Clinical skills Lab: A Need in Nepalese Medical School Ajaya Kumar Dhakal,1 Sanjaya Dhakal2

1Department of Pediatrics, KIST Medical College, Lalitpur, Nepal 2School of Public Health, University of Alberta, Canada

ABSTRACT

Medicine of present world demands high level of competency in both ISSN: 2091-2749 (Print) 2091-2757 (Online) clinical examination and performing a procedure in patients. The traditional methods of bedside skill learning and teaching should be supplemented by instruction in clinical skills lab of basic important clinical skills. Every medical school should work towards establishment and incorporation of clinical skills lab in basics science subjects and clinical posting along with other subjects Correspondence to make it Practice oriented and Student centred learning. Dr. Ajaya Kumar Dhakal Department of Pediatrics Keywords: clinical skills Lab, curriculum, medical education KIST Medical College, Lalitpur, Nepal Email: [email protected]

Peer Reviewed By Dr. Ashis Shrestha Patan Academy of Health Sciences Email: [email protected]

Dr. Sumana Bajracharya Patan Academy of Health Sciences INTRODUCTIONS Email: sumanabajracharya@pahs. edu.np Medical education in Nepal begin with establishment of ayurvedic school in 1933 followed by Civil Medical School for “basic level” health worker in Kathmandu1 However advanced training started with MBBS studies in 1978 and post graduation training in 1982 under Institute of Medicine, Tribhuvan university.1 The opening of new medical schools has helped in production of health manpower at start of 21st century. The majority of these medical school follow traditional classroom lecture along with bedside teaching and lately problem based learning has been started as method of teaching learning activities.2

The three learning principle” knowledge, attitudes and skills” in medical education, are acquired thorough bedside teaching, lectures, demonstration, audiovisual presentation, role play.3 Historically, clinical skills were learned through observation of different procedure for certain period or set number of cases followed by performing same procedure under supervision. In one of studies done among medical students in Nepal, 25% of students were not satisfied with the clinical skills acquire during undergraduate education so that they are not self assured in starting a residency programme.2 Hence clinical skills lab can enrich, supplement, expedite and bridge these learning activities during medical training.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):49-51 49 Ajaya Kumar Dhakal: Clinical skills Lab: A Need in Nepalese Medical School

Clinical skills lab along with traditional bedside teaching Institute of Medicine has mandated the rotation of using modern audiovisual aids are fundamental part of students through clinical skills lab during second year undergraduate curriculum development and medical of medical school, junior internship and at start of education throughout world in present context4 and we internship.8 should also incorporate basic clinical skills lab facilities in our medical education using our own resources for According to the curricula of Institute of Medicine ,the transition to modern medicine. important skills that student will learn in skills lab are clinical skills (rectal examination, Ear examination, gynaecological examination and auscultation of heart PRESENT SCENARIO IN NEPAL sounds and breath sounds) and procedural skills (cardiopulmonary resuscitation and intubation in Nepal Medical Council, an autonomous regulatory neonate, child and adult, peripheral and central venous body for monitoring Medical education in Nepal, in its access, ECG interpretation, umbilical catheterization in publication “Accreditation Standards for MBBS” has laid neonate, pleural aspiration and insertion of chest tube, specific criteria to achieve “The competencies of the wound closure, universal precautions).8 MBBS Graduate” .The guidelines mandates competency of graduates in clinical skills, communication skills, Clinical skills lab not only nurtures clinical skills, but also research, population health and health system, ethics aid in imposing theoretical book knowledge of clinical and information management and instructed all the medicine into clinical practice which is indispensable in 5 medical college to include in undergraduate curriculum. patient management either at an outpatient clinic or during inpatient ward posting.9 Medical student after graduation from medical school, should able to perform basic clinical skills and procedure The importance of clinical skill laboratory can be independently at primary health care setting in any evaluated and defined from Students, Patient and clinical scenario that should leads to early and accurate Physician perspective. Students have to learn much diagnosis and patient management. This vision led to procedure in short time or many times they may not even incorporation of clinical skill lab training as integral part get a chance to perform some procedure due to large of medical education in the revised 2008 curriculum of number of students in a group or a change in pattern 6 Institute of Medicine. of patient management from inpatient to outpatient, as result many students will begin internship training The Institute of Medicine, Tribhuvan University with minimum skill. Those issues can be overcome by Teaching Hospital has started clinical skills lab in 2008 integrating skills lab as a part of learning, which will at Maharajgunj Medical Campus, which is equipped help to enter internship with greater skill, experience, with manikins, models and equipments required to confidence and also reduces stress of internship .10 A train the basic clinical skills. The Skills Lab runs through number of other issues revolving around the patient administrative efforts of National Centre for Health including shortening of hospital stay, ethical issues of Professions Education (NCHPE), situated at Mohego practicing in real patients, and rights of patient can also building. Under guidance of Nepal Medical Council and limit the learning process. Despite of these setbacks, it using the 2008 curriculum of Institute of Medicine, is important to note that the integration of patient in Tribhuvan University as a reference, many other Medical medical educational process will teach students patient Colleges have initiated towards or already implementing management, working in a team for a goal, ethics, clinical skills training for their students. interpersonal relationship and communication skills which will ultimately improve the clinical competence of CLINICAL SKILLS LAB students.11 A Physician overburden in clinical work may not able to devote his time for skill teaching at bedside Clinical skills lab teaches history taking, physical or even at outpatient clinics, which definitely hampers examination, investigation skills, logical diagnostic clinical competence in students and one of the solution approach, medical value, team concept and close loop to these issues could be establishment of clinical skill lab. feedback using effective communication with used of simulators, manikins, simulated patients and case scenarios under the guidance of teacher.7 Clinical Skills ESTABLISHMENT OF CLINICAL SKILLS LAB Lab is designed for teaching and assessing learners The cost of establishment of clinical skill lab will be at different level of skill, experience and expertise in higher for developing countries like ours, as expensive controlled and safe environment, according to individual instrument has to be imported with added administrative needs. To successfully train and achieve the goal of and logistic cost, maintenance cost, added cost for space practiced oriented and student focussed learning,

