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Background: A return visit to the emergency department by the same patient within a stipulated time frame has implications in quality of care provided as well as overcrowding. We aimed to find out the outcome and describe the characteristics of the patients presenting with revisits to emergency. Methods: This hospital based observational study recruited all consecutive cases with revisits within 30 days to emergency department from February to August 2019 after ethical approval. Clinical presentation and outcome were noted. Results: Out of 21,215 discharges from the emergency during the study period, 176 patients had revisits (0.829%). The mean age (SD, 95% CI) was 49.74 (18.77, 46 to 52) years with male: female ratio of 1.02. The mean number of days (SD, 95% CI) for revisit was 4.94 (4.92, 4 to 5). Deterioration in triage category was seen in 33.5%; 11.9% had an ‘improved triage category’. High acuity triage score during revisit was 38%. Common revisit diagnosis was chronic kidney disease (35.8%) and infections (30.1%). Revisit diagnostic category change was seen in 20%, with mortality of 6.25%. Patients requiring admission returned within a mean of 4 days (SD, 95% CI = 3.6, 3.3 to 4.9) compared to 6 days (5.6, 4.5 to 6.8) for non-admitted patients. Early revisits (p = 0.040), lower systolic blood pressure at index visit (p = 0.001) and revisit (p = 0.002) were associated with admissions. Conclusion: Revisits were common in the earlier days of the initial discharge from the emergency. Chronic problems tended to revisit more.

Detailed study of material compatibility of the various electronics packaging materials for immersion cooling is essential to understand their failure modes and reliability. The modulus and thermal expansion are critical material properties for electronics mechanical design. Substrate is a critical component of electronic package and heavily influences failure mechanism and reliability of electronics both at the package and board level. This study mainly focuses on two major challenges. The first part of the study focuses on the impact of thermal aging in dielectric fluid for single-phase immersion cooling on the non-halogenate substrate’s thermo-mechanical properties. The second part of the study is the impact of thermal aging on thermo-mechanical properties of substrate in the air. The non-halogenated low Coefficient of Thermal Expansion (CTE) bismaleimide triazine (BT) resin laminate is used for its ultra-low CTE which in turn reduce the warpage of substrate. Moreover, the substrate has high glass transition temperature and high stiffness suitable for the application which requires high heat resistance. The substrate is aged in ElectroCool EC100 dielectric fluid, and air for 720 hours at three different temperatures: 22°C, 50°C, and 75°C. The complex modulus is characterized before and after aging for both parts and compared.

Traditional air-cooling along with corresponding heat sinks are beginning to reach performance limits, requiring lower air-supply temperatures and higher air-supply flowrates, in order to meet the rising thermal management requirements of high power-density electronics. A switch from air-cooling to single-phase immersion cooling provides significant thermal performance improvement and reliability benefits. When hardware which is designed for air-cooling is implemented within a single-phase immersion cooling regime, optimization of the heat sinks provides additional thermal performance improvements. In this study, we investigate the performance of a machine learning (ML) approach to building a predictive model of the multi-objective and multi-design variable optimization of an air-cooled heat sink for single-phase immersion-cooled servers. Parametric simulations via high fidelity CFD numerical simulations are conducted by considering the following design variables composed of both geometric and material properties for both forced and natural convection: fin height, fin thickness, number of fins, and thermal conductivity of the heat sink. Generating a databank of 864 points through CFD numerical optimization simulations, the data set is used to train and evaluate the machine learning algorithms’ ability to predict heat sink thermal resistance and pressure drop across the heat sink. Three machine learning regression models are studied to evaluate and compare the performance of polynomial regression, random forest, and neural network to accurately predict heat sink thermal resistance and pressure drop as a function of various design inputs. This approach to utilizing numerical simulations for building a databank for machine learning predictive models can be extrapolated to thermal performance prediction and parameter optimization in other electronic thermal management applications and thus reducing the design lead time significantly.

Structural components such as printed circuit boards (PCBs) are critical in the thermomechanical reliability assessment of electronic packages. Previous studies have shown that geometric parameters such as thickness and mechanical properties like elastic modulus of PCBs have a direct influence on the reliability of electronic packages. Elastic material properties of PCBs are commonly characterized using equipment such as tensile testers and used in computational studies. However, in certain applications viscoelastic material properties are important. Viscoelastic influence on materials is evident when one exceeds the glass transition temperature of materials. Operating conditions or manufacturing conditions such as lamination and soldering may expose components to temperatures that exceed the glass transition temperatures. Knowing the viscoelastic behavior of the different components of electronic packages is important in order to perform accurate reliability assessment and design components such as PCBs that will remain dimensionally stable after the manufacturing process. Previous researchers have used creep and stress relaxation test data to obtain the Prony series terms that represent the viscoelastic behavior and perform analysis. Others have used dynamic mechanical analysis in order to obtain frequency-domain master curves that were converted to time domain before obtaining the Prony series terms. In this paper, nonlinear solvers were used on frequency domain master curve results from dynamic mechanical analysis to obtain Prony series terms and perform finite element analysis on the impact of adding viscoelastic properties when performing reliability assessment. The computational study results were used to perform a comparative assessment to understand the impact of including viscoelastic behavior in reliability analysis under thermal cycling and drop testing for Wafer Level Chip Scale Packages.

