Ram Kumar Ghimire

Surviving 27 weeks fetus expelled out of the ruptured rudimentary horn and detected a month later as a secondary abdominal pregnancy

A pregnant woman, gravida 3 with two living children, who frequently experienced syncope from 23+5 weeks of pregnancy onwards and recurring every week for a period of 3 weeks, was repeatedly treated in line for a case of acid peptic disease/appendicitis in various peripheral hospitals of Nepal, until ultrasonogram/magnetic resonance imaging diagnosis of an (undisturbed) live 27+5 weeks abdominal pregnancy was made at our hospital. On laparotomy, this materialized to be secondary to the rupture of a left rudimentary horn pregnancy (evidenced from its sealed margin) which still retained a complete placenta, from where an umbilical cord was seen, traversing across towards the right side of the abdominal cavity just below the liver, securing its attachment to the surviving fetus and enclosed in an intact amniotic sac. Excision of the rudimentary horn containing the placenta was accomplished, after the delivery of a live baby weighing 650 g who unfortunately died on the third day of life.

Predictors of duration and treatment failure of severe pneumonia in hospitalized young nepalese children

Background Pneumonia in young children is still the most frequent cause of death in developing countries. We aimed to identify predictors for recovery and treatment failure in children hospitalized with severe pneumonia. Methods We enrolled 610 Nepalese children, aged 2 – 35 months from February 2006 to June 2008. Study participants were provided with standard treatment for pneumonia and followed up until discharge. Three multiple regression models representing clinical variables, clinical and radiological combined and all variables, including C-reactive protein (CRP) and viral etiology were used to assess the associations. Results The median age of study participants was 6 months with 493 (82%) infants and 367 (61%) males. The median time (IQR) till recovery was 49 (31, 87) hours and treatment failure was experienced by 209 (35%) of the children. Younger age, hypoxia on admission and radiographic pneumonia were independent predictors for both prolonged recovery and risk of treatment failure. While wasting and presence of any danger sign also predicted slower recovery, Parainfluenza type 1 isolated from the nasopharynx was associated with earlier resolution of illness. Gender, being breastfed, stunting, high fever, elevated CRP, presence of other viruses and supplementation with oral zinc did not show any significant association with these outcomes. Conclusion Age, hypoxia and consolidation on chest radiograph were significant predictors for time till recovery and treatment failure in children with severe pneumonia. While chest radiograph is not always needed, detection and treatment of hypoxia is a crucial step to guide the management of hospitalized children with pneumonia.

Renal Cortical Elastography: Normal Values and Variations

Introduction Renal cortical elastography has shown conflicting but promising results in evaluation of chronic kidney disease and other renal disorders. The purpose of this study was to establish a normogram of renal cortical elasticity values and assess their variation between right and left kidney and their relation with age, gender, body mass index, renal dimensions and skin to cortex distance. Methods The study was a hospital based cross sectional study performed at Tribhuvan University Teaching Hospital, a tertiary care center in Kathmandu, Nepal. All individuals referred for Ultrasound from General Health Check up clinic were included in the study. Patient with abnormal ultrasound findings and abnormal renal function test were excluded from the study. Renal morphometry including length, cortical thickness, and skin to cortex distance were measured in B mode imaging and renal cortical elastography was measured with region of interest box of 1 × 0.5 cm. All analyses were done using Statistical Package for Social Sciences 20.0 soft ware. Results A total of 95 individuals who met the inclusion criteria were included in the study. The mean values of right and left renal cortical shear wave velocity were 1.49 ± 0.19 m/s and 1.54 ± 0.19 m/s respectively. Statistical significant difference was observed between the renal cortical shear wave velocity of right and left kidney. The renal shear wave velocity was seen to decrease with age, however the correlation was not statistically significant. No significant difference was also noted in renal shear wave velocity among various sex or Body mass index groups. Statistically significant negative correlation was noted between skin to cortex distance and renal cortical shear wave velocities. However no statistically significant correlation was noted between renal dimensions and renal cortical shear wave velocities. Conclusions The normal cortical elasticity values in terms of shear wave velocity of right and left kidney were established. Renal elasticity is independent of the age, gender, Body mass index and renal dimensions.

Complex Cervical Aortic Arch With Hypoplasia: A Simple Solution to a Complex Problem

We report a rare case of a 6-year-old boy with a complex right-sided cervical aortic arch, with retroesophageal hypoplastic transverse arch, left subclavian artery arising from the Kommerell diverticulum of the descending aorta, and a vascular ring formed by the ductus ligament. An extraanatomic ascending-to-descending aorta bypass was done through a median sternotomy along with division of the ductus ligament, without any complications and good results.

