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Introduction Intentional pesticide poisoning is a major clinical and public health problem in agricultural communities in low and middle income countries like Nepal. Bans of highly hazardous pesticides (HHP) reduce the number of suicides. We aimed to identify these pesticides by reviewing data from major hospitals across the country and from forensic toxicology laboratories. Methods We retrospectively reviewed medical records of 10 hospitals for pesticide poisoned patients and two forensic laboratories of Nepal from April 2017 to February 2020. The poison was identified from the history, referral note, and clinical toxidrome in the hospitals and from gas chromatography analysis in the laboratories. Data on demographics, poison, and patient outcome were recorded on a data collection sheet. Simple descriptive analysis was performed. Results Among hospital cases (n = 4148), the commonest form of poisoning was self-poisoning (95.8%) while occupation poisoning was rare (0.03%). Case fatality was 5.3% (n = 62). Aluminum phosphide (n = 38/62, 61.3%) was the most commonly identified lethal pesticide for deaths. Forensic toxicology laboratories reported 2535 deaths positive for pesticides, with the compounds most commonly identified being organophosphorus (OP) insecticides (n = 1463/2535; 57.7%), phosphine gas (n = 653/2535; 25.7%; both aluminum [11.8%] and zinc [0.4%] phosphide) and organochlorine insecticides (n = 241/2535; 9.5%). The OP insecticide most commonly identified was dichlorvos (n = 273/450, 60.6%). Conclusion The data held in the routine hospital medical records were incomplete but suggested that case fatality in hospitals was relatively low. The pesticides identified as causing most deaths were dichlorvos and aluminum phosphide. Since this study was completed, dichlorvos has been banned and the most toxic formulation of aluminum phosphide removed from sale. Improving the medical record system and working with forensic toxicology laboratories will allow problematic HHPs to be identified and the effects of the bans in reducing deaths monitored.

Background: With the increasing number of Chronic Kidney Disease (CKD), emergency visit of these patients is also increasing. This study tried to find some of the reasons for which patients with CKD visit the emergency room and the reasons for their mortality. Method: A cross-sectional study was done in the emergency room of Tribhuvan University Teaching Hospital, Kathmandu, Nepal. We conducted this study from 1 May 2018 to 31 October 2018 among the adult CKD patients under regular hemodialysis. We used a convenience sampling method. Three hundred patients were included. We studied the following variables: patient’s age, sex, risk factors, laboratory parameter during the emergency visit (viz. hemoglobin, pH, serum bicarbonate level, and potassium level), emergency hemodialysis, blood transfusion, and clinical outcome during emergency room stay. Result: We enrolled 300 patients in the study. The mean age was 45.04 years in the mortality group and 45.69 years in the survival group 152 (50.7%) of patients had hypertension. Mean hemoglobin was 6.52gm% (SD = 1.93). Mean hemoglobin in survivor and the non-survivor group was 6.59 gm% and 5.58 gm% respectively. Serum creatinine was 1220.87 mmol/L and 1064.01 mmol/L in mortality and survivor group respectively. Likewise, serum potassium was 6.13 mEq/l and 5.74 mEq/l among mortality and survivor groups respectively. Binary logistic regression showed significant association (p

Emergency workers carry a huge responsibility in Covid 19 pandemic. Emergency staff have to provide prehospital care, early triage and management of patients with suspected or confirmed infection. More importantly, emergency care givers have to do everything to prevent emergency room from spread of the infection, to other patients. Access blocks following increasing flow of patients with suspicion of infection, causes overwhelming patients leading to delayed care and resource shortage to patients with chronic and acute diseases. This surge has put emergency workers at risk: risk from a potential contamination and risk from the effect of extended shifts work in the hospital. At this stage, the major challenges while performing emergency service has been managing triage, human resources, limited stock of personal protective equipment (PPE), proper management of infection prevention and limited laboratories for testing. Due to lack of those requirements, certain guidelines and running the service without such guidelines making the emergency service in difficult situation during such crisis period.