Computational modeling is often leveraged to design and optimize electronic packages for both performance and reliability purposes. One of the factors that affect the accuracy of computational models is the accuracy of the material properties. Microelectromechanical system sensors, in particular, are usually extremely sensitive to slightest material property changes in the package. Therefore, even small measurement variations in material characterization due to different sample preparation methods or different testing techniques can impact accuracy of computational models that are leveraged for designing or analyzing sensor performance. The challenge in material characterization is even greater for materials that require curing. Die attach polymers, for example, have strict curing profile requirements that are used during the manufacturing process. Such curing conditions are usually hard to duplicate in laboratories, and the samples used for material characterization may not necessarily be representative of the actual component in the final product. In this study, the effect of parameters such as temperature curing profile, application of pressure during curing, and sample preparation technique on temperature-dependent thermomechanical properties of two types of die attach elastomers is investigated. The mechanical properties, including the elastic modulus (E), coefficient of thermal expansion, and glass transition temperature of the die attach material, are measured using a suite of techniques such as dynamic mechanical analysis and thermomechanical analysis. The analysis is performed for a wide temperature range corresponding to typical sensor applications. It is shown that sample preparation and characterization techniques have a considerable impact on the measurements, which results in different MEMS sensor performance predictions through computational modeling.

Background Patient abandonment in the emergency department has been reported in various parts of the world although the implications and social circumstances may vary in context to its definition. The current study intends to review the characteristics of twenty- four (24) abandoned patients in the emergency department of tertiary care hospital of Eastern Nepal. Methods This was a prospective observational study conducted among all abandoned patients presenting to tertiary care hospital in eastern Nepal from July 2018 to July 2020. Results Twenty four (24) patients were enrolled in the study. 22 (91.7%) were male and 2 (8.3%) were female with a mean age of 43.2 ± 14.4SD. The median length of stay (LOS) was 72 (Q1, Q3, 23.5, 960) hours in the emergency department. Seven, 7 (43.75%) cases of mortality were due to medical illness, 4 (25%) cases of mortality were due to surgical illness and 5 (31.25%) cases of mortality were with undifferentiated presentations (p= 0.012). 15 of 24 (62.5%) patients over 40 years of age experienced a longer LOS (p = 0.34) and (75%) 12 of 16 have a higher mortality than younger patients (p= 0.30). More than (USD) $50 was invested in an abandoned case that was taken care of by NGOs. 6 (25%) of abandoned patients were taken care of by other centers like NGOs and welfare centers. Conclusions Abandoned patients in the middle-aged adults with medical comorbidity experienced longer hospital stays and as an indicator of mortality. Financial disparities were observed among abandoned patients taken care of by charitable organizations and tertiary care hospital.

Introduction: With increasing of workload of emergency room employees, many of the community’s emergency hospitals are now facing another challenge, i.e. the abandonment of patient in emergency Department. It seems undesirable in most hospital service settings due to loss of revenue and ill-will. The hospital’s staffs feel that they have no option but to keep those sufferers until a further plan can be made. It presents a dilemma for the staffs of Emergency and for the hospital administrators as well. The current case report presents an abandoned patient in Emergency Department of B. P. Koirala Institute of Health Sciences (BPKIHS). Case Report: A 70-year old male brought by police and was left abandoned in emergency ward of BPKIHS in altered conscious state. The patient was managed in emergency ward with conservative management nearly for six weeks. Conclusion: The problem is multidimensional, is in conflict of the concept towards achievement of Millennium Development Goals (MDGs) and a challenge to social security.

Background: Sepsis and Septic shock are a common presentation in the Emergency Department with high morbidity and mortality. Serum lactate level increases substantially in the patients with septic shock. The objectives of this study were to determine serum lactate levels at the time of presentation, find out the outcome and correlate lactate levels with the outcome in the patients with septic shock. Methods: It is a prospective cross-sectional study of patients presenting to the Emergency, who met the criteria for septic shock defined by Surviving Sepsis Guidelines 2012. Patients’ demographics, co morbidity, triage vitals, laboratory and radiological parameters were recorded. The primary outcome was mortality and secondary outcomes were duration of stay in hospital and complications, if any, developed during hospital stay. Results: Eighty-four cases were enrolled, with male to female ratio of 1:1. Mean age was46.40 19.59 years. The significant variables were: serum lactate (p

Background: Basic Life Support (BLS) aims to maintain respiration and circulation in the cardiac arrest victim and involves a major focus on cardiopulmonary resuscitation (CPR) with minimal use of ancillary equipment. The raised standards of care demand that knowledge about BLS/ CPR be updated and include the lay persons as well as medical experts who have the potential to become the teachers of the skill. The objective of the study was to describe the knowledge and attitude of medical personnel (nurses and doctors) towards BLS/ CPR. Methods: This cross sectional study was done among the doctors and nurses working in Department of General Practice and Emergency Medicine, BPKIHS, Nepal after ethical approval. A pre-validated questionnaire (Shrestha et al, WJEM, 2012) with pre-structured questions was used for assessing the knowledge and attitude. Attitude was measured using 5 point Likert. Designation, previous training and demographics were used as describing variables. For data recording and statistical analysis; Microsoft Excel, SPSS 11 and EPI Info were used. Results: Total number of sample size was 84 medical personnel working in emergency department (consultant 12, junior resident 16, house officer 18, and senior nurse 3 and staff nurse 35). Nine (11%) respondents answered more than 10 questions, 57 (68%) answered 6-10 question and 18 (21%) answered less than 5 question. Average mean score (total 15) was 7.40 (SD 2.32, 95% CI 6.90-7.90).Mean score of the positive attitude (total 15) to CPR was 11.1807 (2.43, 10.65-11.71). The mean score for reluctance (total 5) to perform CPR was 3.25 (consultants and those who were certified in BLS or taken BEC course in the department had maximum score in knowledge (p