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):49-51 50 Ajaya Kumar Dhakal: Clinical skills Lab: A Need in Nepalese Medical School and permanent staff dedicated to operation of facilities. 3. Bloom BS, Engelhart MD, Furst EJ, Hill WH, Krathwohl DR. In addition there must be continuing medical education Taxonomy of Educational objective: The classification of 12 and training facilities for faculty. Therefore, we must use educational goals. New york: David Mckay company, Inc; local and socially acceptable available resources along 1956. with judicious use of imported simulation instrument to 4. Al-Yousuf NH. The clinical skills laboratory as a learning teach our students. tool for medical students and health professionals. Saudi medical journal. 2004 May;25(5):549-51. 5. Nepal Medical Council. Accreditation Standards for the WHEN TO INCLUDE MBBS (Bachelor of Medicine and Bachelor of Surgery) Degree Program for Institutions Admitting 100 /150 The Clinical skills lab can be included in preclinical students Annually. Kathmandu,Nepal [cited 2013 years, clinical years with rotation, internship, residency June 10]. Available from: http://www.nmc.org.np/ training program and also as a part of continuing medical downloads/93294.pdf. education. 6. Tribhuvan University Institute of Medicine. Amendments made in the MBBS curriculum (2008). Curriculum for During Preclinical year students are learning basic sciences Bacheolar of Medicine and Bacheolar of Surgery (MBBS). and aren’t exposed to patient directly and inclusion of Maharajgung, Kathmandu, Nepal: Medical Education skills lab during this period will bring better outcomes Department; 2008. 7. Kneebone R, Nestel D. Learning clinical skills – the basic science course along with marked improvement place of simulation and feedback. The Clinical Teacher. in clinical skills, communication skills, acquiring patient 2005;2(2):86-90. 13 medical history and physical examination. Performance 8. Tribhuvan University Institute of Medicine. Course standard of students, assessed with Objective Structural title :Basic clinical Skills. Curriculum for Bacheolar of Clinical Examination(OSCE) , who learned in skills lab Medicine and Bacheolar of Surgery (MBBS). Maharajgung, in addition to traditional learning throughout medical Kathmandhu, Nepal: Medical Education Department; school was significantly higher in comparison to student 2008. p. 215. who were taught in skills lab in final year followed by 12 9. Morgan R. Using clinical skills laboratories to promote month internship. This demonstrate the importance of theory-practice integration during first practice clinical skills lab in clinical years.14 placement: an Irish perspective. Journal of clinical nursing. 2006 Feb;15(2):155-61. PubMed PMID: The skills acquired through the clinical skill lab and its 16422732. 10. Liddell MJ, Davidson SK, Taub H, Whitecross LE. Evaluation application in management of real patients has remained of procedural skills training in an undergraduate a subject of debate and further research. A recent curriculum. Medical education. 2002 Nov;36(11):1035-41. randomized controlled trail found that those students 11. Janicik RW, Fletcher KE. Teaching at the bedside: a new who were trained in skills lab are more professional, can model. Med Teach. 2003 Mar;25(2):127-30. perform procedure faster, had better communication 12. Stark P, Fortune F. Teaching clinical skills in developing skill and provided overall better medical care15 which countries: are clinical skills centres the answer? Education reinforce a previous systematic review which concluded for health. 2003 Nov;16(3):298-306. that skills laboratory training improves procedural skills.16 13. Ali L, Nisar S, Ghassan A, Khan SA. Impact of clinical skill This article also highlighted that most of prior studies did lab on students’ learning in preclinical years. Journal of Ayub Medical College. 2011 Oct-Dec;23(4):114-7. not assess application of skill learn from skill lab in real 16 14. Peeraer G, Scherpbier AJ, Remmen R, De winter BY, patient in a clinic or hospital setting. Hendrickx K, van Petegem P, et al. Clinical skills training in a skills lab compared with skills training in internships: In conclusion the clinical skill lab is supplementary to comparison of skills development curricula. Education for traditional bedside teaching in undergraduate teaching health. 2007 Nov;20(3):125. and we should work towards building a clinical skills lab 15. Lund F, Schultz J-H, Maatouk I, Krautter M, Möltner that is best suited for locally available resources and most A, Werner A, et al. Effectiveness of IV Cannulation importantly dedicated to educate our students. Skills Laboratory Training and Its Transfer into Clinical Practice: A Randomized, Controlled Trial. PLoS ONE. 2012;7(3):e32831. REFERENCES 16. Lynagh M, Burton R, Sanson-Fisher R. A systematic review of medical skills laboratory training: where to from here? 1. Dixit H. Development of medical education in Nepal. Medical education. 2007 Sep;41(9):879-87. KUMJ. 2009 Jan-Mar;7(25):8-10. 2. Marahatta SB, Dixit H. Students’ perception regarding medical education in Nepal. KUMJ. 2008 Apr- Jun;6(2):273-83.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):49-51 51 STUDENT’S SECTION Richa Baniya: Traditional Healing Practices in Rural Nepal PERSPECTIVE

Traditional Healing Practices in Rural Nepal Richa Baniya

4th Year Medical Student, Patan Academy of Health Sciences-School of Medicine, Lalitpur, Nepal

ABSTRACT

Traditional healing practices in rural Nepal has emerged together with its ISSN: 2091-2749 (Print) culture and tradition. In the rural areas traditional culture is still predominant 2091-2757 (Online) and western allopathic medicine has yet to reach those areas. People of rural societies are reluctant to accept changes in their cultural practices. There are also a lot of factors that make people choose traditional healers in lieu of modern hospital/heath post services. However, modern health services are Correspondence slowly replacing traditional healing practices in rural parts of Nepal. Richa Baniya Medical Student Keywords: dhami/jhankri, healing, prevalent, traditional Patan Academy of Health Science, School of Medicine, Lalitpur, Nepal. Email: [email protected] Phone: 9841694058

Peer Reviewed By Mrs. Ira Shrestha Patan Academy of Health Science Email: [email protected]

Dr. Sumana Bajracharya Patan Academy of Health Science Email: sumanabajracharya@pahs. edu.np

Republished with permission from United Nations Youth and Student Association of Nepal (UNYSAN) Vol. I, Issue I, 2014

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):52-53 52 Richa Baniya: Traditional Healing Practices in Rural Nepal

People of primitive societies were mainly dependent most parts of the rural areas, people still visit traditional on the nature for survival and believed nature to be healer.6 Mostly, due to the cultural beliefs people are their mother. When natural calamities struck their psychologically convinced that, if they are treated by the surrounding environment, they interpreted them as traditional healers, they get well soon. People of rural ‘God’s Anger’. When people became sick, they couldn’t societies don’t easily accept the scientific innovation. explain it rationally and believed it as the ‘Curse from Their culture has created a deep faith in traditional the Gods’ or ‘The Punishment of the People’s Sins’. So, healers. people started to worship rivers, forests, mountains, etc. Educated people now believe that traditional healers as God.1 Likewise, people assumed the physical body treat the sick people only psychologically.7 Sometimes of a person would die but not their inner soul. So, they the illness might also be only psychological. In this case, started worshipping the soul of their deceased ancestors the traditional healers will help to make the person as ‘Kul-Debta’. This belief was passed from generation to psychologically stronger. Even today, in rural society generation. traditional healers are practicing their jobs and somehow The concept of witch or ‘Bokshi’ developed simultaneously they are successful in treating people. Whether with this notion. A witch is supposed to keep ghosts with psychological or not is yet unknown, because I have her and orders it to enter a person’s body, at first, causing myself witnessed, a healer calm down a baby, crying for minor illness, progressing towards severe condition and hours, just by chanting hisMantras without touching her. finally death. To get rid of it, faith healers were introduced. There was no rationality behind it nor it was any trick, but They were called ‘Dhami or Jhankri. They were believed it happened. to act as mediator between the spiritual world and the The Dhami/Jhankri has no qualifications. They could be material world and suck the offending spirit from sick either literate or illiterate. They learned the treatment person’s body. 2 methods from their parents or by being disciples of As human beings advanced, they became more senior Dhamis. Some Dhamis even say tales of being intellectual. They started to understand that lack of trained by the people of the jungle for several days to sanitation was the cause of illness. They started to use become a healer. However, people trust them and visit cow dung to clean their house every day and used cow them mainly because it has been their cultural practice urine as an antiseptic. They bathed everyday and rooted and are cheaper and available when needed. Being a part it in their culture. Some people became vegetarians as of the culture, is what makes traditional healing special. meat could cause various diseases. To prevent illness they took proper diet, fruits and even embedded them in their culture, E.g. intake of curd mixed with beaten rice REFERENCES is supposed to keep them cool, and a specific day, during 1. Shakti GM. Plant myths and traditions in India. 3rd ed. summer, was created to take it. Munshiram Manoharlal Publishers; 2001. Being a medical student, it is important to know 2. Westbury V. Traditional healers: the Shamans of Nepal. how traditional healing operates. These deep-rooted www.truia.net/papers/VirginiaShamans.pdf. traditions have beliefs that can lead a person even 3. Sharma A, Ross J. Nepal: integrating traditional and towards death, e.g. a traditional belief that people modern health services in the remote area of Bashkharka. suffering from diarrhea must not be given water/fluid.3 If Int J Nurs Stud. 1990;27(4):343-53. we know the traditional practices of treatment, then we 4. Poudyal AK, Jimba M, Murakami I, Silwal RC, Wakai S, can make people aware of the risks of these treatment Kuratsuji T. A traditional healers’ training model in rural methods. We will also know where to intervene and Nepal: strengthening their roles in community health. . also tell people the benefits of modern health facilities Trop Med Int Health. 2003 Oct;8(10):956-60. and encourage them to utilize those facilities. Now-a- 5. Shankar PR, Paudel R, Giri BR. Healing traditions in Nepal. days, due to cultural transformation, even Dhamis have JAAIM-Online [Internet]. [Cited 2013 Nov 12]. Available started to recommend patients to hospitals in case of from: URL:http://www.aaimedicine.com/ jaaim/sep06/ emergency.4 Healing.pdf 6. PremKK. The Nepalese traditional concepts of illness and The practice of traditional healing in Nepal is gradually treatment [Internet]. [Cited 2013 Nov 12]. Available from: decreasing these days. Modern medicine was introduced URL:http:www.dadarivista.com/Singoli- articoli/2011- in the seventeenth century but became dominant only dicembre/pa3.pdf during the last fifty years.5 Some years ago, even the 7. Kohrt BA, Harper I. Navigating diagnoses: understanding case of snake bites was carried to Dhami/Jhankris but mind-body relations, mental health, and stigma in Nepal. now patients of this case prefer going to health posts. Cult Med Psychiatry. 2008 Dec;32(4):462-91. However, due to lack of modern health facilities, in

