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Chronic Obstructive Pulmonary Disease (COPD) patients generally present with respiratory acidosis and type 2 respiratory failure. Here we present a case of 65 years old female, who is a known case of COPD and presented in our emergency department with severe metabolic alkalosis (pH 7.730, HCO3- greater than 99.9mmol/l). She was referred from other center after the development of seizure. Urinary sodium was sent which indicated the cause of metabolic alkalosis was contraction alkalosis; we then treated the patient with IV fluids, antibiotics and Mechanical Ventilator. Arterial Blood gas analysis was initially done every 4 hours till the pH was corrected. After pH was corrected the patient was extubated to intermitted Non Invasive Ventilation (NIV) for type 2 respiratory failure. With pulmonary rehabilitation we could discharge the patient with inhalers; without the need for NIV or supplementary oxygen. This is one of the rare cases where the patient presented with a very high bicarbonate level, high partial pressure of carbon dioxide in arterial blood, and high pH. The patient was successfully managed with IV fluids and mechanical ventilation.

To achieve a better and more sustainable future for all, it is necessary to accomplish sustainable development goals (SDGs) by 2030. Among these goals, some of them are associated with slums and upgrading their status. Evidence-based development policies and programs are recommended for achieving developmental goals and for this purpose data along with their distribution pattern are the key components. The objective of this study is to present different slum definitions used in Nepal, and to make an update on the existing data about the slums inside the Kathmandu Valley and to explore their distribution. To accomplish this, published documents as well as secondary data about slums were collected and they were further verified and updated. Different names were found to be commonly used as a synonym for the slum. The total number of slum settlements inside the valley was found to be 65 with a total number of households 4,696 a total population of 28,412 having a total male population of 14,829 (52.20%), and a total female population of 13,583 (47.80%). The distribution of slums across different wards inside the Valley was explored and was found to be over dispersed Poisson distribution revealing that slum settlements are widely dispersed among different local level administrative units (wards) inside the valley, and further, a large variation on the number of households, population size, and average household size were found among those slum settlements. Due to these, it is challenging for the government to address the biggest deprivations of the slum communities’ people to improve their living conditions and maintaining appropriate state of harmony in the Valley.

Patients diagnosed and hospitalized with SARS COV-2 are managed with corticosteroids due to its known benefits for the prevention of airway inflammation secondary to acute respiratory distress syndrome seen commonly in viral pneumonia. However, these patients carry a high risk of developing secondary bacterial and fungal infection. We present a case of 60-year-old male with COVID-19 pneumonia. The patient was diagnosed with pulmonary mucormycosis 18 days following admission. The patient was treated with broad-spectrum antibiotics, remdesivir and corticosteroids along with antifungals including voriconazole and amphotericin B with no significant improvement. However, even after extensive medical management patient was eventually intubated and succumbed to its complications. Mucormycosis although an uncommon infection should be considered due to extensive use of glucocorticoid therapy and concurrent comorbidities present among COVID-19 patients.

Background: Acute pancreatitis sequelae require a multidisciplinary approach and ICU care. Ulinastatin is a serine proteases inhibitor that reduces inflammation by suppressing the infiltration of neutrophils and elastase release and inflammatory mediators that help improve clinical symptoms and reduce mortality. This study aims to evaluate the clinical utility of Ulinastatin. Methods: Fifty-two patients admitted to ICU with acute pancreatitis were divided into; Ulinastatin group who received a 3 to 5 days course of 200,000IU, and Control Group who didn’t receive ulinastatin. Pearson's Chi-square and Fisher's exact test were used and a p-value < 0.05 was considered statistically significant. Results: Mean age was lower among the Ulinastatin group at 43 years (p-Value 0.014) and Hepatic dysfunction was more among this group (p-value 0.04). Among new onset of organ dysfunction, only CVS dysfunction was significant among the Control group ( p-value 0.044) while respiratory function recovery (p-value 0.04) and coagulation profile improvement (p-value 0.017) was statistically significant among the Ulinastatin group. The mean duration of hospital stay was shorter among control group, 9.65 days vs 14 days, a p-value of 0.05and also the average duration of stay in MDICU was lower, 4 days vs 8.5 days, p-value 0.0044 in comparison to Ulinastatin group. Overall mortality incidence was 15.38%, 19% in Ulinastatin group vs 11.5% in Control group. Conclusion: This retrospective study is our experience in the use of Ulinastatin which has shown little efficacy in declining mortality and/or hospital stay duration though it helps prevent new organ dysfunctions.