Background: Rose Angina Questionnaire (RAQ) is a useful screening questionnaire for ischemic heart disease validated in different settings; however, its diagnostic ability to predict myocardial infarction (MI) in the emergency is less clear. Objectives: To find out the usefulness of RAQ to predict MI in patients presenting to the emergency. Methods: A cross-sectional study was conducted at the BP Koirala Institute of Health Sciences (BPKIHS), a teaching hospital in eastern Nepal from 1 January to 30 March 2017, after ethical clearance from the Institutional Review Committee. Informed consent was obtained from the patients for their anonymised information to be published in this study The samples were collected from 100 patients with chest pain aged 40 to 70 years presenting to the emergency. RAQ was applied and its performance to detect MI was compared with emergency and cardiologist diagnosis of MI. Sensitivity, specificity, positive predictive value and negative value were calculated along with descriptive analysis. Results: A total of 100 patients were analysed with the mean age of 63.78 years (SD 11.60) and male to female ratio of 1.94. RAQ detected 58 cases (63.8%) with emergency department (ED) diagnosis of MI (true positive) and identified 3 (33.3%) cases with non-MI (true negative). The true positive rate for RAQ to detect MI after cardiologist consultation was 71.6%. RAQ had a sensitivity of 84.91% (95% confidence interval (CI) 72.41% –93.25%) to detect positive troponin, 63.74% (52.99–73.56) to detect positive electrocardiogram (ECG) and 71.60% (95% CI 60.5% to 81.07%) to detect final diagnosis of MI. Conclusion: RAQ is a good screening tool to detect MI in the emergency that can be used in isolation or in combination with other diagnostic modalities to detect it early.

Reliability of electronic packages is a major concern as different failure modes are induced due to factors such as temperature cycling, mechanical stresses, and humidity. Finite element analysis (FEA) is often performed to assess reliability under different loading conditions such as thermal cycling, drop testing, power cycling and vibrational loads. Having accurate material property data is one of the key requirements to perform successful FEA study, and a significant amount of time and money is spent to perform accurate material characterizations. Lump modeling approach, where components are represented by a block and assigned effective properties, is commonly used to model printed circuit boards (PCBs) using their elastic properties. However, previous work done by Liu et. al. [1] has shown that viscoelastic properties of PCBs have a direct influence on dynamic characteristics of PCBs under drop impact. In this paper, the viscoelastic properties of PCBs made of low loss materials are characterized and used in finite element analysis to study reliability of wafer level chip scale packages (WCSP) under drop testing conditions. The wafer-level packaging is one of the advanced modern-day packaging techniques that is popular because it is lighter, smaller and less expensive. Low loss materials are used for high frequency applications as they provide improved electrical performance and have low dielectric constant. They also offer improved impedance control, low moisture absorption, and good thermal management. Megtron 6 board, type of low loss materials is characterized using Dynamic mechanical analysis (DMA). Measurements at different frequencies are used to obtain a master curve for the complex modulus over a wide range of frequency. The master curve is used to obtain Prony series constants that are used in ANSYS Mechanical to perform reliability analysis under drop testing conditions. Using JEDEC standard JESD22-B111, an acceleration pulse of 1500 G was applied for a duration of 0.5 ms. The FEA results are used to compare the two cases where PCBs are modeled with and without the inclusion of viscoelastic properties. Results from the FEA simulations are observed to compare total deformation, equivalent strain and total acceleration of the package with and without viscoelastic properties of the board.

Background: Alcohol use remains a major cause of preventable death worldwide occurring prematurely. Despite its global burden, alcohol still is a legal drug. Various studies have also shown that factors like education, occupation, influence from films and family, for stress relief, pleasure during alcohol use, better self-esteem, and occupational boredom are associated with alcohol use. The consumption of alcohol, even in relatively small amounts, increases the risk of being involved in a crash for motorists and pedestrians. It is also associated with impaired judgments and so is often linked to road traffic accident. Objectives: To assess the prevalence, type of alcohol use, and the associated factors for the initiation of alcohol use among bus drivers and staffs of long route bus of Dharan. To assess the knowledge, attitude, and practice regarding alcohol use for their willingness to quit it with medical help. Materials and Methods: The cross-sectional survey was conducted in 250 long route drivers and staffs in Dharan Bus Park in 2016 with the help of a self-designed questionnaire in Nepali language. The sample size was preliminarily estimated on the basis of the prevalence of alcohol use. The “Alcohol consumer” refers to drivers who used alcohol at least once in the previous year. Results: Alcohol dependency among Hindu was found to be significantly more than other religious group. The prevalence of alcohol consumption was found to be 78%. About 51% drivers are likely to have alcohol problems, 39% are alcohol abuser, and 45% are alcohol dependent. Conclusion: Drinking and driving increase the vulnerability to injury and death on the road. The study creates awareness among drivers about the harmful use of alcohol and psychosocial consequences.

Introduction: Domestic violence is certainly an important condition, and certainly carries significant health consequences. Screening is probably acceptable to most patients attending an emergency department. The objective of this study is to find out the frequency of domestic violence victims attending emergency department, to find out the factors related to domestic violence, type, and severity of injury and to identify the impact of domestic violence in the victims. Materials and Methods: This was a cross-sectional observational study done in the Department of General Practice and Emergency Medicine of BP Koirala Institute of Health Sciences from January 2014 to December 2014. Anyone presented with a physical injury intentionally caused by a relative, partner, or other household member (spouse, partner, sibling, ex-partner, child, and other wives/partner of spouse). Results: The total number of patient enrolled in this study was 423. Among which 71.9% were female and 28.1% were male. About 27% of female and 31.9% of male were in the age group of 20–30 years. Majority (42.4% females and 48% males) of the victim's family had agriculture for primary occupation. Among the study groups, 40.9% of cases were beaten by direct hit and 24.3 with weapon, 5% of cases were only reported as rape, and 23.6% as homicidal case. Conclusion: Domestic violence is particularly insidious form of gender-based violence. In the place where they should feel the greatest safety and security- the family-women often face terror form of physical, psychological, sexual, and economic abuse.