Introduction: Amniotic fluid cavity filled with liquor amnii is a natural floating bed for fetus required for its existence and growth in sterile environment, regulation of temperature, avoidance of external injury and reduction of impact of uterine contractions. Amniotic fluid has high influence on the fetal outcome and is directly related to the perinatal morbidity and mortality. This study aims to compare the pregnancy outcomes in patients with borderline AFI between 5-8 cm and normal AFI >/= 8-24 cm. Method: This was a prospective observational study of 108 pregnant women. After Amniotic Fluid Index (AFI) assessment, they were categorized into two groups: those with AFI 5-8 cm (Group 1) and with AFI >/=8-24 cm (Group 2) accordingly. Pregnancy outcomes was noted in terms of mode of delivery, amniotic fluid colour & fetal birth weight. Result: Six(11.1%) had instrumental delivery & 28 (51.8%) had Cesarean section in borderline AFI group. 6 (11.1%) had instrumental delivery & 14 (26%) had Cesarean section in normal AFI group. 28 (51.9%) had meconium stained amniotic fluid in borderline AFI group & 13 (24.1 %) had meconium stained amniotic fluid in normal AFI group. 110 (18.5%) newborns had fetal birth weight of

Introduction: Community-acquired pneumonia is an infectious disease with a global burden. Thrombocytopenia can be an effective and inexpensive tool in predicting the severity of pneumonia which can be useful in the primary care level. The objectives were to identify the clinical and laboratory predictors of hospitalized patients with pneumonia, determine the incidence of thrombocytopenia in those patients, its association with severity, compare it with leucocyte count, assess severity using clinical prediction scores, need of mechanical ventilation, need of transfer to intensive care unit and mortality. Methods: After informed consent, diagnosed and admitted cases of community-acquired pneumonia were examined after which patients' demographic and clinical data as well as laboratory parameters including white cell count and platelets were filled in proforma. Clinical prediction scores for pneumonia were calculated and the need for mechanical ventilation, inotropes, transfusions as well as mortality assessed. Patients were followed up until discharge to see the severity of pneumonia. Results: The incidence of thrombocytopenia among patients with pneumonia was 36.9% (41 out of 111). The overall mortality rate was 9%. More pneumonia patients having thrombocytopenia (14.6%) died than pneumonia patients having leukocytosis (13.8%). There was a significant association between thrombocytopenia and severity of pneumonia, both alone, (p = 0.007, OR = 4.03) and on adjusting for the WBC and GCS (p=0.017, OR = 3.81).Significant associations were found between thrombocytopenia and the need for ICU in patients with pneumonia (p=0.001), mechanical ventilation (p = 0.001), presence of edema, confusion, age variation (p=0.024) and septic shock (p=0.021). Conclusion: Thrombocytopenia can serve as an effective predictor of the severity of pneumonia.

Background: Chronic kidney disease is increasing day by day and so is condition of renal replacement therapy; mainly hemodialysis. Emergency visit of the patients under maintenance hemodialysis is frequent. The objective of the study is to study clinical parameters of these patients so that in future these deranged parameters can be focused during patient management and decrease their emergency visit. Methods: A prospective cross sectional study was conducted in emergency services of Tribhuvan University Teaching Hospital from 1st May 2018 to 31st October 2018 among the adult chronic kidney disease patients under maintenance hemodialysis. Ethical approval was taken from Institutional review board, Institute of medicine, TribhuvanUniversity.Nonprobability sampling method was used. Total of 300 patients were enrolled in the study. Patients’ age, sex, causes, laboratory parameter during emergency visit, need of emergency hemodialysis, and need of blood transfusion were studied. Results: Out of total 300 patients, mean age was 45.64 years (S.D =17.15). 190 (63.3 %) were male and 110(36.70%) were female. 152(50.70%) of patients had hypertension. Diabetes and Glomerulonephritis both had equal prevalence of 63(21%). Mean hemoglobin was 6.52gm% (S.D = 1.93). Mean pH was 7.17 (S.D =0.154). Mean serum potassium and creatinine level were 5.77 mEq/L (S.D =0.76) and 1076.03 mmol/l (S.D =367.25) respectively. Area under the Receiver Operating Curve was 0.660 for potassium and 0.598 for serum creatinine. Conclusions: Causes of chronic kidney disease, decreased hemoglobin level, increased serum creatinine and potassium level and metabolic acidosis are causes of frequent emergency room visit among CKD patients. So these conditions need to be addressed to decrease emergency visit of these patients. Keywords: chronic kidney disease; emergency presentation; mortality. DOI: http://doi.org/10.3126/jkahs.v2i2.25167