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):52-53 53 STUDENT’S SECTION Anil KC: Reflection on peer assisted learning at PAHS PERSPECTIVE

Reflection on Peer Assisted Learning at PAHS Anil KC, Sandesh Karki

Medical Student, School of Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal

ABSTRACT

Peer tutoring is an organized learning experience in which one student ISSN: 2091-2749 (Print) serves as the teacher or tutor, and one is the learner or tutee. Peer- 2091-2757 (Online) teachers and their students share a similar knowledge base and learning experience, which allows the peer-teachers to use language that their learners understand and to explain concepts at an appropriate level. Peer- teachers and student-learners also share a similar social context because of their similar social roles, and because of this, student learners feel more Correspondence at ease with a peer teacher than with a senior clinician. Peer tutoring is a Anil KC beneficial way for students to learn from each other in the classroom and Medical Student, Patan Academy in small groups, so benefit is not only for the tutee but also to the tutor, of Health Sciences, Lalitpur, Nepal E-mail : [email protected] predominantly through the development of their own clinical and teaching Phone: 9841160839 skills and from the positive feedback obtained by their tutees, thus creating a highly pleasant learning atmosphere and a win-win situation for all. Peer Reviewed By Dr. Jay N Shah Keywords: peer assisted learning (PAL), PBL, tutor Patan Academy of Health Sciences Email: [email protected]

Dr. Ashis Shrestha Patan Academy of Health Sciences Email: [email protected]

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):54-56 54 Anil KC: Reflection on peer assisted learning at PAHS

INTRODUCTIONS METHODS

Peer tutoring is a program to help students who require We started these tutoring sessions by discussing with additional assistance in academic subjects. Students are the third and fourth batch students. They also showed tutored by upper year students who have successfully us the same enthusiasm towards our program. List of completed the course. Peer tutoring is students helping the tutors were prepared one week prior to the actual students. Peer tutoring offers assistance for students peer tutoring sessions, usually from final year medical having difficulties in a specific course.1,2 Problem Based students and fourth year medical students. We select Learning(PBL) is one of the key teaching learning the different topics after discussing with thest 1 year methodology in Patan Academy of Health Sciences medical students one week prior, so that both tutor and (PAHS). Peer tutoring can inhanced the in-depth learning learner have sufficient time to prepare about the topics. along with PBL.3 International interest in peer-teaching We select more than one tutor for a same topic but only and peer-assisted learning (PAL) during undergraduate one will be responsible for running the session was main medical programs has grown in recent years, reflected tutor for that topic and others helped. both in literature and in practice.4,5 During peer tutoring session, students are divided into small groups of 10 members and session was run by 1 TARGET GROUP tutor. Other silent tutors assisted the main tutor if there was confusion. Students asked questions in between as PAHS is newly established academy with dedication this was primarily discussion session. Normally, a session to improve the health status of the people of Nepal by was for 30-45 minutes and in a day maximum four producing doctors who are willing and able to provide sessions. We have completed six sessions till now and the health care in rural Nepal. When we were in basic number of participants are increasing with each session. sciences, there were so many learning issues for PBL and our discussion mainly focused on clinical aspects. After finishing the complete course of basic sciences we felt PLAN we need some guidance for the junoir students. Though teachers were present for all the time but hesitance and Monitoring the effectiveness and productivity of tutoring feeling of being inferior in class, many of us canot ask sessions is a necessity .We can sustain it by involving a questions and dissucssed with teacher in class. There large number of students as tutor and regular supervision used to be so many issues which remained unasnwered. and monitoring from the faculties. We are taking regular As we were the first batch, we didnt have our senoir for written feedback from student to improve it. It would be the guidance, so we thought we will not let this happen more beneficial for the tutor if there were tutor training to our juniors and started the peer-teaching and peer- session by the academy, so that the creativity of tutor can assisted learning (PAL) in our medical school. be also improved. This can be accomplished by quizzing students on the topic they have covered or by conducting Peer tutoring and PAL is useful for all level of students. short MCQs by tutor, These sessions will help for the We do have some form of peer tutoring like learning in participants to monitor their progress by themselves groups or PBL itself, but they were not fruitful for the and examination team can follow up the participants needy students. In many of the medical schools, there and assess their improvement and if some students are scenarios like students who have good relation with are having constantly low grades then, they should be senior students get benefited during exam preparation encouraged to attend tutoring session. Monitoring can time. So our peer tutoring can reach up to the all juniors be continued by having students monitor themselves, for who are interested. We are especially focusing on example, by having the tutor keep track of correct and students who are not able to complete exit exam like basic incorrect answers by making marks on a card. The results science comprehensive examination and clinical science from each monitoring card from a tutoring session can comprehensive examination. Our targeted students are then be used to fill in a progress chart which, over time, students who have just started their basic sciences and will be an indicator of progress. one to one peer tutoring session for students who have not completed their exit exam. We are also planning to do examination skills for the third year students where they can learn and practice adequate practical skills.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):54-56 55 Anil KC: Reflection on peer assisted learning at PAHS

CONCLUSIONS References

Here is an old saying: “To teach is to learn twice.” Peer 1. Yu TC, Wilson NC, Singh PP, Lemanu DP, Hawken SJ, Hill assisted learning will help us all to develop the AG. Medical students-as-teachers: a systematic review of competence and knowledge to both senior and juniors peer-assisted teaching during medical school. Adv Med by learning together. These sessions will also increase the Educ Pract. 2011 Jun;2:157-72. respect, love and friendly environment among the inter 2. Cornwall MG. Students as teachers: Peer teaching in batch students which will help to decrease the conflict higher education. Amsterdam: Centrum Onderzoek and ego. These sessions will also be helpful to increase Wetenschappelijk Onderwijs; 1979. 3. Bruffee KA. Collaborative learning: Higher Education, the social skills like sense of teamwork, brotherhood and nd communication skills. It would be an example for other Interdependence, and the Authority of Knowledge. 2 ed. Baltimore: The Johns Hopkins University Press; 1999. medical school. 4. Secomb J. A systematic review of peer teaching and learning in clinical education. J Clin Nurs. 2008;17(6):703– 16. 5. Weyrich P, Schrauth M, Kraus B, Habermehl D, Netzhammer N, Zipfel S, et al. Undergraduate technical skills training guided by student tutors–analysis of tutors’ attitudes, tutees’ acceptance and learning progress in an innovative teaching model. BMC Med Educ. 2008;8:18.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):54-56 56 NURSING SECTION Indra Shrestha: Educational Intervention on Universal Precautions Among Nurses ORGINAL ARTICLE

Impact of Educational Intervention on Knowledge and Practice of Universal Precautions among Nurses Ms. Indra Shrestha(Rai)

College of Nursing, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal

ABSTRACT

ISSN: 2091-2749 (Print) Introductions: The purpose of this study was to find out the effectiveness of 2091-2757 (Online) educational intervention in improving knowledge and practice of universal precautions among nurses.

