Bir Hospital Research Articles

Estimation of Liver Fat by FibroScan in Patients With Nonalcoholic Fatty Liver Disease.

BackgroundAssessment of nonalcoholic fatty liver disease (NAFLD) includes estimation of liver fat (steatosis). Controlled attenuation parameter (CAP) value obtained by FibroScan® (Echosens, Paris, France) is an alternative to liver biopsy for diagnosing and estimating steatosis (S). This study aimed to estimate the liver fat by CAP in NAFLD patients.MethodsAn observational cross-sectional study was conducted at the Liver Unit of Bir Hospital, from January 2021 to May 2021 after ethical clearance from the Institutional Review Board of the National Academy of Medical Sciences. A convenient sampling method was used. Data were analyzed with descriptive and inferential statistics involving bivariate and multivariate analysis.ResultsA total of 127 NAFLD patients were enrolled. The mean (±SD) CAP value was 271.53 (±50.69) dB/m. Total cholesterol, triglyceride, and body mass index (BMI) correlated positively (p<0.05) while systolic blood pressure correlated negatively with CAP value (p=0.031). On multivariate analysis, patients with BMI ≥25 kg/m2 were found 3.7 times more likely to have CAP ≥291 dB/m (S3, severe steatosis) than those with BMI <25 kg/m2 (p=0.048, 95% CI 1.01, 13.50). The mean (±SD) CAP values were 276.19 (±49.93) and 246.60 (±48.50) dB/m among those with BMI ≥25 kg/m2 and <25 kg/m2, respectively (p=0.016, using independent t-test). CAP steatosis grading correlated positively with both the ultrasound grading (p<0.001) and fibrosis grading by liver stiffness measurement (p=0.004). ConclusionIn this observational cross-sectional study of NAFLD patients, the mean (±SD) CAP value was 271.53 (±50.69) dB/m, which corresponds to moderate steatosis (S2). Obese NAFLD patients with ≥25 kg/m2 were 3.7 times more likely to have severe steatosis (S3) than nonobese NAFLD patients with BMI <25 kg/m2.

Assessment of Labial Alveolar Bone Thickness in Maxillary Central Incisor using Cone Beam Computed Tomography

Introduction: The maxillary anterior region is becoming a major concern due to its aesthetic relevance. The buccal bone thickness is important for implant placement, orthodontic treatment and restorative treatment.&#x0D; Objective: To assess the thickness of alveolar bone in the maxillary central incisor using cone beam computed tomography (CBCT).&#x0D; Methods: A cross-sectional observational study was conducted at Department of Dental Surgery, Bir Hospital where CBCT of 53 samples from July 2019 till December 2019, the archived CBCT images was assessed retrospectively. The thickness of the labial bone in a direction perpendicular to the outer surface of the tooth root was measured at a distance of 2 mm from the cementoenamel junction (CEJ). The measurement was taken thrice and the mean measurement was considered.&#x0D; Results: The labial alveolar bone thickness in maxillary central incisor was found to be 0.55±0.27 mm at a distance of 2 mm from the CEJ. Only 2 (3.8%) of the samples had an alveolar thickness of &gt;1 mm. No statistically significant difference was found with respect to gender and age.&#x0D; Conclusion: The average thickness of the labial alveolar bone in maxillary central incisor using cone beam computed tomography was found to be thin.

Prevalence of CTX-M β-Lactamases Producing Multidrug Resistant Escherichia coli and Klebsiella pneumoniae among Patients Attending Bir Hospital, Nepal.