Introduction: Sepsis is a common problem encountered in emergency room which needs to be intervened early. It is always difficult to have quick prognostic marker of sepsis in busy emergency. So this study was conducted to determine whether base deficit can be used as an indicator of mortality among septic patients in emergency room setup like ours. Methods: It was a hospital based descriptive cross sectional study done at Tribhuvan University Teaching Hospital, Kathmandu from March 2018 to December 2018. Acute physiology and chronic health Evaluation II score (APACHE II), Base deficit, Sequential Organ Failure Assessment (SOFA) score on first day of arrival in emergency room was calculated. The association of 28-day outcome with acute physiology and chronic Health Evaluation II score, Base deficit value and SOFA score were derived. Results: Out of 229 patients with septic shock 62 died (27%) and among 71 patients without septic shock, 12 died (16.9%).Overall mortality was 24.66 % (n= 74).The area under the ROC curve for Base deficit(0.864;95% C.I.=0.822-0.906), APACHE II (0.782; 95% C.I=0.718-0.848, SOFA (0.689;95% C.I=0.620-0.757) were greater than 0.7 except for SOFA which signifies these test to have fair efficacy to predict mortality. Conclusions: High base deficit value predicts mortality in patients with sepsis and septic shock. The base deficit could be used as an alternate marker to predict mortality in septic patient. We recommend for large multicenter study with randomization so that the findings can be applied to general population and of different geographical situations.

Introduction: Upper gastrointestinal bleeding is a gastrointestinal emergency. It is characterized by hematemesis or melena or both. Rapid identification and stabilization of patients with upper gastrointestinal bleeding presenting to the emergency department is essential for patient survival. This study was done to inspect the use of the Clinical Rockall score to predict the outcome in patients with Upper gastrointestinal bleeding. Methods: A cross sectional study of 272 patients who presented to the emergency department of Tribhuvan University Teaching hospital within a period of one year with hematemesis or melena or both was performed. The Clinical Rockall Score was calculated for each patient based on the points assigned for clinical variables. Results: The most common cause of upper gastrointestinal bleeding was esophageal varices 86 (31.6%), followed by ulcers 53 (19.5%). Hematemesis was the most common mode of presentation in 133 (48.9%) followed by melaena in 95 (34.9%) and both in 44 (16.2%). High clinical Rockall score of >4 was associated with outcomes like transfusion in 81% patients, rebleeding in 61.9% and mortality in 69% of patients. The predictive accuracy of clinical Rockall score for transfusion, the AUROC was 0.737 (95% CI: 0.678-0.791, P=0.001); for rebleeding, the AUROC was 0.863 (95% CI: 0.8-0.927, P= 0.001) and for mortality, the AUROC was 0.877 (95% CI: 0.81-0.944, P= 0.001). Conclusions: Clinical Rockall Score is a simple and rapid non endoscopic risk score that can be applied at the time of presentation to the emergency department to predict mortality outcomes in patients with acute UGIB.