Currently, there is no cure for Human immunodeficiency virus /Acquired immunodeficiency syndrome (HIV/AIDS) but, there are medications to control HIV and prevent opportunistic infections. Clinicians must be vigilant enough to extract history and send relevant laboratory investigations to diagnose the disease in early stage. Patient may not have known his /her diagnosis or intentionally avoided to reveal the disease status which further complicates the diagnosis and treatment. This is case of a 51 years male, where social stigma forces the patient to hide his diagnosis and reluctant to seek medical treatment ultimately reaps the life. Hence, government and concerned authority must work up for wide availability of HIV/AIDS medications and motivate people to seek medical advices as soon as possible. Concerned authority must motivate people to consider it as any other treatable disease.

ImportanceThe usefulness of computed tomography of the head (CTH) in patients with acute-onset atraumatic altered mental status (AMS) is poorly understood, but use in these patients remains high.ObjectiveTo evaluate the use of CTH (event rate) in patients with AMS and the positive outcome event rate of the performed CTH studies.Data SourcesThe PubMed/MEDLINE, PubMed Central, Embase, and CINAHL databases were searched using predefined Boolean parameters. All studies that met inclusion criteria until January 31, 2022, were included.Study SelectionRandomized clinical trials and observational, cohort, and case-control studies were included. Conference abstracts, reviews, letters, case reports, case series, systematic literature, and meta-analyses were excluded.Data Extraction and SynthesisThe systematic literature review was performed per Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data were independently extracted by 2 authors. Data were pooled using a random-effects method.Main Outcomes and MeasuresEvent rate of CTH use in patients with acute atraumatic AMS. The CTH event rates and positive CTH event rates were calculated with 95% CIs.ResultsOf 9338 studies identified, 26 qualified for the systematic review and 25 for the meta-analysis. The 25 studies in the meta-analysis included a total of 79 201 patients. The CTH event rate was 94% (proportion, 0.94; 95% CI, 0.76-1.00), and the positive CTH event rate was 11% (proportion, 0.11; 95% CI, 0.07-0.15). There was significant heterogeneity among the studies included (I2 > 50%, P Conclusions and RelevanceIn this meta-analysis, CTH use among patients with acute-onset atraumatic AMS was very high with a low yield. Large-scale studies are needed to guide clinical decision-making in such a situation.

The development of prostate-specific membrane antigen (PSMA) ligands labeled with radionuclides is a ground-breaking achievement in the management of prostate cancer. With the increasing use of

Background: Practice guidelines have the potential to improve processes and outcomes of care if strategies to facilitate implementation include attention to feasibility and acceptability in the local setting. The purpose of this study was to evaluate the feasibility and acceptability of a guideline for using a high-flow nasal cannula (HFNC) in intensive care units (ICUs) that was introduced in Nepal. Methods: We measured the proportion of eligible patients in seven ICUs who received HFNC between September 14, 2020, and December 9, 2021. We compared measures of oxygenation between patients who successfully survived HFNC and those who did not. We used an electronic survey of healthcare workers to measure the guideline's acceptability, appropriateness, and feasibility. Results: Out of the total (7,121) patients admitted to ICUs during the study period, 4,099 (57%) were eligible and 584 (14%) of the eligible patients received HFNC during the first three days (12% before and 14% after the introduction of the guideline). The median ROX time index (integral of ROX index (PaO2/FiO2 x respiratory rate) over time) of patients who were successfully treated with HFNC (n=146) was greater than that of patients who failed HFNC (n= 42; 0.8 vs. 0.04; p=0.001). Respondents rated the HFNC guideline highly for acceptability, appropriateness, and feasibility. Conclusions: Introduction of the guideline was associated with a small increase in the use of HFNC, but the guideline was feasible, acceptable, and appropriate for use in clinical practice.

