Civil Service Hospital Research Articles

Safety and Efficacy of Azathioprine as a Second Line Therapy for Primary Immune Thrombocytopenic Purpura

Immune thrombocytopenic purpura remains common blood disease in Nepal. Azathioprine is an oral immunosupressive medicine which has been used widely in various autoimmune disease and solid organ transplant patients. It is inexpensive, easily available and well tolerated medicine. This study was carried out to evaluate efficacy and safety of azathioprine as a second line medicine for primary ITP patients who were refractory to steroid therapy. The observational, pre-post study was conducted at Government of Nepal Civil Service Hospital, Kathmandu from January to October 2014. Twenty four primary ITP patients who were steroid refractory were treated with Azathioprine. Patients were termed steroid refractory if platelet counts were less than 30,000/ul on day 21st of steroid therapy. From day 22 onwards oral azathioprine 2mg/kg was started and steroids were tapered 10mg/week and stopped. Platelet counts of more than 30000/ul after one month of stopping steroid, while still on azathioprine, were termed response to azathioprine. Platelet count of more than 100,000/ul was termed complete response. The associations among age, gender, duration and platelets counts were analyzed by chi square test and Fisher's exact test (when individual cell frequency was less than 5). The comparison of platelets counts among the start and day 90 of Azathioprine therapy was performed by the paired t-test. The study showed that there was not significant association among age and gender of the patients and their platelets count on the start of Azathioprine therapy (p value 0.354 and 0.725 respectively) and on day 90 of Azathioprine therapy (p value 0.082 and 0.762 respectively). The duration-wise comparisons of platelets count on both the start and day 90 of Azathioprine therapy were significant (p values 0.029 and 0.008 respectively). The paired comparison among platelets count on the start and day 90 of Azathioprine therapy was highly significant (p value 0.000). The study showed the therapeutic implication of azathioprine in ITP patients. It also showed that efficacy of azathioprine was comparable with other modes of treatment. In low income countries like Nepal azathioprine can be considered as second line treatment for steroid refractory ITP patients.

Laparoscopic splenectomy: case series of 24 patients

Introduction and Objective: Splenectomy has mostly been performed by open surgery. Laparoscopy seems to be a meaningful alternative to open technique.Materials and Methods: This study was done in patients presenting to hematology and surgery department of Civil Service Hospital who underwent laparoscopic splenectomy from January 2013 to November 2015Results: There were 24 patients (16 females, 8 males). The diagnoses were idiopathic thrombocytopenic purpura in 19, hereditary spherocytosis in 2, @hemolytic anemia in 2, b-hemolytic anemia in 1. The mean operative time was 130+49 minutes. The mean postoperative stay was 5+2.11 days. Laparoscopic splenectomy could be completed in 21 patients. Rest 3 needed conversion to open (causes being excessive bleeding form splenic vein, splenic tear, and excessively low platelet counts). Three patients needed additional pfanneinsteil/lumbar incision to retrieve the spleen.Conclusion: Laparoscopic splenectomy could be successfully contemplated in patients with hematological diseases, more so if spleen is of normal or mildly enlarged; and could be an advantageous alternative to open splenectomy.

Laparoscopic rectopexy for rectal prolapse

Introduction: Rectal prolapse surgery has been considered advanced laparoscopic surgery; hence it has mostly been performed by open surgery. However, with advancement, laparoscopic rectopexy can be feasible in patients with rectal prolapse.Materials and Methods: This study was done in patients presenting to Surgery Department of Civil Service Hospital who underwent laparoscopic rectopexy from January 2013 to November 2015Results: There were 8 patients (4 females and 4 males). The mean operative time was 160+49 minutes. The mean postoperative stay was 3+1.21 days. There was no conversion. One child underwent suture rectopexy, whereas adults underwent posterior mesh rectopexy. No patients needed blood transfusion. Postoperatively one patient has constipation, and she needed occasional laxatives. Conclusion: Laparoscopic rectopexy is a minimally invasive advanced procedure with all the advantages of laparoscopy. With further experience operative time could be reduced.

Laparoscopic cloasure of Duodenal ulcer perforation

Introduction and Objective: Duodenal ulcer perforation creates a peritonitis which is sometimes hard to manage, especially with minimally invasive approach. This study is about laparoscopic approach to peritonitis due to duodenal ulcer perforation.Materials and Methods: It was a prospective study in patients presenting with duodenal perforation peritonitis to emergency of Civil Service Hospital from January 2013 to November 2015.Result: There were 6 patients (4 males and 2 females). The mean duration of presentation was 16+2.32 hrs. The mean operative time was 55+17.34 minutes. One patient developed right lower zone pneumonia which resolved on conservative management. There was no conversion.Conclusion: Laparoscopic management of duodenal perforation is a feasible procedure in select young patients who present early and without any without comorbities

Prevalence and Antibiotic Resistance Patterns of Bacterial Isolates from Urine Samples of Patients Attending Kwara State Civil Service Hospital Ilorin, Nigeria