Background: In pleural effusion, differentiating exudative and transudative fluid is an important clinical evaluation. The objective of the study was to determine the efficacy of pleural fluid serum bilirubin ratio in differentiating exudative and transudative effusions. In resource-limited settings with no facilities to measure lactate dehydrogenase (LDH) levels, using pleural fluid bilirubin ratio may help in better clinical decision. Methods: It was a prospective observational study, conducted in the emergency department of Tribhuvan University Teaching Hospital. All the patients attending for emergency care with pleural effusion from 6th Jan 2015 to 5th Jan 2016 were included. The cases were divided as exudates and transudates on basis of final diagnosis. Serum and pleural fluid specimen were collected and sent for investigations. The data for various laboratory parameters especially those of lights criteria and bilirubin ratio were then analyzed and fluid nature was compared with results from parameters and final diagnoses. Results: Among 103 cases, 71.84% had exudate and 28.16% had transudate. The commonest cause of effusion was pneumonia 35.92%, second being tubercular 23.30% followed by malignant effusion 12.60%, congestive heart failure 11.65%, chronic kidney disease 10.67% and liver cirrhosis 5.82%. The mean bilirubin ratio for exudates exceeded that for transudates. Considering the cutoff point of 0.6, the sensitivity, specificity, positive predictive value and negative predictive value were respectively 88.00%, 93.00%, 97.00% & 75.00%. Conclusions: Pleural fluid serum bilirubin ratio can be utilized as a diagnostic tool for differentiating exudative and transudative effusions. Keywords: bilirubin ratio; exudates; light’s criteria; pleural effusion; transudates.

BACKGROUND: Limited number of studies has compared metformin with other Oral Hypoglycemic agents (OHAs) for reducing BMI and few of the results are controversial. Perhaps, this is of clinical importance because the Nepalese population presents different dietary habits in comparison with the European population. The objective of this study was to study the comparative evaluation of metformin with other OHAs influence on Body Mass Index (BMI) in Nepalese patients with diagnosed type 2 Diabetes Mellitus (T2DM)). METHODS: A prospective cross sectional database of patients treated at diabetic clinic, TUTH, was analysed. Patients (N = 115) with type 2 Diabetes Mellitus and with complete BMI and HbA1c and treated with metformin and other OHAs, for at least three visits were included. Analysis of BMI and the type of oral agent was performed. Individuals were categorized as ideal weight, overweight, or obese (BMI 30 kg/m2, respectively). RESULTS: There were differences between the values of BMI at presentation, the third, the sixth and the ninth months, between the metformin-treated groups compared to other OHAs treated groups. Metformin was given to 48 patients and OHAs to other 57 patients. In the metformin group, mean BMI decreased significantly during the treatment time, from 29.93±5.7 to 28.95±5.2 (

Introduction: Urinary tract infections are commonly encountered in day to day practice of a general practitioner.The purpose of this study is to determine if there is an association between urinary tract infections (UTI) and sexually transmitted infections (STI), as both may present with similar symptoms. Methods: This was a hospital based, prospective observational study in 104 women of 18 to 49 years age group, done during a period of six months at Patan hospital. Urinalysis results and genital examination findings were recorded.STI was defined as a vaginal swab positive for Trichomonas vaginalis(TV)/Neisseria gonorrhoeae (NG)/Chlamydia trachomatis(CT).UTI was defined as urinary WBC >=6per high power film. A urine c/s >105 colonies of a single pathogen was considered urine culture positive. Results: Mean age of patients was 28.38 years. The most prevalent organism was TV (6/104, 5.8%), followed by NG(4/104,3.8%) and CT(2/104, 1.2%). 11.5% of women had STI , while 57.7% were urine culture positive. Out of those with urine culture positive, 83.3% had urinary WBC 30/hpf. The relation between pyuria and urine c/s positivity was significant ( p value 0.005). The prevalence of STI in urine c/s positive group was 13.3%, and in urine c/s negative group was 9.1% ( p value 0.553). Conclusion: There was no statistically significant difference in the prevalence of STI between urine culture positive and negative groups.