Background: Epidemiological data on critically ill patients is crucial for understanding resource utilisation, gaps in quality of care and for supporting surveillance of endemic or emerging diseases. We report the epidemiology of critically ill patients from 17 intensive care units (ICUs) in Nepal using an established and standardised ICU registry. Methods: The ICU registry data is collected prospectively and includes data on case mix, severity, organ support and outcomes. We conducted a retrospective observational study with all adult (≥18 years) critically ill patients admitted to 17 ICUs in Nepal between September 2019 and September 2022. We report on case mix, treatment received, severity of illness, standardised mortality rates (SMR), discharge outcomes and ICU service activity. Descriptive statistics were used to report the findings. Results: Of the 18603 unique admissions, 14% were operative, with 35% emergency surgeries. Patients’ median age was 57 (IQR 40-71) and 59% were male. Hypertension and diabetes were common comorbidities and pneumonia accounted for 26% of all admissions. During the ICU stay, 39% of patients received mechanical ventilation, 29% received vasoactive medication and 10% received renal replacement therapy. The median predicted risk of death was 0.1 (IQR 0.1-0.3) using APACHE II and 0.2 (IQR 0.1-0.4) using eTropICS. The median SMR was 0.7 (IQR 0.5-0.8) and 0.8 (IQR 0.6-1.4) using eTropICS and APACHE II, respectively. Median length of stay was 4 days (IQR 2-7). Eighteen percent died in the ICU; of those alive at discharge, 12% went home, 84% went to another department and 3% went to another hospital. COVID-19 was the most common notifiable disease reported (12% of all admissions). Median ICU turnover was 9% (IQR 6-14) with bed capacity ranging from 43-278. Conclusions: These findings should guide forecasting and service planning to ensure ICUs can optimally care for critically ill patients in Nepal.

Tetanus, an infection caused by the gram-positive, obligate anaerobic bacillus Clostridium tetani, is still prevalent in developing countries. Fever is an unusual symptom in tetanus. The disease must be managed by preventing tetanospasmin absorption, treating symptoms, stabilizing autonomic instability, using antibiotics, and controlling the airway with assisted ventilation if necessary. We present a case report of a tetanus patient who had persistent pyrexia despite ruling out all the obvious causes of fever ,that coincide with the persistence of muscle spasms and/or use of prolonged duration of benzodiazepines.

Large cavitary pulmonary infarctions are extremely rare. Here, we report an unusual case of large pulmonary infarction due to pulmonary embolism (PE). This was complicated by secondary infection with Actinomyces leading to cavitary abscess formation. The patient had minimal non-specific symptoms despite extensive involvement and was treated with lobectomy, antibiotics, and anticoagulation, with expedited recovery. This case depicts a rare association between PE/pulmonary infarction and pulmonary actinomycosis. Furthermore, it highlights a high index of suspicion needed to diagnose these two conditions in low-risk individuals without traditional risk factors.

Cardiac tumors are extremely rare. Here, we report an unusual case of cardiac plasmacytoma that occurred 11 years after complete remission of the original multiple myeloma (MM). The tumor primarily manifested as a solitary extramedullary plasmacytoma (SEP) with extensive infiltration into the heart and large vessels. There was no evidence of systemic involvement. The relapsing tumor assumed a unique immunophenotype from CD138+/CD38+/CD56- to CD138-/CD38+/CD56-. The patient responded to chemotherapy consisting of carfilzomib, cyclophosphamide, and dexamethasone. This case highlights the importance of multimodal imaging evaluation and tissue diagnosis for accurately characterizing this rare disorder.