The emergence of multidrug resistant (MDR) bacteria which is attributable to extended spectrum β-lactamases (ESBLs) production of CTX-M types is an obvious problem worldwide. This study is aimed at determining the prevalence of CTX-M β-lactamases producing multidrug resistant Escherichia coli and Klebsiella pneumoniae among patients attending Bir Hospital. A cross-sectional study was conducted between April and September 2019 at Bir Hospital, Kathmandu, and Department of Microbiology, National College, Kathmandu, Nepal. A total of 5,690 different clinical specimens were subjected to cultural, microscopic, and biochemical analyses for the identification of the isolates. Antimicrobial susceptibility testing of the isolates was done, and MDR isolates were selected and processed for further ESBL confirmation by the combination disks method. All confirmed ESBL isolates were screened for CTX-M type β-lactamases (blaCTX-M) by PCR. Of the total 345 isolates (227 Escherichia coli and 118 Klebsiella pneumoniae), 232 were MDR. All 232 (67.24%) MDR isolates were suspected as ESBL producers on the screening test. However, on the phenotypic test, 135 (58.18%) of total MDR bacteria were confirmed as ESBL producers with the highest proportion in K. pneumoniae (59.37%). The major source of ESBL producers was urine. ESBL producing isolates were mostly identified from outpatients and patients belonging to age group 41-60. Gentamicin was found to be effective against ESBL producers. The prevalence of blaCTX-M was (89.62%) with the highest frequency for E. coli (93.81%). High prevalence of ESBL of CTX-M types among MDR E. coli and K. pneumoniae was detected from clinical specimens of patients in Bir Hospital. This study warrants the need for the judicious use of antibiotics as well as emphasize the use of modern diagnostic tools for the early detection of MDR and ESBL producers to curb the emergence and spread of MDR and ESBL producing bacteria in the clinical settings of Nepal.

Carotid Intima-media Thickness in Patients with Non-alcoholic Fatty Liver Disease Attending a Tertiary Care Center: A Descriptive Cross-sectional Study.

Non-alcoholic fatty liver disease is fatty infiltration of the liver in the absence of other causes of steatosis. It is strongly associated with central adiposity, high body mass index, insulin resistance states, hypertension, hyperlipidemia which are features of metabolic syndrome. The objective of study is to find out the carotid intima-media thickness of non alcoholic fatty liver disease patients attending a tertiary care center. This was a descriptive cross sectional study conducted at National Academy of Medical Sciences, Bir Hospital from July 2018 to June 2019 among 70 diagnosed cases of non alcoholic fatty liver disease based on ultrasound findings. Data collection was started after receiving ethical approval from Institutional Review Board of the Institute. Convenience sampling method was used. Data were entered using Microsoft Excel. The carotid intima-media thickness of both sides were measured by ultrasound. Statistical Package for Social Sciences version 20 was used for analysis. Out of 70 cases, the mean carotid intima-media thickness was 0.7140±0.1796mm on right and 0.7161±0.1828mm on left side. Among 70 cases 45 (64.3%) were Grade II non alcoholic fatty liver disease and 25 (35.7%) were Grade I. It was 0.5720±0.1275mm and 0.7929±0.1546mm in Grade I and II non alcoholic fatty liver disease cases respectively on right side whereas it was 0.5676±0.1259mm and 0.7987±0.1557mm respectively on left side. This study showed increased carotid intima-media thickness in non alcoholic fatty liver disease cases.

Study of Endoscopic Findings in First Episode of Upper Gastrointestinal Bleeding

Background and Aims: Upper gastrointestinal bleeding (UGIB) is one of the most common and grave emergencies encountered in Emergency department in Tertiary health care centre in our country. Upper endoscopy has a crucial role in the diagnosis and treatment of upper gastrointestinal bleeding. The aim of this study is to assess the endoscopic findings in patients presenting with first episode of UGIB.&#x0D; Methods: This was a hospital based cross sectional study of patients with haematemesis, melena or both who underwent UGI endoscopy at Bir Hospital during January 2019 to January 2020. Patient demographics, site and nature of lesions and risk factors for bleeding were analyzed.&#x0D; Results: Among 72 enrolled patients 48 (66.67 %) were male and 24 (33.3 %) were female. Haematemesis 27% was the most common presenting complain followed by melena 25.5% and fainting/ dizziness 22.5%. Endoscopy was done in all cases and gastric ulcer disease 27.8% was the commonest cause of first episode of UGI bleeding followed by variceal bleeding, gastric erosion and duodenal ulcer, 25%, 16.7%, 12.5% respectively.&#x0D; Conclusions: Peptic ulcer disease was the most common cause of first episode of UGI bleeding in our context. Among peptic ulcer diseases gastric ulcer was more common than duodenal ulcer. Haematemesis and melena were the commonest clinical presentation of UGI bleeding.