Antibiotic resistance has become alarming throughout the world and most especially in third world countries in particular. Human urine samples(n= 80) of patients attending the Kwara state Civil Service Hospital Ilorin, North Central Nigeria were analysed for Urinary Tract Infections(UTIs) and Antibiotic Susceptibility pattern of isolated organisms. The urine samples were cultured on blood agar, MacConkey agar and Cysteine lactose electrolyte deficient (CLED) agar while antimicrobial susceptibility test was determined using Kirby-Bauer disc diffusion method. The following bacteria were isolated Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa, Proteus mirabilis, Staphylococcus epidermidis, Enterococcus faecalis and Klebsiella pneumoniae. The isolates comprise of 57.1% Gram negative bacteria and 42.9% Gram positive bacteria. This study revealed that antibiotics such as Ciprofloxacin and Ofloxacin(100% and 71.4% susceptibility respectively) are the most effective against the isolates, the antibiotic resistance pattern of the isolates indicates emerging multi drug resistance among urinary tract bacterial pathogens.  

Development and implementation of healthcare waste management policy at Civil Service Hospital, Nepal

AbstractOver the last 5 years, the Civil Service Hospital (Nepal) has dealt with various serious health hazards including infectious diseases and other important risks. A management committee was appointed to develop a healthcare waste management policy in 2013. The policy deals with the management of safety issues associated with occupational hazards, as well as raising public awareness of the importance of proper waste management. Safe management of healthcare waste enhances patient safety and promotes occupational safety. This policy was categorised into three chapters: preliminary discussion, organisational and managerial aspects and occupational health and safety. The policy was implemented in several phases. During the first phase, medicine, orthopedics, gynecology, obstetrics and paediatric services were targeted, while the second phase included the surgical, post‐operative and haematology wards, the high care unit and emergency and laboratory departments. The third phase involved the pharmacy, out‐patient department and hospital administration, while the fourth phase eventually included the whole hospital. Development of this policy was guided by Government of Nepal Solid Waste Management Act 2011 and the World Health Organisation Guidelines.

Impact of intervention on healthcare waste management practices in a tertiary care governmental hospital of Nepal.

BackgroundHealthcare waste is produced from various therapeutic procedures performed in hospitals, such as chemotherapy, dialysis, surgery, delivery, resection of gangrenous organs, autopsy, biopsy, injections, etc. These result in the production of non-hazardous waste (75–95%) and hazardous waste (10–25%), such as sharps, infectious, chemical, pharmaceutical, radioactive waste, and pressurized containers (e.g., inhaler cans). Improper healthcare waste management may lead to the transmission of hepatitis B, Staphylococcus aureus and Pseudomonas aeruginosa.MethodsThis evaluation of waste management practices was carried out at gynaecology, obstetrics, paediatrics, medicine and orthopaedics wards at Government of Nepal Civil Service Hospital, Kathmandu from February 12 to October 15, 2013, with the permission from healthcare waste management committee at the hospital. The Individualized Rapid Assessment tool (IRAT), developed by the United Nations Development Program Global Environment Facility project, was used to collect pre-interventional and post-interventional performance scores concerning waste management. The healthcare waste management committee was formed of representing various departments. The study included responses from focal nurses and physicians from the gynaecology, obstetrics, paediatrics, medicine and orthopaedics wards, and waste handlers during the study period. Data included average scores from 40 responders. Scores were based on compliance with the IRAT.ResultsThe waste management policy and standard operating procedure were developed after interventions, and they were consistent with the national and international laws and regulations. The committee developed a plan for recycling or waste minimization. Health professionals, such as doctors, nurses and waste handlers, were trained on waste management practices. The programs included segregation, collection, handling, transportation, treatment and disposal of waste, as well as occupational health and safety issues. The committee developed a plan for treatment and disposal of chemical and pharmaceutical waste. Pretest and posttest evaluation scores were 26% and 86% respectively.ConclusionsDuring the pre-intervention period, the hospital had no HCWM Committee, policy, standard operating procedure or proper color coding system for waste segregation, collection, transportation and storage and the specific well-trained waste handlers. Doctors, nurses and waste handlers were trained on HCWM practices, after interventions. Significant improvements were observed between the pre- and post-intervention periods.

Assessment of Patient Satisfaction on the Information Provided by Nurses During Hospitalization

Patients have explicit desires or requests for services when they visit hospitals. However, inadequate discovery of their needs may result in patient dissatisfaction. This study aimed to find the levels and determinants of patient satisfaction driven by nurses.The researchers have conducted comparative cross-sectional study using quota sampling at Medical ward, surgical ward, orthopedic ward and gynecology and obstetrics ward of Civil Service Hospital, Kathmandu, Nepal. A pre-tested and contextually developed structured questionnaire been used to conduct interviews and check-list had been prepared for conducting non participatory observation. Descriptive statistics, analysis of variance, and factor analysis was used to analyze the result and interpretation was done on narrative basis.The Cronbach alpha test on information provided by nurses and was found moderately reliable. Similarly, Application of test on information payment, information of referral and information of time of discharge shows that the satisfaction given on information of payment, information of referral and information of time of discharge is not different.