Negotiations about how to measure attainment of the proposed health targets of the Sustainable Development Goals seem a complex and politically fraught process. It is important that there are adequate indicators to measure health-system strengthening to achieve the proposed Sustainable Development Goal 3: ”ensure healthy lives and promote well-being for all at all ages”. The Millennium Development Goals stimulated admirable improvements in health in many countries. However, these goals have recognised shortcomings, particularly related to fragmentation of health systems and health inequities. Although condition-specifi c measures of health outcomes are important indicators, the risk of focusing on these measures is that policy makers and funders pursue vertically oriented approaches to health care when resources are scarce and stakeholders’ specific interests prevail. Measures of health-system strengthening, including structure and process measures, should form a core part of the post-2015 development agenda. There is strong evidence and broad agreement that primary care is central to health-system strengthening. If appropriately planned and delivered, it is person-centred with a populationbased approach. Primary care, including multidisciplinary team-based models of family practice, can serve as the regular entry point into health-care systems and meet most health-care needs, including disease prevention and health promotion. Primary care helps to establish and maintain healthy populations in equitable and effi cient ways, and is essential to achieve universal health coverage. To strengthen primary care, clear and explicit indicators that monitor progress are needed, which measure the distinctive dimensions that make this type of care eff ective. These dimensions include comprehensiveness, coordination, and continuity of care. Indicators must measure safety and quality of primary care, as well as integration with the rest of the health system and workforce development. Although challenging, examples of internationally validated methods exist, such as the Primary Care Assessment Tools. With a commitment to the collection of relevant data, indicators transferable to varying country contexts and stages of primary care development can be implemented. Crucially, to achieve greater investment in this area than that at present, measures of primary care expenditure as a proportion of total health expenditure are needed. Health systems founded on strong primary care are essential to achieve the Sustainable Development Goals. We call on the UN and all other stakeholders to show an unambiguous commitment to the measurement and development of high-quality, comprehensive primary care. We must aim for this commitment in all countries, irrespective of level of income, and cannot aff ord to wait another 15 years to do so.

Diabetes is one of the major public health problems in Nepal. Very few studies on correlation between waist hip ratio and random blood sugar have been done in remote areas of Nepal particularly in minor ethnic groups like Thami. This study attempted to compare waist hip ratio and blood sugar level in Thami community.This cross sectional study was conducted in sub-health post of Lapilang village of Dolakha district of Nepal. A total of 243 local inhabitants from Thami Tribe participated in the study. Waist hip ratio was calculated after taking measurements of waist and hip using flexible measuring tape; and, blood glucose level was measured by glucometer.The mean age of the participants was 46.02 years; among participants 126 (51.9%) were males and 117 (48.1%) were females. Mean waist hip ratio was 0.87, mean blood sugar level was 124.5 mg%. Increase in Waist hip ratio correlated significantly with increase in random blood sugar level both in males (p=0.008) and females (p=0.007).Increase in waist hip ratio is associated with increase in random blood sugar level. Therefore, there is a need of public awareness program to reduce waist circumference thus reducing weight of people to prevent development of diabetes mellitus in long run.

In troduction: Diabetes is one of the major public health problems in Nepal. Very few studies on correlation between waist hip ratio and random blood sugar have been done in remote areas of Nepal particularly in minor ethnic groups like Thami . This study attempted to compare waist hip ratio and blood sugar level in Thami community of Nepal. Methods: This cross sectional study was conducted in sub-health post of Lapilang village of Dolakha district of Nepal. A total of 243 local inhabitants from Thami Tribe participated in the study. Waist hip ratio was calculated after taking measurements of waist and hip using flexible measuring tape; and, blood glucose level was measured by glucometer. Results: The mean age of the participants was 46.02 years; among participants 126(51.9%) were males and 117(48.1%) were females. Mean waist hip ratio was 0.87, mean blood sugar level was 124.5mg%.Increase in Waist hip ratio correlated significantly with increase in random blood sugar level both in males(p=0.008) and females(p=0.007). Conclusions: Increase in waist hip ratio is associated with increase in random blood sugar level. Therefore, there is a need of public awareness program to reduce waist circumference thus reducing weight of people to prevent development of diabetes mellitus in long run. Keywords: blood sugar level; diabetes; Thami community; waist hip ratio

