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Background: Anecdotal reports suggest an increasing prevalence of kidney problems in returnee Nepali migrant workers from the Gulf countries and Malaysia. Aims and Objectives: This study aims to (a) explore the magnitude of the kidney health-related problems in returnee Nepali migrant workers; and, (b) assess the need for further scientific investigations. Materials and Methods: This was a self-administered survey of practicing nephrologists in Nepal. All 51 nephrologists working in Nepal (at the time of this study) were approached by email for anonymous participation using an online survey platform. Data were collected between December 2019 and February 2020. Descriptive statistics were generated for data analysis. Results: A total of 38 nephrologists completed the survey. Almost all their migrant patients were: younger than 40 years, males, from rural areas of Nepal, and had worked in Gulf countries or Malaysia. Most (92.1%) of the respondents reported that the causes behind kidney-related problems of returnee migrant workers were of unknown etiology and less likely to be linked to traditional risk factors. Chronic kidney disease and glomerulonephritis were the most common kidney health-related problems. The vast majority of respondents (76.3%) thought that the returnee migrant workers are at a higher risk of kidney-related problems than the general Nepali population. Conclusion: Nepali labor migrants in the countries of the Gulf and Malaysia could be at a higher risk of kidney health-related problems than the general Nepali population. Further rigorous scientific investigation is warranted to examine the kidney-health-related risk of Nepali migrant workers.

Background: One of the important factors that could affect better health care delivery during COVID-19 pandemic remains the better working environment for healthcare professionals. Support provided by the family, society and workplace would play an important role to boost their work performance. This study aimed to assess the perception of family, social and organizational support among the frontline healthcare professionals during COVID-19 pandemic in selected districts of Nepal. Methods: This descriptive cross-sectional study consisted of 325 healthcare professionals working in different hospitals of Bagmati province of Nepal. Data were collected using self-administered structured questionnaire via Google form. Collected data were analyzed using descriptive and inferential statistics. Results: Adequate support was perceived by 50.5% of the respondents and the mean overall perceived support score was 98.83±11.2. The highest perceived score (37.25±4.37) was on family support domain followed by social support (33.55±4.08) and the organizational support (28.01±5.7). Factors like advanced age, higher education level, male sex, and working in the government hospitals showed significant association with perceived family and social support. Type of the institutions and tenure status were main predictors for the perception of adequate organizational support. Conclusions: For their inspiration to work, adequate support to healthcare professionals not only from family but also from the society and organizational level would be quite important. Apart from some non-modifiable factors, other factors like adequate and timely provision of monthly salary, guaranteed medical treatment if they fall sick have been found to play important role to keep the them motivated to their work.

Not applicable as this is an editorial.

Background: Nurses can play a pivotal role to identify and prevent acute kidney injury (AKI) at the earliest and their level of understanding about the disease remains quite important. So, this study was conducted with an aim of assessing the level of understanding of AKI among nurses. Methods: A cross-sectional descriptive study was conducted among 122 nursing staffs working at different wards of a tertiary hospital. Knowledge on AKI was evaluated on different headings-definition, risk factors, bed side nursing observations, and supportive care. Semi-structured ques­tionnaire was used to collect the responses through self-administered method. Analysis was done through frequency, percentage median, chi-square test and through odds ratio using Microsoft Excel and SPSS version 16 for windows. Results: A total of 122 nurses were included in the study. Mean age of the respondents was 26.7±5.88 years. Only 43.4% of the respondents could correctly define AKI on the basis of creati­nine value. Non-steroidal anti-inflammatory drugs (NSAIDs) and aminoglycosides as nephrotoxic drugs could be listed by 59.8% and 23.7% of the respondents respectively. About 40% of the nurses mentioned the requirement of observation of both intake and output as a part of management of AKI. Overall, 53.3% of the nurses were found to have an inadequate knowledge of AKI. Conclusions: Inadequate knowledge of AKI among nurses can hinder the early recognition and management. Therefore, there seems to be a strong need of formal and structured refreshing course for the nurses to provide current updates on identification, risk assessment, recognition and response of AKI.