Background: Knowledge, attitudes and practices (KAP) surveys are possibly the most frequently used studies in health-seeking behaviour research. Health care workers serve as key players in the prevention and management of diseases. Their perceptions, attitudes and practices have implications for the management of diseases in both health centers and communities. Objective: To assess knowledge, attitude and practice towards STDs among health attendant staffs (health aids and health attendants) of BPKIHS. Methods: This is a descriptive cross sectional study. The study population was Health attendants and Health aids workers working in different departments of BPKIHS. Modified structured questionnaire was used for data collection. SPSS version 11.5 was used for data entry and analysis. Results: 180 Health attendants and Health aids working in different departments of BPKIHS participated in the study. 29% belonged to 30-34 age groups. 86% of study population had heard about STD/HIV/AIDS. 29% expressed that having intercourse without using condoms is known as unprotected sex. Unprotected sexual habits (40.6%), using mask, gloves while working (30%) were methods listed for prevention of transmission of STDs/HIV/AIDS. Conclusion: Majority were from 30-39 years group.86% had heard about STDs/HIV/AIDS. The commonest method to protect from STDs/HIV/AIDS were listed as avoiding multiple sex partners and use gloves and mask while working. Health Renaissance 2015;13 (3): 95-106

Background: The term chronic headache is commonly taken as headache lasting for more than three months. It is common in general practice with minimal research on the topic in Nepal. Objective: To sort out the common diagnoses of chronic headache and to study the clinical features and demographic profile of patients presenting with chronic headache. Method: A descriptive cross sectional study was conducted (2012 August to 2013 August) at General Practice outpatients in BP Koirala Institute of Health Sciences, a medical university in eastern Nepal. Approval and ethical clearance was taken from Research Committee and Institutional Ethical Review Board. Descriptive statistical analysis was done. Result: 168 patients constituting 1% of outpatient visits presented due to chronic headache. Mean age was 29.57 years (SD 10.53) and female to male ratio was 3.67. Mean number of days of headache was 19.46 days (SD 4.62). Numerical pain score was reported at 7.1/10 (SD 1.85). The mean duration of presentation was 22 months (SD 11). 40% reported impaired activity of more than one week. Headache was classified as chronic migraine in 20.2%, chronic tension type headache in 16.7%, and chronic daily persistent headache in 11.9%. The diagnosis did not fit into any diagnostic criteria in 51.2% cases. Conclusion: Chronic headache is common in females and young age group. Patients present late despite significant pain scores. Significant proportion is still unclassified. Health Renaissance 2015;13(2): 22-29

Pramendra Prasad Gupta,1 Rabin Bhandari,1 Deebya Raj Mishra,2 Krishna Kumar Agrawal,3 Rupak Bhandari,1 Sunil Jirel,1 Gyanendra Malla1 1Department of General Practice and Emergency Medicine, B. P. Koirala Institute of Health Sciences, Dharan, Nepal; 2Department of Internal Medicine, B. P. Koirala Institute of Health Sciences, Dharan, Nepal; 3Department of Internal Medicine, Nepal Medical College and Teaching Hospital, Kathmandu, Nepal Background: Drug-induced hypersensitivity reaction is of great clinical significance in therapeutics. The objective of this reporting of two cases is to show that anaphylaxis reaction can occur with pantoprazole. Case summaries: A 38-year-old female reported to the emergency ward in a critical condition, with a history of periorbital edema, edema of the skin, pruritus, nausea, vomiting, and difficulty breathing 20 minutes after ingestion of a pantoprazole 40 mg tablet. A 32-year-old female reported to the emergency ward in a critical condition, with complaints of rashes all over the body, itching on the whole body, and swollen lips and eyes after ingestion of a pantoprazole 40 mg tablet. Conclusion: It is necessary for all health care providers to know that pantoprazole can cause anaphylaxis, which is a life-threatening reaction, and to be cautious while prescribing it. Keywords: anaphylactic reactions, pantoprazole, proton pump inhibitors

Acute organophosphate poisoning is the most common pesticide poisoning which can be manifested in three unique phases of toxic effects e.g. Acute Cholinergic Crisis, Intermediate Syndrome (IMS), Delayed Polyneuropathy. Looking at the previous cases reports the incidence of Intermediate Syndrome has been reported to be as high as 80%.The present study attempted to report a comparable form of incidences encountered in Emergency Department of BP Koirala Institute of Health Sciences (BPKIHS) in Eastern Nepal. Chlorpyriphos was the commonest compound associated with IMS. Early recognition with plasma acetylcholinesterase level as well as Peradeniya Organophosphorus Poisoning (POP) Scaled score might be useful tool in early diagnosis of Intermediate Syndrome.