Statistical Quality Control; a Tool for Monitoring Epidemic Diseases Outbreak

This study is aimed at designing CUSUM and EWMA control chart and comparing their performances. The data used in this paper are records of outbreak of some diseases collected from Edo State Civil service Hospital, Benin City and are therefore secondary data. The data covered the period, January 2006 to December 2010. Cumulative Sum (CUSUM ) and Exponentially Weighted Moving Average (EWMA) control charts scheme were designed and used to study the rate of outbreak of some diseaes. Finally, the performances of the two designed control chart schemes were compared. Both CUSUM and EWMA were capable of detecting shifts in diseases data. EWMA charts tended to be slightly slower in providing alarms, but were much easier to set up. Overall CUSUM charts are more efficient to use. Use of these techniques could allow detection of changes in time to mitigate the recurrent pattern of the outbreak of epidemics. Keywords: Cumulative Sum (CUSUM), Decision Interval (DI), Exponentially Weighted Moving Average (EWMA), Lower Control Limit (LCL), Upper Control Limit(UCL), Acceptable Quality Level (AQL), Rejectable Quality Level (RQL), In-control Average Run Length (ICARL), Out-of-Control Average Run Length (OO-ARL), Average Run Length (ARL), Run Length (RL)

Study of Mumps in Children attending a Tertiary Care Centre

Introduction: Mumps is a self-limiting viral infection of the salivary glands with systemic manifestations and complications. It primarily affects young children, with increased incidence in winter and spring. Mumps infection is endemic in developing countries because of poor vaccination coverage. This study is intended to highlight the increased number of mumps cases in children attending tertiary care center in Nepal and thus to emphasize the importance of mumps vaccination, so as to decrease the disease occurrence and disease burden by vaccinating all children. Materials and Methods: This was a prospective study done in Civil Service Hospital of Nepal over a period of 2 years from November 2009 to October 2011. All children less than 14years of age with symptoms of fever and parotid swelling were included in the study group. A detailed history pertaining to the disease was taken, that included; history of exposure and prior vaccination against mumps. Children were asked to follow up either after 5 days or in case of noticing any signs and symptoms of complication. Results: There were total 113 cases diagnosed clinically as mumps of which there were 71 males (62.83%) and 42 females (37.16%) with the peak incidence of disease in the month of March and September with 22 cases (19.46%) in each month. The increase incidence was seen in 4-6 years of age with 58 cases (51.32%). There were 70 patients (61.94%) that had history of exposure to mumps infection. All the patients in this study had either unilateral or bilateral parotitis. None of the children were vaccinated against mumps. And all the school going children had to be off school for a period of 3-5 days. Conclusion: There were large number of children with mumps and none of them were vaccinated. Child can be prevented from the infection by vaccination and thus avoiding possible sufferings and complications. Thus we recommend the use of mumps vaccination in Routine immunization programme. Key words: Mumps; Parotitis; School absenteeism; Nepal; Vaccine DOI: http://dx.doi.org/10.3126/jnps.v32i1.5499 J. Nepal Paediatr. Soc. Vol.32(1) 2012 53-56

Clinical Profile and Sensitivity Pattern of Salmonella Serotypes in Children: A Hospital Based Study

Introduction: Enteric fever is a systemic infection caused by the bacteria, Salmonella enterica serovar Typhi (S.typhi) and Salmonella enterica serovara Paratyphi (S. paratyphi A, B and C). Most of the burden of the disease is limited to the developing world and the disease still has the issues like wide spectrum of clinical presentation and multidrug resistance. Objectives: This study was done to analyze the clinical profile and antibiotic sensitivity pattern in the cases of culture positive enteric fever. Methods: A prospective cross-sectional study was conducted in Civil Service Hospital from February 2010 to January 2011 in the paediatric population in the age group of 2 to 14 years. Children with Salmonella species isolated in blood culture were included in the study. Results: Out of the 40 children with culture positive enteric fever, male to female ratio was 1.3:1 with common age group between 11-14 years. S typhi was isolated in 25 cases while S. paratyphi in 15 cases. Clinical features of S. typhi and S. paratyphi were indistinguishable. Both S.typhi and S. paratyphi were found to be 100% sensitive to drugs like Ceftriaxone, Cefotaxime, Cefixime and Chloramphenicol. Sensitivity to Ofloxacin was 100% in S. paratyphi and 92% in S.typhi. Similarly sensitivity of Azithromycin was 92% and 93% for S.typhi and S. paratyphi respectively. Conclusion: Salmonella serotype is still 100 % sensitive to third generation cephalosporin. Some percentage of resistance is seen with Ofloxacin in S. typhi and with Azithromycin in both S.typhi and S. paratyphi. Key words: Enteric fever; S.typhi; S.paratyphi; Sensitivity DOI: http://dx.doi.org/10.3126/jnps.v31i3.4382 J Nep Paedtr Soc 2011;31(3): 180-183

Enteric Fever in Children of Nepal

DOI: http://dx.doi.org/10.3126/jnps.v31i3.5351 J Nep Paedtr Soc 2011;31(3):167-168