Cryptococcal meningoencephalitis (CM) is one of the major causes of mortality and morbidity in immunocompromised patients estimating 650,000 deaths each year. Across the globe, CM has been occasionally seen in apparently immunocompetent patients who otherwise don't have established risk factors. The clinical presentation of CM in immunocompetent hosts is subtle and often results in complications including persistent neurological deficits and death. We present a case of Cryptococcal neoformans meningitis in a diabetic female with no other identified risk factors. Although her clinical presentation was atypical, her clinical course was uncomplicated. The pathophysiology in immunocompetent hosts appears somewhat different, so is the clinical presentation. Since there are no separate evidence-based treatment recommendations, it is challenging to treat this group of patients. There seems to be a need for further studies for management in CM for HIV negative, non-transplant immunocompetent patients.

Pancreatic cancer (PC) is an aggressive malignancy with poor prognosis and is the fourth leading cause of cancer deaths in the United States. The 5-year survival rate is about 6% of all stages combined; this has remained largely unchanged over the past several decades despite advances in cancer treatment. The head of the pancreas is the most common location. Obstructive cholestasis is most common presentation. PC is a complex and heterogeneous tumor with several genetic mutations involved. An average PC cell contains 63 genetic alterations per tumor malignancy from the successive accumulation of genetic mutations. Understanding and identifying these genetic alterations can be the key step to developing novel treatment approaches and overcoming drug resistance. Gemcitabine monotherapy is the current and established standard of care treatment in advanced (metastatic or locally advanced) PC. Epidermal growth factor receptor (EGFR) has a critical role in KRAS-induced PC tumorigenesis. Mutant KRAS upregulates endogenous EGFR expression and activation. Without EGFR, active RAS levels are insufficient to induce the epithelial transformation necessary for cancer transformation. It was shown that genetic ablation or pharmacological inhibition of EGFR or its ligand blocks KRAS-mediated tumorigenesis in vivo. EGFR is known to be expressed in other cancers such as lung, colon, and breast. Expression of EGFR occurs in both pancreatic intraepithelial neoplasia and pancreatic ductal adenocarcinoma. EGFR is overexpressed in about 80% of pancreatic lesions. Targeting EGFR in cancer has been achieved by two major approaches. First, monoclonal antibodies against EGFR competitively bind the extracellular ligand-binding region of the receptor in its inactive mode, blocking the receptor from ligand binding. Examples include cetuximab and panitumumab. The second approach involves small-molecule tyrosine kinase inhibitors that prevent the autophosphorylation of receptors by competing with adenosine-5′-triphosphate for the intracellular tyrosine kinase domain of the receptor, inhibiting EGFR signaling. Examples include erlotinib, gefitinib, and lapatinib. Erlotinib is approved by the Food and Drug Administration in combination with gemcitabine in metastatic pancreatic cancer. Skin rash from erlotinib toxicity correlates with better treatment outcome. Patients with KRAS mutation are less likely to respond to erlotinib. EGFR may be involved in early-stage of development of PC and is associated with tumor progression to invasive cancer. More studies on the correlation between EGFR overexpression and prognosis or predictive value in PC are urgently needed.

Assessment of level of consciousness is very important in predicting patient's outcome from neurological illness. Glasgow coma scale (GCS) is the most commonly used scale, and Full Outline of UnResponsiveness (FOUR) score is also recently validated as an alternative to GCS in the evaluation of the level of consciousness. We carried out a prospective study in 97 patients aged above 16 years. We measured GCS and FOUR score within 24 h of Intensive Care Unit admission. The mean GCS and the FOUR scores were lower among nonsurvivors than among the survivors and were statistically significant (P < 0.001). Discrimination for GCS and FOUR score was fair with the area under the receiver operating characteristic curve of 0.79 and 0.82, respectively. The cutoff point with best Youden index for GCS and FOUR score was 6.5 each. Below the cutoff point, mortality was higher in both models (P < 0.001). The Hosmer-Lemeshow Chi-square coefficient test showed better calibration with FOUR score than GCS. A positive correlation was seen between the models with Spearman's correlation coefficient of 0.91 (P < 0.001).