Background: Dengue fever is one of the most common tropical diseases caused by an arbo­virus. This virus is a member of genus Flavivirus and flaviviradae family, is transmitted by bite of Aedes aegypti mosquito. Its outbreak is being reported from different parts of the world including Nepal. This disease is prevalent throughout Nepal mostly in terai regions. The aim was to study the epidemiological and clinical spectrum of dengue fever at tertiary care hos­pital in Chitwan. Methods: This study was a hospital based prospective study where a total of 241 patients di­agnosed with dengue fever were assessed. This study was carried out from September 2019 to February 2020. Data was entered on predesigned proforma and analyzed by using SPSS version 16.0. Mean and standard deviations was calculated for continuous variables and frequencies for categorical variables. Results: More than half (56%) of the dengue patients belonged to the age group of 25-44 years. Out of 241 patients, 61.4% were males. Apart from fever the other common symptoms were ret­roorbital pain/headache comprising around 80% of patients. The mean duration of hospital stay in our study was 3.86 days. Approximately 72% (173) patients had leucopenia and 8.7% (21) had severe thrombocytopenia(

Background: Vitamin D deficiency is a common problem in many countries throughout the world. This study aimed at understanding the status of vitamin D deficiency in relation to age, gender, geography and season among relatively bigger numbers of population residing in central and western regions of Nepal.Methods: This retrospective cross-sectional study was carried out by reviewing the records of vitamin D tests in two centers of Nepal- namely united reference laboratories at Pokhara and Chitwan Medical College at Chitwan. A total of 3320 individuals who were tested for clinical suspicion of vitamin D deficiency over a period of one year were included in the study. Results: Mean vitamin D level was 18.7 ng/mL. Majority of subjects tested for vitamin D were females (71.36 %) with female to male ratio of 2.49:1. Hypovitaminosis D (? 30 ng/mL) was found in 84.5% subjects and was moderate to severely deficit (

Background: Urinary tract infection (UTI) is characterized by pathological invasion of the urinary tract by microorganisms. Majorities of organisms causing UTI are gram negative bacteria, most common of which is E. coli. Urine culture and sensitivity test is used to isolate the organism and to identify the susceptible drug of choice for appropriate treatment. This hospital-based study was carried out to analyze the spectrum and antibiotic susceptibility of microorganisms causing UTI. Methods: A retrospective study was done to analyze the results of urine culture and sensitivity test done at Chitwan Medical College Teaching Hospital over a period of two and half years. Standard guideline and protocol were used to collect the urine sample and to perform the test. Data analysis was done using SPSS version 21.0. Result: Out of 12, 925 urine samples submitted for culture and sensitivity test during the study period, bacterial pathogens were isolated from 3, 173 (24.54%) samples, which was significantly higher among females (28%) than the males (17%). The most common organism isolated on the culture was E. coli (68.5%) followed by Klebsiella (18.4%). Sensitivity of the uropathogens was seen highest with colistin (79.2%) followed by teicoplanin (64.58%), Aztreonam (63.25%) and Ni­trofurantoin (61.16%). Most common antibiotics that showed resistance to the microorganisms in this study were Ampicillin (60.93%), Cotrimoxazole (53.72%), Cefixime (40.57%) and Levofloxacin (32.93%). Conclusions: This study has found a usual pattern of UTI with higher prevalence among females and E. coli being the most common organism. Nitrofurantoin has been found to have a good sus­ceptibility for the treatment of UTI.

IntroductionInfection of the central venous catheter (CVC) is a major complication seen among patients undergoinghemodialysis. Identifying CVC related infection (CRI) and its risk factors and causative organisms is important for better implementation of preventive strategies.MethodsA prospective study was conducted at Chitwan Medical College for a duration of 2 years from January 2017to December 2018 among the patients undergoing hemodialysis via CVC. The data collected were related topatients’ demographics, site of catheter insertion, and duration, microbiological data including cultures fromcatheter sites, blood, and catheters’ tips and antibiotic sensitivity. Catheter related infection was divided intocatheter related local infection (CRLI) and catheter related blood stream infection (CRBSI). Data was analyzedusing IBM SPSS Statistics version 21.0.ResultsA total of 41 cases of CVC related infection (CRI) were documented with an incidence rate of 6.94 episodesper 1000 catheter days at risk. Out of the total CRI, 39.02% were CRLI and 60.98% were CRBSI. Fever with chillsand rigor were the most common clinical presentation. Risk factors for the development of CRI were durationof catheter in situ, repeated change of CVC and the use of CVC for indications other than hemodialysis (HD).Staphylococci and Klebsiella were the most common organisms isolated in culture.ConclusionThe rate of CRI among Nepalese patients undergoing hemodialysis is high. Prolonged duration of CVC usage,recent change of catheter and the use of the HD catheter for the purpose of institution of intravenous medication have been found as the risk factors for CRI.KeywordsCatheter related infection, central venous catheter, hemodialysis