Diagnostic accuracy of monofilament test to detect diabetic neuropathy

Background Diabetic peripheral neuropathy (DPN) is a significant independent risk factor for diabetic foot, and an effective screening instrument is required to diagnose DPN early to prevent future ulceration and amputation. This study aims to determine the diagnostic accuracy of monofilament test to detect diabetic peripheral neuropathy.&#x0D; Methods This cross-sectional study was conducted in National Academy of Medical Sciences, Bir hospital, Mahabouddha, Kathmandu from February 2016 to January 2017. A total of 96 diabetic patients attending inpatient and outpatient Department were selected. Diabetic peripheral neuropathy was assessed by measurement of loss of protective sensation (LOPS) by monofilament test and compared with vibration perception threshold by standard biothesiometer. The sensitivity, specificity, positive predictive value and negative predictive value of monofilament test were calculated.&#x0D; Results The prevalence of diabetic peripheral neuropathy was 26%. The sensitivity, specificity, positive predictive value and negative predictive value of monofilament test were found to be 92.0%, 95.8%, 88.5% and 97.1% respectively. There was strong association between LOPS by monofilament and vibration perception threshold by biothesiometer.&#x0D; Conclusion This study showed a strong diagnostic accuracy of monofilament test to detect DPN when compared with biothesiometer. As monofilament test is a cheap, easily available, and portable, it can be used in the periphery where biothesiometer is not available.

Microalbuminuria and its associations with clinical profile and complications of type 2 Diabetes Mellitus

Background and Aims: Microalbuminuria is an early marker of diabetic nephropathy, which accounts for a significant reduction in life expectancy of diabetic patients. Timely detection of microalbuminuria facilitates appropriate preventive and therapeutic approaches to minimize risks. The aim of this study is to determine the prevalence and association of microalbuminuria with clinical profile and complications of type 2 diabetes mellitus.&#x0D; Methods: This study was a descriptive, cross sectional study involving 100 diabetic subjects between July 2018 to January 2019 at Bir Hospital. Microalbuminuria (mg/dl) was defined as spot urine albumin to creatinine ratio of 30-300 mg/g (Kidney Disease Improving Global Outcomes guidelines) in a single spot urine sample. Statistical analysis was done using Statistical package for the social sciences version 20.&#x0D; Results: Microalbuminuria was found in 35% of the sample and the rate was significantly higher among males (P =0.027). Microalbuminuria was significantly related to Body mass index (P = 0.018), duration of diabetes (P =0.000), retinopathy (P = 0.000) and stroke (P = 0.043). No statistically significant relation was found between microalbuminuria and age (P = 0.366), hypertension (P = 0.208), HbA1c (P = 0.098), dyslipidemia (P = 0.171) and ischemic heart disease (P = 0.651).&#x0D; Conclusions: This study shows high prevalence of microalbuminuria in Nepalese Type 2 diabetes mellitus. Screening for microalbuminuria should be done for all the type 2 diabetes mellitus patients for early detection and management of complications of diabetes mellitus.