Thermal interface materials (TIMs) are an important component in electronic packaging, and there is a concerted effort to understand their reliability when used under various environmental load conditions. Previous researchers have investigated gap fillers and other types of TIMs to understand their performance degradation under loading conditions such as thermal cycling and thermal aging. Most of the study in the literature focuses on studying the changes in thermal properties, and there is a lack of understanding when it comes to studying the mechanical behavior of TIMs. Degradation of mechanical properties is the cause for the loss in thermal performance and is critical during TIM selection process. Moreover, mechanical properties such as modulus and coefficient of thermal expansion (CTE) are critical to assess performance of TIMs using finite element analysis (FEA) and potentially save time and money in the evaluation and selection process. Due to the very soft nature of TIMs, sample preparation is a challenging part of material characterization. In this paper, commercially available TIMs are studied using testing methods such as thermomechanical analyzer (TMA), dynamic mechanical analyzer (DMA), and Fourier infrared spectroscopy (FTIR). These methods are used to characterize the material properties and study the changes in properties due to aging. In this work, the followings are presented: impact of filler content on the mechanical properties, sample preparation method for curable TIM materials with specified thicknesses, and impact of thermal aging on mechanical properties.

Holacracy can be seen as a strategy for decentralized management and organizational governance in which authority and decision-making are delivered by means of autonomous and self-organizing groups or teams. Although the topic is not new, its application in software development has not a long history behind it. This study is meant to give an overview on holacracy for software development teams, its features, benefits gained, as well as its challenges. To do so, in this paper, authors present a multivocal literature review in which a panoply of sources including research and grey literature is reviewed. Our study shows that adapting holacracy towards self-organizing software development teams can result in increased product transparency, improved decision making, more efficient progress, and a higher sense of individual responsibility. However, there are reported challenges such as implementation difficulty and increase in employee outflows.

Thermal conductive gap filler materials are used as thermal interface materials (TIMs) in electronic devices due their numerous advantages, such as higher thermal conductivity, ease of use, and conformity. Silicone is a class of synthetic materials based on a polymeric siloxane backbone which is widely used in thermal gap filler materials. In electronic packages, silicone-based thermal gap filler materials are widely used in industries, whereas silicone-free thermal gap filler materials are emerging as new alternatives for numerous electronics applications. Certainly, characterization of these TIMs is of immense importance since it plays a critical role in heat dissipation and long-term reliability of the electronic packages. Insubstantial studies on the effects of various chemical compounds on the properties of silicone-based and silicone-free TIMs has led to this study, which focuses on the effect of thermal aging on the mechanical, thermal, and dielectric properties of silicone-based and silicone-free TIMs and the chemical compounds that cause the changes in properties of these materials. Characterization techniques such as dynamic mechanical analysis (DMA), thermomechanical analysis (TMA), differential scanning calorimetry (DSC), Fourier transform infrared spectroscopy (FTIR), and broadband dielectric spectroscopy (BbDS) are used to study the mechanical, thermal, and dielectric characteristics of these TIMs, which will guide towards a better understanding of the applicability and reliability of these TIMs. The experiments demonstrate that upon thermal aging at 125 °C, the silicone-free TIM becomes hard, while silicone-based TIM remains viscoelastic, which indicates its wide applicability to higher temperature applications for a long time. Though silicone-based TIM displays better mechanical and thermal properties at elevated temperatures, dielectric properties indicate low conductivity for silicone-free TIM, which makes it a better candidate for silicone-sensitive applications where higher electric insulation is desired.

Background: Perinatal mortality includes both deaths in the first week of life and fetal deaths (stillbirths). Over 130 million babies are born every year, and more than 10 million infants die before their fifth birthday and almost 8 million before their first birthday.Objectives: To make an effort to find out impact of birth interval on fetal outcomes like, low birth weight (weight less than 2500 grams regardless of gestational age), perinatal death (death within 28 weeks of gestation to 7 days of birth) in subsequent pregnancies.Methods: This was a cross-sectional study conducted in BPKIHS, Dharan in 2011. Patients included were women of second gravida between age group 20 -35 years .The consecutive convenience sampling method was used to collect the data. Study population was divided into three birth interval groups of 59 months respectively and fetal outcomes (low birth weight, gestational age, early neonatal death, Apgar score) were compared.Results: Out of included population majority (55.63%) of the women had age range of 20-25 years with the mean age of 25.30. Among the total 168 who were included 20(11.91%) were belongs to birth interval 59 months group.Conclusion: There was increased risk of preterm and low birth weight and perinatal death in women with birth interval 59 months. Health Renaissance 2015;13(3): 169-176

Objectives Nepal is a least developed country, with limited healthcare resources. An 18 month Fellowship in Emergency Medicine has contributed some improvements to care. This study assessed time to first analgesia in higher and lower acuity patients. Methods A prospective observational study of 101 patients in each of the Australasian Triage Scale (ATS) 2, 3 and 100 in ATS 4 was undertaken at B.P. Koirala Institute of Health Sciences. Convenience sampling was used coinciding with researcher's duty hours. Pain scores and time to analgesia were recorded. Results A total of 302 patients were included. The doctors identified pain in 274 (90%, 95% confidence interval [CI] 86.74–93.65), severity recorded in 92 (30.5%, 95% CI 25–36). Median time from triage to analgesia was 30 min (interquartile range [IQR] 15–60) for ATS 2 patients, 60 min (IQR 40–70) for ATS 3 and 69 min (IQR 45–116) for ATS 4. Tramadol was the analgesic used most commonly (33%), followed by diclofenac (25%), morphine (16%), paracetamol (14%) and ketamine (2%). Analgesia was provided to 212 (70%, 95% CI 64.6–75.2), 65 (30.66%, 95% CI 24.5–37.3) with ATS 2, 85 (40%, 95% CI 33.4–47) with ATS 3 and 62 (29.2%, 95% CI 23.2–35.8) with ATS 4. A total of 44 patients (20.7%, 95% CI 15.5–26.8) with mild, 101 (47.6%, 95% CI 40.7–54.6) with moderate and 60 (28.3%, 95% CI 22.3–34.8) with severe pain received analgesics. Conclusion Time to analgesia for triage score 2 is lower compared to higher triage score. However, a large proportion of patients still do not receive analgesia. This is likely addressed by using a combination of strategies.