Background: Scrub typhus, an emerging rickettsial disease caused by the organism Orientiatsutsugamushi , is associated with multi-organ involvement. We prospectively studied the clinical manifestations of the disease during a major outbreak in central part of Nepal. Aims and Objective: This study was carried out with an aim to analyze the clinical presentations, laboratory parameters, complications and outcomes of scrub typhus. Materials and Methods: A prospective observational study was conducted in the Department of Medicine in a tertiary teaching hospital. A total of 1398 patients admitted with acute febrile illness were subjected for Scrub Typhus Detect™ IgM ELISA test, among which 502 (35.90%) patients tested positive and were included in the study. Acute kidney injury was defined according to KDIGO guideline. Statistical analysis was done with SAS University Studio package using t-test for continuous variables and chi-square test for categorical variables. Results: Mean age of the patients was 30.37±18.81 years with 26.29% in the pediatric age group (

Objectives: Vitamin D deficiency is being studied all over the world and is a global health problem. Recent studies haveshown that Vitamin D may have a significant role in reducing the incidence of autoimmune diseases. This study was conducted to find out the level of Vitamin D in patients with thyroid disorders and compare Vitamin D levels in Anti Tpo positive and negative patients. Subject and Methodology: 60 patients from Chitwan Medical College outpatient clinic were included in the study from February to May 2016. A brief history and clinical examinations were taken from all patients along with laboratory tests for thyroid functions, TPO antibody level of 25(OH) Vitamin D3 level and Serum Calcium level. Results: Both patients of hypothyroidism (autoimmune and nonautoimmune) had severe Vitamin D deficiency. Most of the hyperthyroid cases had Vitamin D insufficiency. Anti TPO positive and negative patients both had Vitamin D deficiency. Conclusion: Our study shows there is significant Vitamin D deficiency in hypothyroidism and hyperthyroidism irrespective of its autoimmunity. This study certainly encourages us to screen Vitamin D and supplement Vitamin D to all thyroid disorders patients.

Background Job satisfaction among nursing faculty is critical to improving quality of nursing education, producing future nurses who will contribute directly to the health of patients at a local and national level. This study explores factors associated with job satisfaction among graduate nursing faculties in different universities of Nepal. Methods A cross-sectional study was conducted among nursing faculty with at least one year of teaching in their respective institutions. A 36-items job satisfaction questionnaire with 6-point Likert type responses was administered online. The questionnaire was pre-tested with 30 faculties pooled from multiple institutions. Link to the final survey was sent via e-mail to 327 nursing faculties working in 39 nursing colleges. Respondents were contacted by phone as a follow up to the email to politely remind them about the survey. Data analysis was carried out with SAS University Edition software. Chi-Square test and t-test were used for simple descriptive analysis. A multivariate binary logistic regression model was used to identify the significant factors associated with nursing faculties’ job satisfaction. Adjusted odds ratio was calculated and significance was considered at p ≤ 0.05 with 95% confidence interval. Results The response rate was 54.4%. After retrospective cleaning of data, usable response rate was 52.3% (n = 171). The average age of the nursing faculties was 36.8 ± 7.0 years. Based on the overall job satisfaction score, 36.8% nursing faculties were satisfied with their current job. The coefficient for Cronbach’s alpha was 0.895 suggesting very good reliability of the overall measure. The significant factors associated with job satisfaction were the involvement of the faculties in decision making process related to the department (OR = 4.83) and adequate access to reference materials (OR = 2.90). Conclusions This study suggests that nursing faculties have positive attitude towards their job but are dissatisfied with the benefits offered to them and the operating condition of their institutions. Expanding the teaching learning resources, such as reference books, subscription to journals, and continuing education opportunities for nursing faculties through participation in professional meetings would be helpful in improving the quality of nursing education in Nepal.