Clinical and laboratory differences and role of gene xpert in tuberculous pleural effusion

Background: The diagnosis of pleural effusion and its cause are essential for pleural fluid analysis. We have evaluated clinical and laboratory differences among the tubercular pleural effusion.&#x0D; Methods: The cross-sectional, observational hospital based study was conducted in Bir hospital, Nepal. All patients were evaluated by clinically and laboratory investigations. Patients enrolled for study have pleural effusion and pleural fluid analysis indicative of an exudative pleural effusion using lights criteria. The criteria of enrollment of the patients were pleural fluid for Adenosine deaminizes value more than 40 IU/L, positive for gene xpert test and pleural effusion of any cases with sputum positive pulmonary tuberculosis. Patients were divided into two groups lymphocytic and neutrophilic predominant pleural effusion.&#x0D; Results: Among 100 patients with diagnosis of exudative tubercular pleural effusion, the most common symptom was pleuritic chest pain in 85%, followed by fever in 84% and cough in 82%. Among the tubercular pleural effusion, 21% had neutrophils predominant and 79% had Lymphocytes predominant. The patients with neutrophil predominant Tubercular pleural effusion had higher fever rates (90.5vs.82.5%) than those with lymphocyte-predominant Tubercular pleural effusion. The mean value of Neutrophil predominant pleural fluid for lactate dehydrogenase (LDH) level was 1657.5 IU/L and protein was 5.3gm/dl and in lymphocyte predominant pleural fluid for LDH value was 610.2 IU/L and protein was 4.6 gm/dl; the difference was statistically significant with P value of &lt;0.001. Only 15% of patients had sputum positive for Acid fast bacilli. Among the sputum positive patients, 47% had positive for pleural fluid for gene xpert test with all patients had rifampicin sensitive. The sensitivity of pleural fluid for gene xpert test was 46.6%, and specificity was 90%.&#x0D; Conclusion: In pleural effusion, the positivity of gene xpert for pleural fluid was higher among the sputum positive patients. The prevalence of Neutrophil-predominant pleural effusion was common in tubercular pleural effusion.

Comparative Study of Percutaneous Nephrolithotomy in Supine and Prone Positions.

The aim of the study is the compare efficacy and safety of percutaneous nephrolithotomy in supine and prone positions. Percutaneous nephrolithotomy is conventionally performed in prone position but in recent years numbers of supine percutaneous nephrolithotomies is increasing globally. The hospital based cross-sectional observational study was conducted in the Department of Urology, Bir Hospital from July 2018 to January 2020. A total of 81 consecutive patients undergoing percutaneous nephrolithotomy were divided into two groups, with 38 patients in Supine (Group 1) and 43 patients in Prone (Group 2) positions, respectively. Patient's demographics, access time, operative duration, stone free rate, radiation dose and duration, irrigation fluid volume, post-operative hemoglobin drop and complications were compared. Demographic and stone characteristics were comparable in both groups. Supine Group (Group 1) had significantly shorter operative duration than Prone Group (Group 2), 44.63 ± 12.44minsvs 53.02 ±12.67mins (p< 0.04). The mean radiation duration was 99.11 ± 61.17secs in Group 1 and 108.40 ± 51.65 secs in Group 2 (p=0.46), respectively. Although the mean radiation dose was lower in Group 1 (375.1µGym2) than in Group 2 (465.7 µGym2), it was not statistically significant(p=0.24). The stone free rate at 1 month duration were comparable with 92.1% and 93.02% in Group 1 and Group 2 respectively (p=0.16). Overall complication rates were similar in both groups (15.7% in Group 1 vs 16.2% in Group 2), respectively. None of the patients in both groups had complications higher than Clavien IIIa. PCNL in supine position has significantly shorter operative time with similar complications and stone free rates as compared to prone position.