Objectives: To study the clinico-epidemiological profile of different causes of Acute Flaccid Paralysis (AFP) including Acute Encephalitis Syndrome (AES) and their associated co-morbidities. Methodology: A prospective hospital-based study was carried out including all cases fulfilling AFP case definition. History, clinical examination, necessary investigations were performed and required treatment given. Regular follow-ups were done and final classification made alongwith AFP surveillance team. Results: Out of 43 children included in the study, 18 expired and 25 completed follow-up. Final classification showed 53.5% AES, 9.3% Guillain Barre Syndrome (GBS), 9.3% dyselectrolytemia, 9.3%, peripheral neuritis, 7% Non-Polio Entero Virus (NPEV) and 11.6% others. Fever, altered sensorium and convulsions were present in 79.1%, 65.1% and 58.1% respectively. Eighty-four percent had asymmetrical paralysis with quadriparesis in 72%. Cerebrospinal fluid was abnormal in 34.9%. Japanese encephalitis serology was positive in 4.7%. The mean GCS was 9.53±4.27 with a significant difference between survivors and non-survivors (p=0.02). Almost half (52.2%) required ICU care, of which 14 expired (p=0.005). Seventeen children needed mechanical ventilation, of which 13 died (p

Drug-induced Parkinsonism develops in a number of patients with schizophrenia or schizo-affective disorders. Conventionally, anti-parkinsonism drugs, such as levodopa and dopamine agonists have been avoided due to their potential to result in an increase in psychotic symptoms, hallucinations and behavioral disturbance. We present ten cases series of drug-induced Parkinsonism in whom a trial of antiparkinsonism medications administered commenced with good effect. In particular, there was no deterioration in psychotic symptoms. A number of cases had asymmetrical signs, suggesting that these patients had a component of idiopathic Parkinson’s disease in addition to long standing drug-induced Parkinsonism. The diagnosis of idiopathic Parkinson’s disease on clinical grounds is often difficult in patients who have been on or are currently on an anti-psychotic drug. A trial of levodopa or a dopamine agonist is worth considering, albeit cautiously. In our series of cases a relapse or exacerbation of psychotic symptoms did not occur after commencing levodopa and dopamine agonists.

Objectives: Triage is recognized as important in providing timely care to emergency patients. However, systematic triage is only practised in two EDs in Nepal. The first objective of this study was to assess the performance of one of these departments in seeing triaged patients in a timely fashion. Second, an epidemiological survey of patients presenting to the ED was performed to describe the conditions seen and initial resuscitation undertaken. Methods: We performed a descriptive cross-sectional study in the ED of B.P. Koirala Institute of Health Sciences, eastern Nepal where the Australasian Triage Scale (ATS) is used. One hundred and sixty patients triaged as ATS 2 were recruited. The time taken for the duty doctor to see the patient was noted. The presenting problems, vital signs and level of consciousness were measured at presentation. The resuscitation measures were recorded. Results: The mean waiting time was 2.1 ± 1.7 min with a range of 1–10 min, which meets the benchmark for ATS 2. At triage, the most common presenting problems were circulatory shock (23.1%), altered consciousness (21%), respiratory difficulty (16.9%) and poisoning (15%). Oxygen, i.v. fluids and antibiotics were the most common therapies used in the initial resuscitation of patients. Conclusion: Patients triaged as ATS 2 were seen in a timely fashion. Seriously ill patients requiring resuscitation present commonly to this ED. This is a big challenge for junior doctors. Improved training, treatment protocols and equipment are needed to help manage this burden.

Acute appendicitis is among the commonest surgical diseases faced by an emergency clinician. A prompt diagnosis is mandatory to reduce morbidity and mortality, which may be difficult for junior doctors who first see the patient in the emergency department. This study was conducted to assess the efficacy of Alvarado score as a tool to improve the accuracy of diagnosis of appendicitis. We did a prospective pre- and post-test study in 381 patients with right iliac fossa pain in the emergency department of BP Koirala Institute of Health Sciences. Alvarado scoring was used for the post-test study. We found that the Alvarado scoring system is an effective diagnostic method, which decreases overdiagnosis of appendicitis in the emergency department, and at the same time reduces the risk of missing acute appendicitis cases. It is inexpensive and easy to implement by junior doctors with good results.

Nepal is a least developed country, with limited healthcare resources. An 18 month Fellowship in Emergency Medicine has contributed some improvements to care. This study assessed time to first analgesia in higher and lower acuity patients.A prospective observational study of 101 patients in each of the Australasian Triage Scale (ATS) 2, 3 and 100 in ATS 4 was undertaken at B.P. Koirala Institute of Health Sciences. Convenience sampling was used coinciding with researcher's duty hours. Pain scores and time to analgesia were recorded.A total of 302 patients were included. The doctors identified pain in 274 (90%, 95% confidence interval [CI] 86.74-93.65), severity recorded in 92 (30.5%, 95% CI 25-36). Median time from triage to analgesia was 30 min (interquartile range [IQR] 15-60) for ATS 2 patients, 60 min (IQR 40-70) for ATS 3 and 69 min (IQR 45-116) for ATS 4. Tramadol was the analgesic used most commonly (33%), followed by diclofenac (25%), morphine (16%), paracetamol (14%) and ketamine (2%). Analgesia was provided to 212 (70%, 95% CI 64.6-75.2), 65 (30.66%, 95% CI 24.5-37.3) with ATS 2, 85 (40%, 95% CI 33.4-47) with ATS 3 and 62 (29.2%, 95% CI 23.2-35.8) with ATS 4. A total of 44 patients (20.7%, 95% CI 15.5-26.8) with mild, 101 (47.6%, 95% CI 40.7-54.6) with moderate and 60 (28.3%, 95% CI 22.3-34.8) with severe pain received analgesics.Time to analgesia for triage score 2 is lower compared to higher triage score. However, a large proportion of patients still do not receive analgesia. This is likely addressed by using a combination of strategies.