Background The management of proliferative lupus nephritis (LN) comprises timely and coordinated immunosuppressive therapy. This study aimed to evaluate and compare the effectiveness and safety profile of low dose mycophenolate mofetil (MMF) and cyclophosphamide (CYC) in induction therapy of LN in Nepalese population. Methods We conducted a prospective, open-label, randomized trial over a period of one and half years. Forty-nine patients with class III to V lupus nephritis were enrolled, out of which 42 patients (21 in each group) could complete the study. CYC was given intravenously as a monthly pulse and MMF was administered orally in the tablet form in the maximum daily dose of 1.5 g in two divided doses. Results The mean age of the patients was 25.43 ± 10.17 years with female to male ratio of 7.3:1. Mean baseline serum creatinine was 1.58 ± 1.38 mg/dL and eGFR was 62.38 ± 26.76 ml/min/1.73m2. Mean 24-h urinary protein was 4.35 ± 3.71 g per 1.73 m2 body surface area. At 6 months, serum creatinine (mg/dL) decreased from 1.73 to 0.96 in CYC and from 1.24 to 0.91 in the MMF group with improvement in eGFR (ml/min/1.73 m2) from 60.33 to 88.52 in CYC and from 64.42 to 89.09 in MMF group. Twenty-four-hour urinary protein (gm/1.73m2) reduced from 4.47 to 0.94 in CYC and from 4.5 to 0.62 in the MMF group. Primary end point was achieved in higher percentage of patients with MMF than CYC (28.6% vs. 19%) while equal proportion of patients (67% in each group) achieved secondary end point in both groups. Number of non-responders was higher in CYC group than in the MMF group (14.3% vs. 4.8%). There was no difference in the rate of achievement of secondary end point in both CYC and MMF groups (3.16 vs. 3.05 months). The occurrence of adverse events was higher in the CYC than in MMF group (56 vs. 15 events). Conclusion Present study has concluded that MMF, used in relatively lower dose, is equally effective in inducing remission with reduction of proteinuria and improvement of kidney function with lesser adverse events than CYC in the induction therapy of proliferative lupus nephritis. Trial registration Retrospectively registered to ClinicalTrials.gov PRS. NCT03200002 (Registered date: June 28, 2017).

Objective: The main objective of this study was to identify the problems of Nepalese breast cancer survivors living in an urban area who had completed their treatment for at least 6 months. Methods: A cross-sectional descriptive study was conducted to assess the problems of breast cancer survivors who were registered at the Nepal Cancer Support Group. Fifty-one women who were diagnosed with breast cancer (Stage 0 to III) and were currently disease-free were enrolled in the study. They were interviewed using structured interview schedule using the Breast Cancer Prevention Trial Symptom Scale. Statistical analysis was carried out with SPSS (version 16). Results: The mean age of the women at the time of enrollment was 47.3 years. The most common modality of treatment they received was the combination of surgery, chemotherapy, and radiotherapy (84%). Top five symptoms experienced by the survivors on the basis of frequency and severity were tiredness (61%), lack of energy (57%), forgetfulness (57%), lack of interest in sex (52%), general body aches (49%), and feeling of worrisome and anxiousness about future (49%). Women with age

ObjectiveTo assess the nutritional status of patients on maintenance hemodialysis by using modified quantitative subjective global assessment (MQSGA) and anthropometric measurements.MethodWe Conducted a cross sectional descriptive analytical study to assess the nutritional status of fifty four patients with chronic kidney disease undergoing maintenance hemodialysis by using MQSGA and different anthropometric and laboratory measurements like body mass index (BMI), mid-arm circumference (MAC), mid-arm muscle circumference (MAMC), triceps skin fold (TSF) and biceps skin fold (BSF), serum albumin, C-reactive protein (CRP) and lipid profile in a government tertiary hospital at Kathmandu, Nepal.ResultsBased on MQSGA criteria, 66.7% of the patients suffered from mild to moderate malnutrition and 33.3% were well nourished. None of the patients were severely malnourished. CRP was positive in 56.3% patients. Serum albumin, MAC and BMI were (mean + SD) 4.0 + 0.3 mg/dl, 22 + 2.6 cm and 19.6 ± 3.2 kg/m2respectively. MQSGA showed negative correlation with MAC ( r = −0.563; P = < 0.001), BMI ( r = −0.448; P = < 0.001), MAMC ( r = −0.506; P = < .0001), TSF ( r = −0.483; P = < .0002), and BSF ( r = −0.508; P = < 0.0001). Negative correlation of MQSGA was also found with total cholesterol, triglyceride, LDL cholesterol and HDL cholesterol without any statistical significance.ConclusionMild to moderate malnutrition was found to be present in two thirds of the patients undergoing hemodialysis. Anthropometric measurements like BMI, MAC, MAMC, BSF and TSF were negatively correlated with MQSGA. Anthropometric and laboratory assessment tools could be used for nutritional assessment as they are relatively easier, cheaper and practical markers of nutritional status.