Qtc Prolongation as Prognostic Marker in Organophosphate Poisoning

Background &#x0D; The long QT syndrome (LQTS) is a disorder of myocardial repolarization characterized by a prolonged QT interval on the electrocardiogram (ECG). This syndrome is associated with an increased risk of polymorphic ventricular tachycardia, a characteristic life-threatening cardiac arrhythmia also known as torsades de pointes. A rate related corrected QT interval (QTc) can be calculated as QT/√RR and normally is ≤0.44s. Some references given QTc upper normal limits as 0.43s in men and 0.45s in female. OP compound supposed to block K+ channel and Na+/Ca++ channel and hence causing prolongation of QT interval. As we know that prolongation of QT interval may precipitate polymorphic ventricular tachycardia and sudden cardiac death, so it become important in case of OP poisoning and related mortality. In this study, I calculated corrected QT interval in diagnosed cases of OP poisoning admitted at Bir Hospital and compared QTc among those with complications and without complication. I also tried to evaluate QTc as a predictor for duration of hospital stays, ICU admission, vasopressor and mechanical ventilation requirement, higher POP score and low GCS.

Neuronavigation system in neurosurgery: Technical details and our early clinical experiences

Introduction: Image-guided surgery is the need of time in neurosurgery. The use of neuronavigation has a significant impact on various neurosurgical procedures. We report our clinical experience and surgical techniques of neuronavigation assisted intracranial and spinal surgeries.&#x0D; Materials and Method: This is observational longitudinal study of 65patients who underwent surgeries using navigation system in the department of neurosurgery, National Neurosurgical Referral Center, National Academy of Medical Sciences (NAMS) Bir hospital and National Trauma Center, over the period of one and a half year. Description of Navigation techniques, its applications and surgical outcome were studied. Medtronic Stealth station 7 and Brain Lab Curve Neuronavigation system, which can be used as both frame based and frameless image guided system were employed in this study.&#x0D; Results: We used Neuronavigation system in 60 cases of cranial procedures and 5 cases of spinal stabilizing procedures. Among intracranial surgeries we utilized this system to effectively make bone flaps and burr holes, to detect critically located deep-seated, subcortical and skull base tumors and to operate on intra parenchymal lesions with grossly unclear margins.&#x0D; Neuronavigation system was used in 5 cases of spinal procedures for pedicle screw placement.&#x0D; Conclusion: Neuronavigation is a tool that provides numerous advantages to the neurosurgeon like more accurate planning approach, ability to use smaller approaches, higher precision for intraoperative localization of different anatomical structures and offering greater surgical safety. This technique, although apparently very complex in the beginning, becomes very user-friendly gradually and positively appreciated by everyone who uses it, after going through a relatively short learning curve.

Prevalence of Obesity in Inguinal Hernia Repair Patients in a Tertiary Care Center.

Inguinal hernia is a common surgical problem, with a lifetime risk of 27% in men and 3% in women. Its cumulative incidence is 17.2% and 12.3% in body mass index of <25 kg/m2 and 25-30 kg/m2 respectively. Obesity had been regarded as the risk factor for the development of an inguinal hernia. However, recent epidemiologic studies have suggested the decreased prevalence of inguinal hernia in increased weight and body mass index individuals. The aim of this study is to find out the prevalence of obesity in inguinal hernia repair patients in a tertiary care center. A descriptive cross-sectional observational study was performed in Bir Hospital from May 2018 to December 2019 after taking ethical approval from the institutional review board of NAMS. Convenient sampling was done with a sample size of 219. Statistical analysis was done using SPSS version 23 and Microsoft Excel software by descriptive statistics. The mean body mass index was 22.10±3.07 kg/m2. Body mass index category 18.5-22.9 kg/m2 had 133 (61%) male and seven (3.2%) female patients, category ≥30 kg/m2 had four (1.8%) male. Most of inguinal hernia repair patients were farmers 158 (72.5%). Common risk factors noted were smoking 142 (65.1%), heavy work 112 (51.4%), chronic cough 65 (29.8%). Most of the complications occurred in the normal body mass index category and the prevalence of complications decreased as the body mass index increased. The recurrence was found in 3 (1.4%) inguinal hernia repairs. The majority of inguinal hernia repair patients were non-obese, and complications were less in obese patients.