Methods: This was a cross sectional observational study conducted at Patan Hospital in August 2008. Fifty nurses with minimum one year of experience Correspondence were included. Twelve, out of 50 samples were selected by drawing lot for Ms. Indra Shrestha (Rai) the study of practice of universal precautions. A semi-structured questionnaire College of Nursing, Nepalese was used to measure the knowledge and practice of universal precautions. Army Institute of Health Sciences, Kathmandu, Nepal Results: The findings revealed that there was significant difference inthe Email: [email protected] pre and post-intervention test mean knowledge. The grand mean score of Peer Reviewed by: knowledge and practice of universal precautions as a whole were 31.86 and Dr. Sumana Bajracharya 44.55 with standard deviations of 10.46 and 3.90; and 68.61 and 87.70 with Patan Academy of Health standard deviations of 3.70 and 2.55 in the pre and post intervention tests Sciences respectively. Email: suamanabajracharya@pahs. edu.np Conclusions: Educational intervention had significant role in increasing knowledge and practice of universal precautions among nurses. Dr. Jay N Shah Patan Academy of Health Sciences Keywords: blood-borne infections, body fluids, knowledge and practice, needle Email: [email protected] stick injury, universal precautions

Plain Language Summary The effectiveness of educational intervention in improving knowledge and practice of universal precautions among nurses was studied. The face to face educational intervention had significant role in increasing the knowledge and practice of universal precautions.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):57-60 57 Indra Shrestha: Educational Intervention on Universal Precautions Among Nurses

IntroductionS practice of hand washing technique included removing watch and jewelry, soap application, rinsing hands from Health care providers nurses, doctors, laboratory fingertips upwards and drying with clean towel. technicians are at risk of acquiring blood-borne infections through occupational exposure to sharp and needle-stick The data were collected by self-administered injuries. Young nurses with less professional experience questionnaire before the educational intervention are more prone to such injuries. Nurses less than 24 followed by educational intervention on the same years of age had 92.2% risk of needle-stick injurires, 13 day. Two weeks later, the post-intervention test was 1 times higher than 40 years and above. conducted by administering the same tool to the same participants. The Center for Disease Control and Prevention (CDC) of USA introduced the concept of universal precautions Permission for study was obtained from the hospital (UP) as guidelines for protecting healthcare workers from authority. Verbal informed consent was obtained from 2 becoming infected with blood borne infection. participants. They were ensured about anonymity, confidentiality and refusal to participate or withdraw The number of sharps and needle-stick injuries per from the study if they wished so. The schedule for person among healthcare workers continues to be a data collection and educational intervention were challenge globally.3 planned according to suitable time given by the hospital The purpose of this study was to find out the effectiveness administration, and was done in three sessions. of educational intervention in improving nurses’ Completeness and consistency of questionnaire was knowledge and practice of UP. checked. SPSS version 11.5 was used for analysis. Frequency, percentage, mean, and standard deviation Methods were calculated. Chi-square, ‘z’-test and ‘t’-test were used for pre and post-intervention analysis of knowledge This was a cross sectional observational study conducted and practices of UP. ‘p’-value <0.05 was considered in Patan Hospital, Patan Academy of Health Sciences, significant. Nepal, in August 2008. The population of this study consisted of nurses working in medical, surgical, orthopedic, maternity, gynecology, intensive care unit Results and neonatal nursery of Patan Hospital. Non-probability All 50 nurses were female with mean age of 25.7 years convenience sampling technique was used. A total (range 21 to 42) and 31 were below 25 years of age. In of 50 nurses were included to test the knowledge of terms of years of working experiences, 40 had 1 to 5 UP before and after educational intervention. The years of experience (26 had 1 to 3 years), seven had 5-10 nurses with minimum of one year of experience, with years and three above 10 years. Only 15 respondents had Proficiency Certificate Level education in nursing, orientation class on UP and none had received in-service willing to participate in the study were included. An training. educational intervention package was developed which included definition, purpose, components of UP, sources The knowledge score regarding body fluids: semen, of infection, and factors contributing to enforcement vaginal and amniotic, cerebrospinal and breast milk of UP. A semi-structured questionnaire consisting of as a source of infection were 42, 18, 12 in the pre- questions related to demographic characteristics and intervention test; and 46, 43, 41 in the post-intervention knowledge regarding UP was developed. The content test respectively. The difference between pre and post- validity was established by developing the instruments intervention test knowledge about cerebrospinal fluid on the basis of literature review in consultation with and breast milk were significant (p=0.000); whereas research committee chairperson, research guide and semen, vaginal and amniotic fluids were not significant subject expert. The reliability of the instruments was (p=0.218). established by pre-testing it on five (10%) nurses working in Tribhuvan University Teaching Hospital. The knowledge regarding decontamination, high-level disinfection (HDL) and sterilization revealed that the Out of 50 nurses, 12 were selected by drawing lot to correct responses ranged from seven to 25 in the pre- observe the practice of UP which included hand washing intervention test and 26 to 44 in the post-intervention technique, use of gloves, and proper disposal of needles test. The difference between the pre and post- after use. The rating scale (1 to 3 score) was usedto intervention level of knowledge score were statistically determine the level of practice of UP. The stepwise significant with score of 14.22% and 34.77%.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):57-60 58 Indra Shrestha: Educational Intervention on Universal Precautions Among Nurses

Table 1. Pre andpost-intervention knowledge about UP among nurses After educational intervention the practice ofUP (n=50) improved for handling of needles, washing hands and Pre-test Post-test X2 p use of gloves, Table 3 and 4. Components No. % No. % Value The stepwise practice of hand washing technique Hand washing: score ranged from 52.88 (rinsing hands from finger tips Before & after performing any procedure 48 96.00 50 100.00 0.315 towards) to 83.33 (drying hands with clean, dry towel) in After removing gloves 30 60.00 42 84.00 0.008 pre-intervention practice and 72.22 (removing watch and After handling contaminated items 38 76.00 48 96.00 0.004 jewelry) to 94.44 (soap application; drying hands) in post- intervention practice. The difference were significant Splashes of Blood/body fluids: with p=0.000. Wash face with soap & water 49 98.00 50 100.00 0 immediately The score on practice of use of gloves ranged from 44.44 Needle-stick injury: to 100.00 in the pre-intervention and 80.55 to 100.00 in the post-intervention. The difference were significant * Not necessary to report 38 76.00 48 96.00 0.007 with p=0.000. Mean Score 40.66 47.66 0.003** Standard Deviation 7.33 3.33 Table 3. Pre and post-intervention practice of UP- handling of needles after use among nurses (n=12) UP= universal precaution, *Negative response , **Z test Mean Score MS ( (%), ± (SD) P value There was least difference in the knowledge score Procedural steps Pre-test Post-test for ‘t’ where the respondents had previous knowledge like test management of blood and body fluids exposures, MS SD MS SD disposal of wastes. The difference between pre and post- 1. Does not recap, bend, break or 100.00 0.00 100.00 0.00 0.000 intervention level were statistically significant for those manipulate needles after use. questions where the respondents did not have previous 2. Carries syringe & needle in a small 100.00 0.00 100.00 0.00 0.000 knowledge. tray. 3. Disposes in puncture resistant 63.80 0.77 100.00 0.00 0.000 The individual knowledge score in pre-intervention container. among 50 respondents was of low level (<50.0%) in 4. If reusing syringes, soaks in 0.5% 47.22 0.50 66.70 0.66 0.162 nine and moderate (50.0% to 75.0%) in 41 and post chlorine solution for10 minutes. intervention it was moderate level (50.0% to 75.0%) in 18 5. Rinses the syringe in clean water. 41.66 0.44 72.22 0.60 0.057 and high (>75.0%) in 33. Mean Score 70.53 87.78 0.000 Table 2. Pre and post- intervention knowledge of UP among nurse Standard Deviation 0.34 0.25 (n=50) Table 4. Pre and post-intervention practice of UP among nurses (n=12) Mean Score (%), ± SD Mean Score (%), ± S.D. X2 p P value Knowledge Items Pre-test Post-test Value Observation Pre-test Post-test for ‘t’ MS SD MS SD test MS SD MS SD General information 35.22 17.66 48.00 3.44 0.000 Hand Washing 62.06 6.33 83.34 5.31 0.000 Sources of infection 24.00 15.88 43.33 2.55 0.000 Use of Gloves 73.26 4.45 92.00 2.09 0.000 Utilization of PPE in UP 45.22 3.66 49.00 1.22 0.164 Handling of Needle 70.53 0.34 87.78 0.25 0.000 Safe work practices in UP 40.66 7.33 47.66 3.33 0.003 Grand Mean 68.61 87.70 Decontamination, High-Level- 14.22 7.77 34.77 9.00 0.000 Grand SD 3.70 2.55 0.000 Disinfection and sterilization Grand Mean Score (MS) 31.86 44.55 0.033** Grand Standard Devation (SD) 10.46 3.90 DiscussionS PPE= Personal Protective Equipment Most of the nurses were in early stage of career with There was significant difference in the pre and post- less than five years experience, 40 within 1 to 5 years (26 intervention mean score of practice of universal within 1 to 3 years). According to Mustafa young nurses precautions. The individual practice score revealed that with less professional experience, working in surgical 12 had moderate level (60.0% to 80.0%) of practice in the and intensive care unit were accepted as risk group and pre-test and 12 had high level (>80.0% ) of practice in the targeted for training program.4 post-test respectively.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):57-60 59 Indra Shrestha: Educational Intervention on Universal Precautions Among Nurses