Sjögren’s syndrome is an autoimmune disease with multisystem involvement and varying clinical presentation. We report the clinical course and outcome of a case who presented with repeated episodes of hypokalemia mimicking hypokalemic periodic paralysis and metabolic acidosis, which was later diagnosed as distal renal tubular acidosis secondary to primary Sjögren’s syndrome. A 50-year-old lady, who was previously diagnosed as hypokalemic periodic paralysis, presented with generalized weakness and fatigue. She was found to have severe hypokalemia with normal anion-gap metabolic acidosis consistent with distal renal tubular acidosis. Subsequent evaluation revealed Sjögren’s syndrome as the cause of her problems. Kidney biopsy done to evaluate significant proteinuria revealed nonproliferative morphology with patchy acute tubular injury and significant chronic interstitial nephritis. The patient responded well to potassium supplementation and oral prednisolone. Presentation of this case highlights the necessity of close vigilance while managing a case of repeated hypokalemia, which could be one of the rare clinical manifestations of Sjögren’s syndrome.

Background. The complications associated with errors in transfusion practice can be minimized by assessing transfusion practices. In Nepal, there is no standard protocol on blood transfusion. So, this study was conducted with an aim to assess the blood transfusion practice among healthcare personnel. Methods. A descriptive observational study was conducted in two tertiary hospitals in Kathmandu, Nepal, over a period of 10 months. Bedside blood transfusion procedures were observed using structured checklist. Results. Altogether, 86 observations were made. Time taken from dispatch from the blood bank to transfusion was >2 hours in 53.2% of cases. In majority of the cases, blood was kept in the ward in uncontrolled and unprotected manner by the patients’ relatives. Only 8.2% of the patients and/or the relatives were informed about the reasons, associated probable risks (2.4%), and the benefits of transfusion (4.7%). Assessment of vital signs at 15 minutes of initiation of transfusion was done on about 2 to 4% of cases. Conclusion. We found a suboptimal blood transfusion practice in Nepal, which could be attributable to substantial knowledge gap among healthcare personnel and the absence of quality culture, quality system, and quality management in the area of blood transfusion practices.

Background and Aims - Dengue is a systemic viral infection, which is caused by any of the four strains of dengue virus and is transmitted between humans by the bite of Aides aegypti mosquito. Hepatic dysfunction is common in dengue infection with varying degree according to the severity of the disease. The aim of this study was to analyze the spectrum of liver involvement in dengue infection during a major outbreak that occurred in central Nepal between September and December 2010. Methods - A hospital based prospective study was conducted in the department of medicine at Chitwan Medical College. Patients who had fever in the ten preceding days (acute febrile illness) who had serologic evidence of Dengue and had no clinical evidence of bacterial infection anywhere in the body, were included in the study. Clinical, biochemical and radiological evaluation was done among 414 serologically confirmed Dengue cases to assess the spectrum of liver involvement. Statistical analysis of the data was done with SPSS version 16. Results - Dengue fever (DF) and dengue hemorrhagic fever (DHF) were present in 79.3% and 20.5% of the patients respectively. Only 2 out of 414 patients had dengue shock syndrome (DSS). The spectrum of hepatic manifestations included elevation of transaminases (raised ALT and AST in 81.9% and 57.7% respectively), abnormal abdominal ultrasound (49.3%), Hepatomegaly (39.1%), and Jaundice (4.1%). The intensity of hepatic involvement was significantly higher among patients with DHF than those with DF. Conclusion : Liver is one of the major organs to be involved in Dengue infection. Significant difference existed in the spectrum of liver involvement between DF and DHF. DOI: http://dx.doi.org/10.3126/jaim.v2i2.8775 Journal of Advances in Internal Medicine 2013;02(02):42-46