Validity of home-based sonographic diagnosis of obstetric risk factors by auxiliary nurse midwives in rural Nepal

www.thelancet.com/lancetgh 23 Published Online April 8, 2016 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA (N Kozuki PhD, L C Mullany PhD, SC LeClerq MPH, J Katz ScD); Nepal Nutrition Intervention Project – Sarlahi, Lalitpur, Nepal (S K Khatry MD); Tribhuvan University Teaching Hospital, Kathmandu, Nepal (R K Ghimire MD); The Johns Hopkins Hospital, Baltimore, MD, USA (C Bird RDMS, K Blakemore MD); George Washington University Milken Institute School of Public Health, Washington, DC, USA (J M Tielsch PhD) Correspondence to: Naoko Kozuki, 615 N Wolfe Street, W5019, Baltimore, MD 21205, USA nkozuki@jhu.edu Validity of home-based sonographic diagnosis of obstetric risk factors by auxiliary nurse midwives in rural Nepal Naoko Kozuki, Luke C Mullany, Subarna K Khatry, Ram K Ghimire, Sharma Paudel, Karin Blakemore, Christine Bird, James M Tielsch, Steven C LeClerq, Joanne Katz Abstract Background Approximately 2·3 million fetal, neonatal, or maternal deaths occur annually during the intrapartum period or on the day of birth. Several risk factors for intrapartum-related complications require ultrasonography for accurate diagnosis, but sonographic services are scarce in low-resource settings. In this study, we aimed to assess the feasibility of community-based ultrasonography conducted by auxiliary nurse midwives to identify basic obstetric risk factors, in rural Sarlahi District, Nepal. We aimed to assess the validity at which these health workers can detect noncephalic position, multiple gestation, and placenta previa and to explore whether sonographic diagnosis could improve outcomes for women with these high-risk conditions.Background Approximately 2·3 million fetal, neonatal, or maternal deaths occur annually during the intrapartum period or on the day of birth. Several risk factors for intrapartum-related complications require ultrasonography for accurate diagnosis, but sonographic services are scarce in low-resource settings. In this study, we aimed to assess the feasibility of community-based ultrasonography conducted by auxiliary nurse midwives to identify basic obstetric risk factors, in rural Sarlahi District, Nepal. We aimed to assess the validity at which these health workers can detect noncephalic position, multiple gestation, and placenta previa and to explore whether sonographic diagnosis could improve outcomes for women with these high-risk conditions. Methods Three auxiliary nurse midwives (ANM) received two 1-week ultrasound trainings at Tribhuvan University Teaching Hospital in Kath mandu, Nepal. Women at 32 weeks’ or more gestation were enrolled in the study, and received ultrasonography from the ANMs during home visits. ANMs used ultrasonography to identify non-cephalic position, multiple gestation, and placenta previa. Images were saved and later reassessed by gold standard ultrasonographers to determine the validity of the ANM assessment. We also compared adverse outcomes in noncephalic or multiple gestation births from the study group with those in a comparison group of women who did not receive ultrasonography from our study, but the study was not powered to detect a diff erence. Findings We collected data from 815 women. The kappa statistics for diagnosis of non-cephalic position were 0·92, 0·98, and 0·94, respectively, for the three ANMs against the gold standard. Sensitivity, specifi city, positive predictive value, and negative predictive value were between 90% and 100% for all ANMs. For multiple gestation pregnancies (n=6), the ANMs were in perfect agreement with both the gold standard reading and maternal postpartum self-report. Two cases of placenta previa were detected, and the gold standard was in agreement with both. There were 4 adverse outcomes out of 19 women (21%) with non-cephalic or multiple gestation pregnancies in the study group compared with 10 out of 36 (28%) in the comparison grroup. This diff erence was not signifi cant (p=0·586). Interpretation Our fi ndings suggest that it is feasible for ANMs to conduct ultrasonography to identify basic obstetric risk factors in low-income settings. The diff erence in birth outcomes in non-cephalic and multiple births, comparing those antenatally diagnosed by ultrasound and those who were not, was not signifi cant; the sample size was too small to detect a diff erence. Further investigation is warranted to determine whether sonographic diagnosis of selected obstetric factors could contribute to improved care-seeking and health outcomes in low-income settings. Funding Cappsci Data for Life Award, SonoSite Soundcaring Program, National Institutes of Health/National Institute of Child Health and Human Development, Bill & Melinda Gates Foundation. Copyright