We found that there was least difference in the pre and ConclusionS post-intervention scores in terms of knowledge about the utilization of gloves, mask, goggles and gown but Educational intervention had significant role in increasing in practice did not translate in to compliance to use the level of knowledge and practice of universal gloves when starting intravenous (IV) drip and drawing precaution among nurses. blood. The reason for not using the gloves was practical difficulty on palpating the veins and securing of cannula with tape which tends to stick to the gloves and interfere ACKNOWLEDGEMENTS with dexterity. I am grateful to the chairperson and members of research Even though the hospital had written policy for post- committee of Maharajgunj Nursing Campus for their exposure prophylaxis, and respondents had good help in development of study protocol. I appreciate the knowledge about the situations of splashes of blood/ leadership of Patan Hospital for allowing this study and body fluids and needle-stick injuries but lacked to nurses for their kind co-operation. report such injuries in time. This probably requires more awareness training and reporting. HLD was not practiced, References so that may be the reason that there were significant changes in the knowledge in the post-intervention as the 1. Ducel G, Fabry J, Nicolle LE, editors. Prevention of hospital respondents did not have a good knowledge before the acquired infections: a practical guide. 2nd ed. Malta: educational intervention. World Health Organization; 2002. 2. Centers for Disease Control. Universal precautions for There was lack of compliance to remove watches, prevention of transmission of human immunodeficiency bangles, finger rings which interfered with the hand virus, hepatitis B virus, and other bood-borne pathogens washing technique. Trick also found out that the in health care settings. USA: Centers for Disease Control; 1998. adherence to hand washing and proper washing 3. Pruss-Ustun A, Rapiti E, Hutin Y. sharps injuries: global technique by healthcare workers were uncommon. burden of diseases from sharps injuries to health-care Creedon stated that the hospital acquired infections are workers. Geneva: World Health Organization; 2003. serious problem, pathogens are readily transmitted to 4. İlhan MN, Durukan E, Aras E, Türkçüoğlu S, Aygün R. Long health workers hands and hand washing substantially working hours increase the risk of sharp and needlestick reduces transmission.5,6 injury in nurses: the need for new policy implication. Journal of Advanced Nursing. 2006 Dec;56(5):563-8. The good practice of handling needles after use might be 5. Trick WE, Vernon MO, Hayes RA, Nathan C, Rice TW, due to good knowledge and hospital providing resources Peterson BJ, et al. Impact of ring wearing on hand like puncture resistant container at convenient places like contamination and comparison of hand hygiene agents in in the working area and dirty utility room, availability of a hospital. Clin Infect Dis. 2003 Jun 1;36(11):1383-90. IV trolley, and trays to carry syringe. 6. Creedon S. Healthcare workers’ hand decontamination practices: compliance with recommended guidelines. This study shows face to face educational intervention Journal of Advanced Nursing. 2005 Aug;51(3):208-16. 7. Krishnan P, Dick F, Murphy E. The impact of educational had significant role in increasing the knowledge and 7-10 interventions on primary health care workers’ knowledge practice of UP like other studies and should be included of occupational exposure to blood or body fluids. Occup in comprehensive in-service educational program for Med (Lond). 2007 Mar;57(2):98-103. nurses and possibly other healthcare workers. 8. Dargan P, Thakur S, Jain BK, Singh R, Deb M. Awareness and practice of universal precautions by health care The study had small sample size from a single hospital workers in a teaching institute. J Nepal Medical and convenience sampling which may affect adequate Association. 2001;40:125-7. representation of the knowledge of nurses regarding 9. Jovic-Vranes A, Jankovic S, Vukovic D, Vranes B, Miljus practice of universal precaution. D. Risk perception and attitudes towards HIV in Serbian health care workers. Occup Med (Lond). 2006;56(4):275-8. 10. Cutter J, Jordan S. Uptake of guidelines to avoid and report exposure to blood and body fluids. Journal of Advanced Nursing. 2004 May;46(4):441-52.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):57-60 60 NURSING SECTION Jay N Shah: Nursing Posting for Medical Students PERSPECTIVE

Nursing Posting for Medical Students Jay N Shah,1 Ashis Shrestha2

1Professor, 2Lecturer, Patan Academy of Health Sciences, Lalitpur, Nepal

ABSTRACT

Nursing perspective is different from doctors. It is a known fact that doctors and nurses must work together for the better patient care. It is very ISSN: 2091-2749 (Print) important for doctors to know how nursing services are provided. Moreover 2091-2757 (Online) a good communication and team work is an essence of present medical service. So, this attitude should be embedded in the medical education to decrease professional distance and increase mutual respect in future. PAHS has provided this opportunity as a nursing posting with a vision of holistic Correspondence: teaching of medical students and shaping a positive attitude towards all Dr. Jay N Shah health care providers. Patan Academy of Health Sciences, Lagankhel, Nepal Keywords: medical education, medical student, nursing Email: [email protected]

Peer Reviewed By INTRODUCTIONS Dr. Ram Krishna Dulal Patan Academy of Health Sciences, This is interesting to have medical school curriculum require doctors to Email: [email protected] work as nurses during the training. School of medicine, PAHS has included a week long ‘nursing posting’ for medical students. The first week of medical Dr. Sumana Bajracharya school starts with all the medical students work alongside nurses, in shift Patan Academy of Health Sciences duty, providing ‘actual nursing care’ for the patients as per the order for Email: sumanabajracharya@pahs. individual patients. edu.np

VISION

This gives the future doctors a first hand, practical exposure of nursing care for the patients, to ‘feel’ from nurses perspective how to provide for the patients, their expectations while admitted in hospital beds, and develop ‘respect’ for the work provided by nurses in overall patient care, like monitoring vitals, making beds, maintaining IV lines, oxygen delivery, nebulization, food and nutrition, family support and many more.