Introduction: Self-harm forms a significant proportion of patient attending in emergency departments, typically 10-30 per 100000 people commit suicide annually. The objective of this study was to find out the factors responsible for self harm. Methods: This is a cross sectional study of 100 patients of self harm coming to Emergency Department of Tribhuvan University Teaching Hospital from 1stOctober 2007 to 31stMarch, 2008. Questionnaire about demographic information of patient along with details about cause of self harm, and any other illnesses associated was filled. Information about duration of arrival in emergency department, place of self harm was gathered. Patients were clinically examined and hematological and biochemical tests including liver function test and the type of poison used and its level in blood were examined. Results: Total number of patients with self harm was 100 (female - 71%; male- 29%).Among female, 16-30 years age group to be the largest (76%). Mean duration of arrival in emergency department was 3.08 hour. Metacid ingestion (29%) was found to be the most common cause for self harm. There is no difference of self harm for suicide and threat cause. Only 5% of patient with self harm has psychiatry illness in the past. Conclusions: Self harm forms a significant proportion of patient attending the Emergency department and the most common form of self harm used was metacid ingestion. There is compelling evidence for the need to improve delivery of care for patients who inflict self harm. Key words: Cause; emergency department; self harm. DOI: http://dx.doi.org/10.3126/joim.v32i3.4954 Journal of Institute of Medicine , December, 2010; 32:3 14-17

INTRODUCTION: Pralidoxime are enzyme reactivator that are known to reactivate the phosphorylated acetylcholinesterase by binding to the organophosphorus molecule. The use of oximes in acute organophosphorus poisoning has been a controversial subjects for over two decades. This study was conducted with the objective to find out the estimation of serum cholinesterase and use of pralidoxime in organophosphorus poisoning. METHODS: A prospective analysis of all organophosphorus poisoning cases presented at the Emergency Department, Tribhuvan University Teaching Hospital for seven months was done. RESULTS: Out of 26 cases about 60% of poisoning cases were monitored for pseudocholinesterase level. About 50% of them had pseudocholinesterase level within normal limit and 20% had less than 10% of normal value. Only 33% cases with pseudocholinesterase level less than 10% were treated with pralidoxime. CONCLUSIONS: The initial dose of Pralidoxime used was 1 gm followed by maintenance dose of 500mg 6 hourly, the doses prescribed were less than WHO recommended doses. Keywords: cholinesterase, emergency, organophosphorus,poisoning, Pralidoxime.

The curriculum of the post graduate program in General Practice in Nepal is designed to develop comprehensive and effective health care as well as timely life-saving surgical services in the District Hospital. District hospitals in rural Nepal encounter many surgical emergencies. Most of the times, the patient can not afford to go to higher centers. General Practitioners (GPs) are effectively providing surgical services at district hospitals. The aim of this study is to focus the types of surgical cases that were managed by GP and establish the role and utilization of General Practice (GP) specialist as a surgeon at district, zonal and regional hospitals in developing countries. This is retrospective study of all cases at district hospital, Surkhet, (25 beds) of western part of Nepal during the period of one year (March 2000 to February 2001), that were managed by GPs. The surgical services provided by GP specialist at the district hospital were analyzed. A total of 16,975 cases were attended in the hospital during above period. Out of this, a total of 2,327(13.7%) were hospitalized. The total numbers of surgical cases were 1,205(51.8%). Out of this, 514(42.7%) cases had undergone surgery. The general surgery cases comprise 447(87.0%), Gynae / Obstetric and Orthopedic cases 67(13.0%). All surgeries were performed in limited resources by GPs. GP specialist can effectively manage the surgical cases and perform surgery at the district hospital competently. In country like Nepal, where number of surgical specialist are less and not available in majority hospitals, GPs can substitute the surgical specialist and provide emergency surgical services in urban areas (zonal and regional hospitals). Key Words: Surgery, Rural, General Practice, Nepal.