Assessment of Cardiovascular Risk Among Diabetes Patients Attending Tertiary Hospital, Using WHO/ISH Risk Prediction Chart

Background and aims Diabetes mellitus remain risk of developing cardiovascular disease, accounts for 80% of all deaths worldwide.Various prediction tools delineate the risk factors as well as identify high-risk individuals, evaluate potential targets of therapy and enhance cost-effective implementation of treatment. The joint WHO/International Society of Hypertension (WHO/ISH) risk prediction charts used to assess 10-years CVD risk. In Nepal, strong efforts should be implement to reduce the burden of type 2 DM and subsequent CVD. However, attention needs to be toward identifying the high-risk groups and successively reduce CVD burden in the long term. The aimed of study was to estimate the total 10-year cardiovascular disease risk using World Health Organization /International Society for Hypertension (WHO/ISH) Risk Prediction Chart on Nepalese diabetic patients. Methods This was a cross-sectional hospital based study conducted in Bir hospital, Nepal with 250 diabetic patients attending hospital were enrolled. Data were collected using a performed questionnaire, anthropometric & blood pressure measurement and medical and laboratory records. The total 10-year cardiovascular disease risk was measured using the WHO/ISH risk prediction chart.

Serum Vitamin D in Patients with Chronic Periodontitis and Healthy Periodontium.

Periodontitis is inflammatory disorder resulting in progressive destruction of the periodontal ligament and alveolar bone with pocket formation, recession, or both. Vitamin D has a benefit in bone metabolism and anti-inflammatory activity involving T-cell homeostasis. The objective of this study was to compare the vitamin D level in patient with chronic periodontitis and healthy periodontium and evaluate its correlation. A comparative cross-sectional study was done in 80 patients (40 with healthy periodontium and 40 with chronic periodontitis) visiting to Department of Dental Surgery (Periodontology and Oral Implantology Section) of Bir Hospital. Parameters measured were plaque index, gingival index, clinical attachment level and pocket depth for the evaluation of healthy periodontium and chronic periodontitis. The result showed 16.58±6.65ng/mL and 19.06±11.52ng/mL level of vitamin D in female and male respectively (p-value 0.230) and 16.85±13.30 ng/mL and 19.78±5.87 ng/mL level of vitamin D in healthy and chronic periodontitis groups respectively (p-value 0.209). There are no differences in the level of serum vitamin D between healthy and chronic periodontitis groups. No association was seen between vitamin D level and chronic periodontitis.

Salivary Alkaline Phosphatase Level in People with Healthy Periodontium and Generalised Chronic Periodontitis

Introduction: Periodontal disease is a multifactorial chronic inflammatory disease affecting the soft and hard supporting structures of teeth leading to alveolar bone loss and exfoliation of involved teeth when left untreated. Traditional periodontal diagnostic methods are not always able to assess present disease states. Saliva as possible biological sample helps measure current disease state, monitor treatment, and indicate prognosis. Oral fluids contain mediators of disease that include microbial host response and bone-specific resorptive markers.&#x0D; Objective: To investigate and compare salivary alkaline phosphatase level in people with healthy periodontium and generalised chronic periodontitis.&#x0D; Methods: This cross-sectional analytical study was conducted in the department of dental surgery, Bir hospital from January to December 2017. Ethical clearance was obtained from institutional review board. Unstimulated saliva sample for the evaluation of alkaline phosphatase was collected from 35 generalised chronic periodontitis (GCP) patients and 35 volunteers with healthy periodontium after informed consent was obtained and periodontal parameters were recorded. Data collected was analysed using SPSS software v.16.&#x0D; Results: Three and half fold increased level of salivary alkaline phosphatase level in GCP patients than healthy volunteers was found which is highly significant. Correlation of salivary alkaline phosphatase level with clinical features of the chronic periodontal disease was observed.&#x0D; Conclusion: An expected benefit of an oral fluid-based periodontal diagnostics would be identification of highly susceptible individuals prior to aggressive disease. Timely detection and diagnosis of disease offer earlier, less invasive, and more cost-effective treatment.