This program has given opportunity for both nurses and medical students to appreciate each other better, to minimize the professional distance there may be between doctors and nurses. Contrary to the culture of addressing by ‘Doctor this or Doctor that’, feel comfortable by calling the medical students by their first name. This endeavor has given opportunity for rapport building and professional bonding of young medical students with nurses early in start of their medical school. Nurses feel that they have chance to contribute in overall holistic teaching of medical students and shaping their attitude towards health care providers by developing mutual respect in team work for better service delivery to the patients and their family.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):61-63 61 Jay N Shah: Nursing Posting for Medical Students

PRESENT STATUS capturing photo of endoscopy, calling patients serially etc) This program has been gained recognition from nurses 5. Got information about “Vaccine Preventable and medical students, faculties and stakeholders. Disease Surveillance System” of Nepal which is This ‘nursing posting’ for medical students has been also implemented at PH. It was senior nurse’s duty now increased to two weeks from the earlier trial and to record the admitted cases of infective diseased skepticism of one week duration. Students are required individuals’ esp. measles, pneumonia, meningitis, to submit their ‘reflection’ in writing and analyzed for polio and tetanus and reporting it to the Government the further improvements of the curriculum. By the of Nepal every Monday or Tuesday by means of fax. completion of this posting we conduct a “debriefing meeting” attended the students, nursing in-charge of 6. Nursing care Plan Card: the card with concise different wards, faculties, dean and other executives. information of patients and future treatment plan. 7. Observed the feeding done by nurses to the patient. STUDENT’S REFLECTION 8. Observed and performed Ox meter to know the SPO2 and pulse of patient. The reflection from a student posted in Emergency 9. Observed and performed Nebulizer placement to the department. patient.(1:1:2 asthalin : ipratropium bromide: NS), “In the first week of clinical year, we had nursing week sterilized by putting on Vircon solution. posting. I was posted to Emergency room. I learnt so many 10. Observed the medication care provided by nurses to things form nursing posting which is necessary in medical the patient. One of the interesting thing that I found life. For the effective treatment of patient, combined was they used to put the oral tablets directly in a care of doctors, nurses and other staffs is necessary. lead of bottle without directly touching the hand and There should be good communication between all staffs. put it into patient’s mouth. Nice way of preventing The doctors come in round and examine the patient contamination. and prescribe medicine but its the nurses who take 11. NPO: Nil per oral. care of patient most of the time. And there is gapof communication between doctors and nurses sometimes. 12. Cardex: report card which includes patient’s So I learnt about importance of communication between diagnosis, medications, ways of medication, timing doctors and nurses. I learnt about proper waste disposal etc . technique (different colors of bucket for different types • Got knowledge about Nursing that includes: of waste product). Bed making, equipment and recording • Bedside nursing care (bed making, back care, system is also necessary to learn because sometimes oral care) we have to do that work. So I am very happy to learn • Ambulation about all that systems. Due to this nursing posting, the relationship between nurses and medical student has become good which is very important for learning in NURSING REFLECTION further major rotations.” The experience shared by nursing staff while working Few of the important things that I should reflect are: with students.

1. Attended handover work as the duty shifted to next “Working and teaching medical students is a great group of nurses. experience. This is a very noble idea of connecting students with nursing. This is though very important but 2. Participated on bedside nursing care (Assisting nurses is not looked into seriously in existing medical education. to make bed and oral care, back care). 3. Central supply was not working of sterilization of the It is very important that students know how nursing devices and sending them back to the ward, observed functions in every department. This will help students the reporting system of that. to communicate and maintain a good rapport with the team. After all good medical care is a combined effort 4. Observe the coordination and functioning of from everyone. I believe this is a great opportunity for endoscopy ward(counseling to patient, nursing care ourselves as well to get updated. Once students start given to them, recording the patient information putting up their queries we have to take time from into computer, cross checking the report and mechanical work and start reading. This will foster an patients name, assisting the doctor directly by doing academic environment of learning and teaching which sterilization of device, giving oral analgesic to patient, can be done both ways.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):61-63 62 Jay N Shah: Nursing Posting for Medical Students

This is also one area where we see, meet and connect CONCLUSIONS with patients very closely. Apart from academic part that they will learn in this posting, they will also be able to This nursing posting of medical students in the beginning see patients very closely into their hearts and soul. This of medical school curriculum is important and rewarding will definitely improve the quality of health care services to ‘build foundation’ for the future ‘team work’, minimize provided to the patient. If this continues, the day is not the ‘professional gap’ between doctors and nurses and far when patient will always remember being taken care also develop the ‘feelings’ from nurses perspective how by students. important it is to ‘listen’ to the suffering of the patients and their family for holistic patient care. I believe that this is a part of the foundation in a medical study. Once a foundation is strong we can expect the ACKNOWLEDGEMENTS future to be very strong. So, with this type of medical education, we are expecting a cooperative, well We would like to acknowledge Prof. Dr. Kedar Baral, mannered, patient centered and skillful doctor out of Prof. Dr. Shrijana Shrestha, Prof. Dr. Rajesh Gongal, Mrs. PAHS medical students.” Narayani Rai for their support in materializing the vision of Nursing Week.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):61-63 63 MEDICAL EDUCATION Satish Raj Ghimire: Students’ perception and preference of problem based learning ORGINAL ARTICLE

Students’ Perception and Preference of Problem Based Learning During Introductory Course of a Nepalese Medical School Satish Raj Ghimire,1 Shital Bhandary2

1Lecturer, Department of Anatomy, 2Assistant Professor, Department of Community Health Science and Medical Educaton, Patan Academy of Health Sciences, Lalitpur, Nepal ISSN: 2091-2749 (Print) 2091-2757 (Online) ABSTRACT

Introductions: Problem based learning is considered superior to the conventional didactic teaching for contextual learning, long term retention of Correspondence knowledge, development of generic skill and attitudes. This study looked in to Satish Raj Ghimire the students’ perception and preference of problem bases learning in a six- School of Medicine, Patan Academy month introductory course in the beginning of undergraduate medical school of Health Sciences (PAHS-SOM), program. Nepal Email: [email protected] Methods: A 20-item questionnaire with four-point rating scale (1-strongly Phone No: 9841462679 disagree, 2-Disagree, 3-Agree and 4-Strongly agree) was administered to collect first year medical students’ perception on problem based learning during first Peer Reviewed by six month introductory course (June 2010 to November 2010) of first batch Dr. Jay N Shah of medical students. The questionnaire included 13-items for perception and Patan Academy of Health Sciences Email: [email protected] seven for preferences. It also had an open-ended comment section. Results: Students showed positive reaction problem based learning Dr. Ashis Shrestha Patan Academy of Health Sciences irrespective of gender or educational background in providing contextual Email: [email protected] learning and retention of knowledge. Students agreed that it fostered generic skills (communication, group work, critical thinking, reasoning, reflectiveness and self-directed learning). Students wished for more such sessions in more subjects with short content assessment at the end of the sessions.

Conclusions: Problem based learning is fun, provides contextual learning and imparts long term retention of knowledge through students’ active participation in a small group. It also promotes generic skills and self-directed life-long learning.

Keywords: medical school, perception, problem based learning, students

Plain Language Summary The study was conducted to see the effectiveness of problem based learning (PBL) in a six-month long ‘Introductory Course’ of undergraduate medical sciences program. The study found that PBL made topics interesting and created a fun-filled learning environment. It found PBL to be effective in fulfilling learning objectives and making the contents relevant. It also showed PBL to be effective in promoting a set of generic skills and attitudes. Thus, the curricular contents presented in context through PBL can impart meaningful knowledge and a set of generic skills that are important to develop of a habit of self-directed, life-long learning.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):64-68 64 Satish Raj Ghimire: Students’ perception and preference of problem based learning