Background: Poisoning is common in Nepal. The objective of the study was to describe the profile of poisoning cases presenting to the emergency of a medical university in eastern Nepal. The specific focus was on to describe the presentation, demographics, delay to care and describe the triage parameters at presentation. Methods: An observational study was done. The secondary data from case files of all poisoning patients starting February 2012 to March 2013 were analyzed after retrieving them from Hospital record. Results: Poisoning constituted 3.89% of total emergency visits. Mean age was 24 years with female: male 1.32. Median time delay to presentation from the incident was 4 hours. Mortality rate was 5.1%, intubation rate 6.3%. Agricultural products ingestion (763/1399) was the commonest modality. The triage vitals were noted as median 110 mm of Hg (Q25, Q75 100, 120) for systolic blood pressure, median 87 mm of Hg (Q25, Q75 73, 93) for mean arterial pressure and median 97 (Q25, Q75 94, 98) for SPO2 by pulse oximetry. The level of consciousness was noted as alert (87.6%), response to verbal stimuli (3.7%), response to pain stimuli (7.1) and unconscious (1.6%). Comparison between mortality and no mortality groups showed significant difference for mean arterial pressure (n 1399, p

Objectives: Patient-centered communication teaching generally encourages doctors to inform patients of cancer diagnoses. In many countries, including Nepal, it is usually the patient's family that is informed. Much of the evidence about patient preferences is from western studies. The objectives of this study are: To discover the attitudes of medical students and patients in Nepal toward disclosing a cancer diagnosis; and to identify the reasons for these attitudes. Materials and Methods: A cross-sectional survey was administered to medical students and patients in a teaching hospital in Nepal. The participants were asked about their attitudes toward and reasons for informing patients of a cancer diagnosis. The data were analyzed to compare students' and patients' attitudes and to look for differences between the first and fourth year students. Results: Fifty-four percent of the students would inform a patient even if the cancer was incurable, 6% would inform only if curable, and 40% would inform the family instead. Sixty-nine percent of the students and 51% of the patients wanted a close relative informed, even if the relative was incurable (P = 0.0016). There was no significant difference between students (83%) and patients (78%) wanting to be informed of their own diagnosis. The most important reasons for students not informing the patients were fears of loss of hope and of causing depression. Conclusion: The results confirmed the diverse attitudes about informing a cancer diagnosis to patients, in Nepal. Students wanted more information for themselves than they felt patients should be given. This information could enlighten the practice of doctors in Nepal and other similar cultures, as well as guide the communication training of future doctors.

The study is a comprehensive analysis of the cause and effect of fluctuations in the major currency pairs and the effect on the Indian rupee. The study also depicts the variation in the rates of the currency pairs through correlation between them. The objectives of the study are met through the collective and comparative analysis of the data collected for the purpose of the study. Currency market (or Forex market) is a very volatile and liquid market among all the financial market. Currencies are priced in pairs and are traded in pairs. It is useful to know from an investment perspective, regarding the movement they share with each other i.e. whether they move in same direction or in opposite direction. Once the correlations between these pairs and their movement pattern are known, it can be used to control upon overall portfolio’s exposure. The study is useful for those willing to trade in foreign exchange. The inferences drawn from the study can be seen as useful information and can be used to test strategies on correlated pairs in order to avoid over-exposure; to double profitable positions; to diversify risks, and to hedge in the ever fluctuating market. This project is an overview of global forex market and the impact of movement pattern of major foreign currency pairs to Indian rupee currency pairs based on the date of fourteen years from 1/1/2000 to 31/12/2013. Investors can hedge their risks and diversify their portfolio by using the data of correlation between various currency pairs. Fluctuations in one currency pair may or may not impact to another currency pairs. Traders can build their strategies using the currency correlation between different currency pairs to make profit from the market.The study is undertaken in Wings World Finoconsult Pvt. Ltd., Bangalore which is a financial advisory company and is a Subsidiary of FW Markets Ltd. Located in Saint Vincent and the Grenadines under license number 20779 IBC 2013.From the analysis it is found that major foreign currency pairs EURUSD and USDJPY have direct and positive high correlation with EURINR and INRJPY respectively. Whereas, EURUSD and GBPUSD have low and insignificant impact to the exchange rate of USDINR and GBPINR.Investors can take an advantage of the finding of this study to construct the profitable portfolio, hedge the risk, confirm the breakouts and avoid fakeouts while trading in the forex market.

Background Penetrating orbital injuries pose a serious threat to vision, ocular motility, and in some cases, life. The setting and causes of eye injury are diverse, but previous studies have demonstrated that the risk and type of injury is often correlated with age, gender, and race. Pediatric ocular injury is often accidental and may be preventable. A focused history and prompt ocular examination are essential to immediate management. Case presentation This article describes a case of protruding foreign body-related penetrating orbit injury with a retained foreign body in a 4-year-old male from a town in the eastern part of Nepal. The child presented to the emergency with foreign body in situ without receiving any pre emergency care without any medical attendance. The patient was managed with non-operative removal of foreign body in the emergency. The case discussion will review the initial presentation, examination, resultant management decisions, and final outcome. Conclusion Foreign body presentations may be diverse and non-operative management may be considered in selected cases. Resource availability and conditions at presentations may also influence the management decisions. This case presentation has described such a scenario in developing country like Nepal and is expected to be interest across various medical specialties.