Evaluation of Bovine Derived Xenograft Combined with Bioresorbable Collagen Membrane in Treatment of Intrabony Defects

Introduction: Treatment of periodontal diseases done by surgical therapy depends upon extent and severity of disease. The ultimate goal of periodontal reconstructive surgery is to regenerate tissues destroyed during periodontal disease.&#x0D; Objective: To evaluate the effectiveness of bovine-derived xenograft with collagen membrane in treatment of intrabony defects by comparing it with open flap debridement alone.&#x0D; Methods: This non-randomised controlled trial was conducted after ethical clearance, at Bir hospital from 2018 March to 2019 April. The study recruited 38 patients by convenience sampling, age from 25-44 years, with chronic periodontitis, and willing to sign informed consent. Intrabony defects were treated by open flap debridement with bovine-derived xenograft and bioresorbable collagen membrane (Test group) and open flap debridement alone (Control group). Probing pocket depth, clinical attachment level, gingival recession, oral hygiene status, and gingival status were assessed at baseline and six months.&#x0D; Results: Six months after therapy, in Test group probing pocket depth reduction was 5.2 mm and gain in mean clinical attachment level was 4.3 mm. In Control group, mean probing pocket depth reduction was 3.8 mm and mean gain in clinical attachment level was 2.7 mm. The test treatment resulted in statistically higher probing pocket depth reduction and clinical attachment level gain than Control group.&#x0D; Conclusion: Both therapies resulted in significant probing pocket depth reductions and clinical attachment gains, and treatment with open flap debridement with bovine-derived xenografts and collagen membrane resulted in significantly higher probing pocket depth reduction and clinical attachment gain than treatment with open flap debridement alone.

Comparative Study of Autologous Radiocephalic and Brachiocephalic Arteriovenous Fistula in Patients with End Stage Renal Disease

Introduction: End-stage renal disease requires treatment with dialysis or renal transplantation. For the dialysis, autologous radiocephalic (RC) or brachiocephalic (BC) arteriovenous fistula (AVF) is the better option for vascular access for hemodialysis. Aims: The aim of this study is to find out the outcome between RC AVF and BC AVF. Methods: This is the retrospective study, conducted for the period of 24 months from September 2017 to September 2019 in the department of Cardiothoracic and Vascular Surgery of Bir Hospital, Nepal. RC and BC AVF were created for the assess of hemodialysis. Outcome and different complications were taken into consideration. Results: The total number of patients included in this study was 400. The overall failure rate of autologous AV fistula was 12.75%. Out of these, the failure rate was more in RC AV fistula group, 34 (17%) than in BC AV fistula group, 17 (8.5%). The most common complication was bleeding in both groups having an overall rate of 39 (9.75%). The limb edema was more common in BC AV fistula group 16 (8.0%) then in RC AV fistula group 7(3.5%). The overall infection rate was 4.5%. Overall patency rate was 87.25%. Conclusion: Autologous RC AVF and BC AVF are the choices for vascular access for hemodialysis in patients with end-stage renal disease. BC AVF has a better patency rate than RC AVF but with the slight higher risk of complications.

Percutaneous Nephrolithotomy and Horseshoe Kidneys

Introduction: The most common fusion anomaly, horseshoe kidney, is associated with vascular anomalies, malrotation, anterior displacement of the collecting system, superior insertion of ureter into the pelvis, and a higher rate of ureteropelvic junction obstruction; thus increasing the chances of nephrolithiasis. We present our experience with percutaneous nephrolithotomy in this anomaly.Materials and Methods: A retrospective study of all the percutaneous nephrolithotomy performed by standard technique within four years at Bir Hospital was made. A comparison was made with similar cases with the anatomically normal location of the kidney. Intraoperative variables were recorded and postoperative stonefree status and complications were evaluated.Results: Six hundred and twenty-seven patients out of 691 who had undergone percutaneous nephrolithotomy in this period were included. Patients with nephrolithiasis in horseshoe kidney were younger, the incidence of multiple stones was more; without full staghorn calculus and occupying fewer calyces. Upper pole access was easier, a stone clearance of 85.42 % was achieved with no major complications in the horseshoe kidney.Conclusions: Percutaneous access and nephrolithotomy are safe in horseshoe kidney with a good stone clearance rate.