IntroductionS through series of discussions in PBL committee and experts in PBL within and outside of PAHS-SOM. It School of Medicine, Patan Academy of Health consisted of 15 items of which 13 measured students’ Sciences (PAHS-SOM) has created graduate attributes perception on PBL process and two items measured their 1 encompassing cognitive and non-cognitive domains. preference about the PBL. The fifteenth item consisted of To foster these attributes among its medical graduates, six sub-items measuring students’ preference for specific PAHS-SOM has adopted Problem Based Learning (PBL) disciplines. This anonymous questionnaire utilized a four- and Community Based Learning and Education (CBLE). point forced Likert scale (1-strongly disagree, 2-Disagree, 3-Agree and 4-Strongly agree). The questionnaire also PBL is major teaching-learning method for first two and consisted of an open-ended section to comment on the half years of undergraduate medical school program, PBL process and contents. which includes six-month of introductory or foundation course followed by two years of basic sciences. PBL is a Data entry was done in Excel spread sheet. Cronbach’s learner-centered method with distinct advantage over alpha, median and inter-quartile range (IQR) were the conventional teacher-centered didactic method calculated in SPSS 15 for Windows. P-value less than in promoting a long-term retention of information, or equal to 0.05 was taken as statistically significant providing contextual learning and development of result for comparing median. Consensus Index was 2, 3 generic skills and attitudes . used to interpret the Likert scale responses.5,6 Students’ comments were analyzed using pile sorting method in Since didactic lectures are main teaching-learning MS Excel 2007. Ethical approval (Ref: 2011.105.sg) was method in senior high school in Nepal, PBL is introduced obtained from the Institutional Review Committee (IRC) in Introductory Course to foster the cognitive and non- of PAHS. cognitive skills among incoming students of PAHS- SOM. This study was conducted to measure students’ “reaction” on PBL they underwent during introductory Results course. Out of 60 students, fifty seven returned the filled questionnaire. There were 40 (70.17%) male and 17 Methods (29.83%) female students. Fifty two students were from science background with two years (class 11 and 12) of In six months introductory course, a PBL case was natural sciences (physics, chemistry, biology) after high conducted each week with three tutorial sessions of school (class 10). Five students were from health sciences two hours duration conducted on alternate day (starting background with paramedical education training for two on Sunday) and facilitated by a trained tutor. Self-study and half to three years after high school. The median age period of at least one and half times of the total PBL hours of the respondents was 20 years with Interquartile Range was embedded in between the tutorial session. The PBL (IQR) of one year. case was concluded at the end of each week (on Friday) with an hour long large group wrap-up session including The tool was highly reliable with internal construct all seven PBL groups (8 to 9 students in one group) in the reliability more than 90% (Cronbach’s alpha = 0.903). presence of concerned discipline experts and tutors. Perception sub-scale was highly reliable (Cronbach’s alpha = 0.907) and preference sub-scale was acceptable Students underwent PBL tutorial orientation program for (Cronbach’s alpha = 0.708). where a simulated tutorial session was demonstrated prior to the course. A total of 13 PBL cases, three from The median perception scores for female students (in community health sciences (CHS), two each from Physics, comparison to male) and health sciences graduates (in Chemistry, Biology, Medical Informatics and Introduction comparison to high school) was high. The difference to Clinical Medicine (ICM, early clinical exposure) were in perception score was statistically non-significant on implemented. Mann Whitney test (p-value = 0.427 and 0.529). The preference scores among gender and education stream A questionnaire was designed to measure the students’ were not different, Mann Whitney test (p-value = 0.473 reaction, corresponding to Kirkpatrick’s learning for gender and p-value = 0.615 for educational stream). evaluation model.4 The questionnaire was validated

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):64-68 65 Satish Raj Ghimire: Students’ perception and preference of problem based learning

Table 1. Perception and preference scores for PBL by gender and educational stream of medical students in first six months of introductory course Gender Education stream Total Male (n=40) Female (n=17) High School (n=52) Health Science (n=5) n=57 Median Perception score 41 (6.00) 43 (4.5) 41 (6.00) 43.5 (6.5) 41(6.00) Median Preference score 21 (4.00) 21 (4.00) 21 (5.00) 21 (6.00) 21 (4.5) Note: Figures in parentheses show inter-quartile range (IQR), PBL (problem bases learning)

Table 2. Consensus among first year medical students about perception and preference of PBL during six months introductory course Rating Consensus Index Item Numbers Items SD DA A SA Qn(i) 1 0 16 34 7 PBL is more effective in fulfilling the learning objectives of the topicV (0.0) (28.1) (59.6) (12.3) 62.1 2 0 34 12 PBL imparts better content knowledge of the topic (0.0) 11 (19.3) (59.6) (21.1) 68.6 3 0 5 34 18 PBL encourages me to learn in context (0.0) (8.8) (59.6) (31.6) 76.2 4 1 3 39 13 PBL promotes the retention of knowledge (1.8) (5.3) (68.4) (22.8) 81.1 5 1 2 37 17 PBL promotes my participation in the learning process (1.8) (3.5) (64.9) (29.8) 79.3 6 1 3 33 20 PBL promotes my critical thinking skill of the topic (1.8) (5.3) (57.9) (35.1) 75.8 7 1 4 36 16 PBL promotes my reasoning skill of the topic (1.8) (7.0) (63.2) (28.1) 77.4 8 1 0 25 31 PBL promotes my self-directed learning on the topic (1.8) (0.0) (43.9) (54.4) 78.4 9 1 4 26 26 PBL promotes my group skills (1.8) (7.0) (45.6) (45.6) 71.1 10 1 0 28 28 PBL promotes my communication skill (1.8) (0.0) (49.1) (49.1) 78.5V 11 1 3 35 18 PBL helps me to identify my strength and weaknesses (1.8) (5.3) (61.4) (31.6) 77.2 12 1 8 33 15 PBL makes the topic more interesting and fun learning (1.8) (14.0) (57.9) (26.3) 70.8 13 1 2 29 25 PBL promotes to explore different resource materials (1.8) (3.5) (50.9) (43.9) 75.1 14 1 7 21 28 I prefer to have a short content assessment at the end of each PBL case (1.8) (12.3) (36.8) (49.1) 64.7 15.1 8 14 22 11 I prefer more PBL sessions on Physics (14.0) (24.6) (38.6) (19.3) 36.3 15.2 2 11 37 5 I prefer more PBL sessions on Chemistry (3.5) (19.3) (64.9) (8.8) 63.7 15.3 2 1 35 18 I prefer more PBL sessions on Biology (3.5) (1.8) (61.4) (31.6) 77.9 15.4 7 13 22 12 I prefer more PBL sessions on Medical Informatics (12.3) (22.8) (38.6) (21.1) 39.1 15.5 1 3 32 19 I prefer more PBL sessions on Introduction to Clinical Medicine (1.8) (5.3) (56.1) (33.3) 75.8 15.6 1 8 23 23 I prefer more PBL sessions on Community Health Sciences (1.8) (14.0) (40.4) (40.4) 65.0 Note: Figures in the parentheses are percentage, SD – Strongly Disagree, A – Agree, D – Disagree, SA – Strongly Agree

Students agreed that PBL promoted retention of imparted better content knowledge and was more knowledge by participation in the learning process, effective in fulfilling learning objectives . communication skills, self-directed learning, reasoning skills, identifying strengths and weaknesses, learning in More students preferred a short content assessment at context, critical thinking skills and exploration of different the end of PBL case and wanted more cases in Biology, resource materials based on Consensus Index, groups ICM, Chemistry and CHS. Less students preferred to have skills, made topic more interesting and fun learning, more cases in Medical Informatics and Physics.