Priapism is a rare and unusual presentation in Emergency Department of Nepal and is really a challenge for the working Emergency Physicians. In Nepalese context it is a social stigma and is often a pitfall due to possible delayed presentation. A young Nepalese Hindu male presented to our Emergency Department with post coital priapism who seeked help only after ninety-six hours in request of his wife. In limited resource hospital settings with delayed presentation, aspiration and irrigation of corpora cavernosa with heparinized saline had shown good outcome in treatment of priapism without any postoperative complications regardless of prolonged stay in emergency department.

India is the booming market for telecom sector. It is ranked second in telecom network provider all around the world. This industry has witnessed significant growth in subscriber base over the last decade, with better network coverage and competition induced decline in tariffs. This attracted various foreign companies to invest in this sector. This research paper is all about the performance of various telecom companies in India and the proposal of new telecom company TeleIN.

Triage is recognized as important in providing timely care to emergency patients. However, systematic triage is only practised in two EDs in Nepal. The first objective of this study was to assess the performance of one of these departments in seeing triaged patients in a timely fashion. Second, an epidemiological survey of patients presenting to the ED was performed to describe the conditions seen and initial resuscitation undertaken.We performed a descriptive cross-sectional study in the ED of B.P. Koirala Institute of Health Sciences, eastern Nepal where the Australasian Triage Scale (ATS) is used. One hundred and sixty patients triaged as ATS 2 were recruited. The time taken for the duty doctor to see the patient was noted. The presenting problems, vital signs and level of consciousness were measured at presentation. The resuscitation measures were recorded.The mean waiting time was 2.1 ± 1.7 min with a range of 1-10 min, which meets the benchmark for ATS 2. At triage, the most common presenting problems were circulatory shock (23.1%), altered consciousness (21%), respiratory difficulty (16.9%) and poisoning (15%). Oxygen, i.v. fluids and antibiotics were the most common therapies used in the initial resuscitation of patients.Patients triaged as ATS 2 were seen in a timely fashion. Seriously ill patients requiring resuscitation present commonly to this ED. This is a big challenge for junior doctors. Improved training, treatment protocols and equipment are needed to help manage this burden.

Sir,Methicillin-resistant Staphylococcus aureus (MRSA) has been endemic in Australian hospitals for more than 25 years, and in order to limit transmission the focus has been on screening in order t...

Background: Head injury is a common presentation in emergency rooms. Management often is decided by time of trauma, clinical presentations and availability of facilities. Objective: To outline the general characteristics of head injury patients presenting to emergency. Methods: This is an observational (case series) study done in BPKIHS emergency room over a period of six months. All the acute head trauma cases presenting to the department of emergency, BPKIHS, were evaluated based on the semi closed clinical performa including major clinical indicators of intracranial trauma. Results: Among 255 head injury patients, males were more common. Fall was the commonest mode of injury resulting in 71.42% in those under ten years where as road traffic accidents was commonest in twenty to fifty years age group.23% reached the hospital after 12 hours of injury. Loss of consciousness and vomiting were the commonest history. 9.4% had consumed alcohol at presentation. Mild head injury was commonest (76.5%). 23% were discharged from emergency within 12 hours. 14.9% underwent neurosurgical intervention. 187 of 255 underwent CT scan, 132 were abnormal. Contusions were commonest. For the normal CT scan the mean GCS score was 13.65 and for abnormal CT scans the mean GCS was 12.48 with SD of 2.8 and 3.4 respectively, p=0.025. Keywords: head injury; clinical features; emergency; classification; Glasgow coma score; CT scan. DOI: 10.3126/hren.v8i2.4422 Health Renaissance , May-Aug 2010; Vol 8 (No.2):11--113

Introduction: Alvarado score is one of the scoring systems for diagnosis of appendicitis. Objective: To assess the sensitivity and specificity of clinical features used in Alvarado score. Subjects and methods: A prospective study of 171 patients with pain in the right iliac fossa presenting to emergency at BPKIHS, Dharan, Nepal was conducted. The sensitivity and specificity of clinical features and lab parameters used in Alvarado score were evaluated comparing with final diagnosis based on operative and histopathological findings. Results: The sensitivity of clinical parameter were: migrating right iliac fossa pain- 99.1%, anorexia- 45.7%, nausea/vomiting- 73.7%, right iliac fossa tenderness- 100%, fever- 24.5%, rebound tenderness in right iliac fossa- 89.8%, leucocytosis (>10,000)- 84.7% and a neutrophilic shift to the left (>75%)- 68.6%. The specificity of clinical parameters were: migrating right iliac fossa pain- 45.3%, anorexia- 86.7%, nausea/vomiting- 54.7%, right iliac fossa tenderness- 1.8%, fever- 81.1%, rebound tenderness in right iliac fossa- 64.1%, leucocytosis (>10,000)- 83.1% and a neutrophilic shift to the left (>75%)- 71.6%.Conclusion: Migrating right iliac fossa pain, right iliac fossa tenderness and rebound tenderness in right iliac fossa had a high sensitivity, leucocytosis (>10,000) had both high sensitivity and high specificity. Thus, in our set up, use of Alvarado score appears helpful for diagnosis of appendicitis Keywords: Alvarado score; sensitivity; specificityDOI: 10.3126/hren.v9i1.4355Health Renaissance, 2011: Vol.9 No.1:12-14