Pre-stenting for Retrograde Intrarenal Surgery: Need and Duration: a Prospective Randomized Clinical Study

Introduction: To evaluate if retrograde intrarenal surgery with ureteral access sheath requires prestenting. In case pre-stenting becomes an option, how long does it need to be stented. &#x0D; Materials and Methods: After obtaining approval from Institutional Review Board and informed consent, a prospective randomized controlled study was conducted in the Department of Urology, Bir Hospital for 18 months. All the patients enrolled for retrograde intrarenal surgery were grouped into 3 groups: Group 1 – without pre-stenting, Group 2 – one week of pre-stenting, and Group 3 – two weeks of pre-stenting. Success was defi ned as an ability to accommodate a 10/12 F ureteral access sheath during retrograde intrarenal surgery. Ureteral access sheath induced ureteric wall injury was also taken into consideration.Results: Among 179 cases, 152 cases were included in the study. In 36 patients out of 53 (67.92%) in group 1, 10/12 F ureteral access sheath was negotiable without pre-stenting, marking the frequency of distensible ureters. In 44 patients out of 47 (93.66%) from group 2 and all 52 patients (100%) from group 3, ureteral access sheath placement was successful after one and two weeks of pre-stenting respectively. Ureteric wall injury of grade1 and 2, was found in 9 patients (5.9%).Conclusions: The majority of ureters (67.92%) are distensible, not requiring pre-stenting before retrograde intrarenal surgery. One and two weeks of pre-stenting carries a success rate of 93.66% and 100% respectively.

Antibiotic Susceptibility Pattern of Salmonella Enterica serovars Typhi and Paratyphi A Isolated From Patients Suspected of Enteric Fever

Objectives: The study aimed to assess the antibiotic susceptibility profile of Salmonella spp isolated from patients suspected of enteric fever.&#x0D; Methods: This cross-sectional prospective study was carried out from April to June, 2014among 484 patients clinically suspected of enteric fever visiting Bir Hospital, Kathmandu, Nepal. Blood sample collected from each patient was processed for culture in bile broth. Identification of Salmonella spp was done by conventional microbiological techniques including colony characteristics, Gram's staining and biochemical tests. Antibiotic susceptibility testing of identified isolates was done by Kirby-Bauer disk diffusion method following the 2014 CLS I guideline.&#x0D; Results: Out of 484 blood samples, 36 (7.43%) cases showed the growth of Salmonella spp; of which 27 (75%) were Salmonella enterica serovar Typhi (ST) and 9 (25%) were Salmonella enterica Paratyphi A (SPA). Among the Salmonella isolates, 5.55% were multidrug resistant and 41.66% were fluoroquinolone resistant. More than 80% of isolates were sensitive to chloramphenicol, amoxicillin, and cotrimoxazole whereas 58%, 50% and 6% of isolates were sensitive to fluoroquinolone antibiotics i.e. ciprofloxacin, ofloxacin and nalidixic acid respectively. All the isolates were susceptible to ceftazidime. All SPA and 89% of ST were sensitive to azithromycin.&#x0D; Conclusion: Higher percentage of susceptible isolates to chloramphenicol, cotrimoxazole, and amoxicillin suggests the reconsideration of these antibiotics for the treatment of enteric fever. Azithromycin can be considered as drug of choice for the treatment of enteric fever.