SUMMARY Aim To compare the influence of demographic and clinical variables on quality of life (QOL) amongst haemodialysis (HD) and renal transplantation clients in Nepal. Background Renal replacement therapy in the form of renal transplant is a newer modality in Nepal. In this study, effectiveness of renal transplant and maintenance HD in clients with end-stage renal disease were evaluated in a Nepalese context. Method A descriptive, cross-sectional study was conducted to compare the QOL of clients undergoing HD and renal transplantation in two treatment centres in Nepal. Information on QOL was collected by using the WHOQOL-BREF instrument through interviews. Result The clients in the transplantation groups were significantly younger, highly educated and employed. The QOL score of clients with renal transplantation was significantly higher in the physical, psychological and social relationship domains. While assessing QOL score in transplantation groups, females scored significantly higher score in the environmental domain compared with males. Conclusion The QOL score in renal transplant recipients was significantly better than that of clients on HD in three of the four WHOQOL-BREF domains. The limited resources and facilities for renal transplantation and the post-transplant follow-up service in Nepal might have contributed to a poorer outcome on the environmental domain in this group.

Renal involvement and acute kidney injury (AKI) are common clinical manifestations seen in scrub typhus, a vector-borne tropical disease. There are no data on renal manifestation in scrub typhus in Nepal. We conducted a prospective study to analyze the incidence, urinary abnormalities, course, severity, outcome, and the predictors of AKI in patients with scrub typhus during a major outbreak in Central Nepal. Total 1398 patients admitted with acute febrile illness were subjected for Scrub Typhus Detect™ Immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA) test, of which 502 (35.90%) patients tested positive and were included in the study. Mean age of the patients was 30.37 ± 18.81 years (range, 1–79 years) with 26.29% in the pediatric age group. Female-to-male ratio was 1.26:1. Mean duration of fever was 6.8 ± 3.1 days. Mean IgM ELISA value for scrub typhus was 2.17 ± 1.70 without difference in AKI and non-AKI groups (2.17 ± 1.76 vs. 2.16 ± 1.62; P = 0.94). Urinary abnormalities were seen in 42.3% of patients. Mean serum creatinine was 1.37 ± 0.69 mg/dl with significant difference in two groups (1.85 ± 0.87 vs. 1.03 ± 0.17; P = 0.003). AKI was seen in 35.8% of patients with majority having Stage 1 AKI (68.3%) followed by Stage 2 (34.1%) and Stage 3 (1.2%). Hemodialysis was required for 3.94% of patients. In 54% of patients, AKI occurred in fifth and sixth day of fever. ICU admission was required for 18.73% of patients and 8.57% required ventilator support. Mortality rate was 1.79%, which was higher among patients with AKI (2.96% vs. 1.0%; P = 0.106). Multivariate analysis revealed that the presence of pneumonia, shock, and acute respiratory distress syndrome predicted the development of AKI.

Dengue Fever (DF) is only rarely considered as a cause of acute liver failure even globally and only a few case reports of acute hepatic failure and encephalopathy occurring in DF in adults are available. We report a case of Acute Liver Failure due to Dengue during a major outbreak in 2010 in Chitwan. A 20 year old previously healthy female presented to the emergency department of Chitwan Medical College with fever, jaundice and altered sensorium. She was tested positive for Dengue IgM. Her biochemical and clinical parameters were suggestive of acute liver failure with total billirubin of 10.1 mg/dL, direct billirubin of 5.2 mg/dL, ALT 5760 IU, AST 14100 IU, alkaline phosphatase of 1250 IU, PT INR of 1.76 and platelet count of 30,000 /mm3. Other causes for acute hepatic failure like acute viral hepatitis, leptospirosis, malaria, Reye’s syndrome were ruled out. The patient was admitted and managed in the ICU with supportive care and platelet transfusion. With treatment she made a significant clinical and biochemical improvement with AST of 105 IU, ALT of 120 IU and platelet count of 150,000/mm3. She was discharged after 11 days of hospital stay.DOI: http://dx.doi.org/10.3126/kumj.v9i2.6293 Kathmandu Univ Med J 2011;9(2):73-5