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):64-68 66 Satish Raj Ghimire: Students’ perception and preference of problem based learning

Open comment analysis on overall PBL content and PBL is a student centered teaching-learning methodology process revealed PBL as “far better learning method where students first encounter a problem followed by than lecture” or “better than other teaching-learning a systematic, learner-centered inquiry and reflection methods”. It also revealed some concerns related to PBL process. Problem imposed to the student will itself serve process (Table 3). as stimulus to self-directed learning independently or in a group enabling the students to understand the relevant Table 3. Concerns expressed by first year medical students regarding PBL scientific knowledge and principle in context while during six months introductory cource acquiring a set of non-cognitive skills at the same time.10,11 Number of S.N. Concerns Many studies have compared the outcomes of PBL and Students conventional teaching method showing students’ strong 1 Having no knowledge assessment at the end of each PBL session 12 preference to PBL. Moreover, students have shown more positive attitudes toward PBL curriculum and found Having no homogeneity and accuracy of acquired knowledge 2 8 among peers learning more enjoyable with strong awareness of social issues in medicine.2,12 3 Case objectives being not covered 6 As assessment drives learning, most of the students 4 Going out of track during discussion 6 preferred to have a short content assessment at the end 5 Time-consuming learning process 3 of the PBL session to evaluate their learning and find the gap. Students had also expressed in open comment 6 Confusion regarding depth of knowledge required 3 section their apprehension regarding the knowledge 7 Lack of resources for self-directed learning 2 gap and if the appropriate depth of the knowledge had been acquired. However, there are evidences to support 8 Language as English is mandatory for PBL sessions 1 that PBL does not lead to any significant knowledge 9 Self-learning being not-effective 1 deficiency.13,14 As PBL is found to be very effective in promoting long term retention of knowledge, the 10 Evaluation of students’ performance in PBL by tutor being biased 1 assessment at the end of the PBL session which only promotes the short term recall of knowledge contradicts DiscussionS with the evidence of having PBL as main teaching method to foster performance improvement and the long term In this study, the students from both educational streams retention of knowledge.13 i.e. general sciences and health sciences highly rated the process and outcomes of PBL as effective process despite The students performed well in the summative being an entirely new learning method. The PBL made examination of this six months of introductory courses the learning interesting and fun to fulfil the learning involving external examiners: 58 out of 60 students objectives with relevance and understand better for passed the examination. The examination consisted of retention of the knowledge. Majority of students found Structured Integrated Short Answer Questions (SISAQ) (or PBL very effective for development of generic skills and Problem Based Questions) and vignette based Multiple attitudes. Students also expressed their greater interest Choice Questions assessing higher order cognitive in having most of their contents to be delivered through level along with assessment of skill through Objective PBL. Structured Practical/Clinical Examinations (OSPE/OSCE). This is something PBL approach tended to favor when it Similar findings were reported among students pursuing comes to the assessment of elaboration and application 3-years certificate level allied health science (laboratory of knowledge and skills.13 The summative exam result technology, physiotherapy and general medicine) courses also indicates that they had done expected learning after their high school in Kathmandu University School of through PBL, which is on contrary to their concern about Medical Sciences (KUSMS), Nepal.7 Another study from knowledge gap in PBL. KUSMS, Nepal conducted among the second and third year undergraduate medical students reported students’ In this study, majority of the students preferred PBL overall experience and attitude towards PBL during basic cases for contents delivery in most of the subjects sciences as positive and further showed their willingness of Introductory Course namely Biology, Chemistry, to have PBL during clinical years.8 A study from B.P. Introduction to Clinical Medicine and Community Health Koirala Institute of Health Sciences (BPKIHS), Nepal Sciences. The reasons were relevance of these subjects for having partial PBL curriculum during basic sciences also the subsequent basic and clinical sciences course. It also reported greater interest and enthusiasm towards PBL by suggests students’ strong affinity to this type of teaching method. Similar findings have also been reported from the students.9 KUSMS and BPKIHS.8, 9 However, students seemed to

Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):64-68 67 Satish Raj Ghimire: Students’ perception and preference of problem based learning have less agreement in having more cases on Physics REFERENCES and Medical Informatics (MI). The reasons cited were the content difficulty (for physics, “should be taught through 1. Morgan JHC. Designing an assessment tool for lectures”), no relevance to the subsequent medical professional attributes of medical graduates from a new medical school in Nepal. South-East Asian Journal of course (Physics and MI), having no prior knowledge (MI) Medical Education. 2009;3(1):2-7. and delivery mismatch (“MI is better taught through 2. Schmidt HG, Vermeulen L, Van Der Molen HT. Longterm practical sessions”). effects of problem‐based learning: a comparison of competencies acquired by graduates of a problem‐based This study only shows the reaction of students towards and a conventional medical school. Medical education. the PBL process and their performance in the summative 2006;40(6):562-7. exam of Introductory Course. However, their performance 3. Hoffman K, Hosokawa M, Blake Jr R, Headrick L, Johnson in subsequent basic sciences phase of the curriculum in G. Problem-based learning outcomes: ten years of terms of cognitive as well as non-cognitive skills through experience at the University of Missouri-Columbia School PBL remains to be evaluated. of Medicine. Academic Medicine. 2006;81(7):617. 4. Yardley S, Dornan T. Kirkpatrick’s levels and education It is also important to note that Nepal Medical Council, ‘evidence’. Medical education. 2012;46(1):97-106. the accreditation body, in its guideline has advocated 5. Tastle W, Russell J, Wierman M. A new measure to analyze the incorporation of PBL method as innovation in student performance using the Likert scale. Proceedings undergraduate medical education program. Majority (10 of the 22nd annual conference on Information Systems Education (ISECON), 2005. Columbus, OH: EDSIG. p 2142. out of 17) of the medical schools in Nepal now use PBL 15 6. Tastle J, Tastle W. Extending the consensus measure: in one form or the other. The present study and other analyzing ordinal data with respect to extrema. studies have shown the effectiveness of PBL method Proceedings of the 22nd annual conference on and students’ positive attitudes towards the process Information Systems Education (ISECON), 2005. and outcomes of PBL, thereby negating the concern and Columbus, OH: EDSIG. p 2322. scepticism, if any, regarding the appropriateness of this 7. Risal P, Karmacharya BM. PBL - Allied health sciences method in our context too. perspective. In: Dixit H, Joshi SK, editors. Modern Trends in Medical Education. Kathmandu: Kathmandu Medical College; 2009. CONCLUSIONS 8. Karmacharya BM, Risal P. Students’ perception of Problem Based Learning in Kathmandu University School of The students’ perception and preference of PBL in Medical Sciences. In: Dixit H, Joshi SK, editors. Modern a six-month introductory course in the beginning of trends in medical education. Kathmandu: Kathmandu undergraduate medical school program was contextual Medical College; 2009. in fun filled environment promoting retention of 9. Bhattacharya N. Students’ perceptions of problem‐based knowledge and helpful in development of generic learning at the BP Koirala Institute of Health Sciences, Nepal. Medical Education. 1998;32(4):407-10. skills such as communication skill, critical thinking and 10. Barrows HS, Tamblyn RM. Problem-based learning: An reasoning, group skills, reflectiveness along with self- approach to medical education. 1st ed Springer Publishing directed learning and life-long learning habits. Company; 1980. 11. Wood DF. Problem based learning. BMJ. 2003 Feb To minimize the concerns expressed by students the 8;326(7384):328-30. curriculum committee should monitor the implementation 12. Kaufman DM, Mann KV. Comparing students’ attitudes of PBL process by designing PBL cases with well explained in problem-based and conventional curricula. Academic tutor guide to fulfil the case objectives and to keep the Medicine. 1996;71(10):1096-9. discussion on track, conduct PBL case orientation session 13. Strobel J, van Barneveld A. When is PBL more effective? and tutorial skills training for tutors, provide feedback to A meta-synthesis of meta-analyses comparing PBL to students and tutors on their performance. conventional classrooms. Interdisciplinary Journal of Problem-based Learning. 2009;3(1):4. The evaluation on behavioural change and life-long 14. Prince KJ, Van Mameren H, Hylkema N, Drukker J, performance of students is required to establish the Scherpbier AJ, Van Der Vleuten CP. Does problem‐based learning lead to deficiencies in basic science knowledge? long-term effect of PBL in the local context. An empirical case on anatomy. Medical Education. 2003;37(1):15-21. ACKNOWLEDGEMENTS 15. Pradhan B, Ranjit E, Ghimire M, Dixit Y. History of Problem Based Learning in Nepal and Experiences at Kathmandu PBL Committee, School of Medicine, Patan Academy of Medical College. Journal of Kathmandu Medical College. Health Sciences (PAHS-SOM) for their role in validation of 2012;1(1):37-44. questionnaire for this study.

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