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Introduction: Inappropriate use of antimicrobials increases resistance, morbidity, and mortality. Accurate information on the use of antibiotics is crucial to address the problem of antibiotic overuse and resistance. The aim of this study is to explore the antibiotic prescription pattern at inpatient departments of Dhulikhel Hospital. Method: This prospective point prevalence study was conducted in five inpatient departments by making 25 visits between June 2018 and March 2019. Patient planned to be discharged on the day of visit was included in the study. The details of the patients who received at least one antimicrobial for at least one clinical treatment condition or prophylaxis during the hospital stay was recorded. The data on the antimicrobials received, diagnosis, therapeutic indication according to predefined lists, and markers of prescribing quality were recorded. Result: Out of 179 patients, 125 patients (69.8%) were prescribed one or more antibiotics. There was noticeable variation in prevalence of antibiotic prescription across the departments, ranging from 59.5%-78.9 %. The top three prescribed antibiotics were third generation cephalosporins 63 (38%), broad spectrum penicillin 49 (29.5%), and metronidazole 19 (11.4%). The patients received antibiotic for non-bacteriological proven infection 66 (52.8%) and only 8 (6.4%) patient received antibiotic for bacteriological proven infection. Culture and sensitivity testing were sent in 45(36%) patients and urine was the most frequent specimen Conclusion: Study concluded that there is need to further explore factors contributing to the high prevalence of antibiotic use and develop strategies for appropriate antibiotic use in the hospital.

The emergency departments (ED) present as the gateway to healthcare services for an increasing number of older adults. Acute care of this vulnerable population in a busy ED presents its own unique challenge. They have higher mortality in the hospital and following discharge, a higher revisit rate to the ED, and are at a higher risk of functional decline following an ED visit. Extra caution and mindfulness are needed when caring for them as they differ from younger patients in several ways. This article tries to put forward feasible strategies with an integral and holistic view to meet their complex need in the ED.

Background: Acute respiratory tract infection has been recognized as the major cause of morbidity and ranks among the most frequent causes of mortality among the elderly and very young children. This study aimed to assess the pharmacological management of acute respiratory tract infections among patients visiting Emergency Department in Dhulikhel Hos­pital, Kathmandu University Hospital. Methods: A descriptive, cross sectional study was conducted from August 2019 to January 2020 in patients attending Emergency Department of Dhulikhel Hospital. One hundred and sixty five pa­tients with symptoms of acute respiratory tract infections who visited the same department were included in the study. Entry and analysis of collected data was done in Statistical Package for the Social Sciences 20. Descriptive tests were used, and results were expressed as mean, frequency and percentage. Results: Among 165 patients who visited Emergency department with symptoms of acute respira­tory tract infections, majority 137 (83%) had symptoms of shortness of breath, followed by cough 110 (66.7%). Thirty (18.2%) cases were triaged into high acuity (red) zone. Acute exacerbation of chronic obstructive pulmonary disease 118 (71.5%), followed by pneumonia 16 (9.7%) were the most common diagnosis. Intravenous hydrocortisone was the most commonly used pharma­cotherapy in 125 (75.8%) patients. Oxygen was most commonly used supportive therapy in 137 (83%) cases. Regarding the outcome, 75 (45.5%) were admitted to wards and 64 (38.8%) were discharged. Conclusions: Most of the acute respiratory tract infections were managed by using intravenous corticosteroid, antibiotics and nebulized bronchodilators.

Purpose During the outbreak of Coronavirus disease of 2019 (COVID-19), the preparedness of emergency departments (EDs) for triaging of the patients and safety of staff is of utmost importance. The aim of our study was to develop and implement COVID-19 ED triage and protected intubation protocols for COVID-19 patients with in-situ simulation (ISS) training. The latent safety threats (LST) detection also served as a platform to test new system amendments and refine the protocols and workflows with infection control issues. We also explored the effectiveness of this approach based on Kirkpatrick's model of evaluating training outcomes. Participants and Methods The protocols and simulation scenarios were developed and validated. A total of 22 triage and 13 intubation simulation sessions were conducted in the ED with multidisciplinary staff (physicians=18, nurses=20) during a period of four months. Each simulation was followed by a debriefing session to discuss the team performance. Pre- and post-simulation performances were compared. LSTs were identified and remediated. An online voluntary feedback was collected from the participants to explore the opinion about the ISS sessions and confidence level using a 5-point Likert scale. Results There was a significant improvement in triage knowledge score after ISS [5.5/10 (IQR 4-6) versus 8.5/10 (IQR 8-9), p 75%) following the ISS for triage case scenarios. A pre-designed checklist was used during protective intubation simulations. Some important LSTs were missing medications, lack of mechanism to deliver patient samples to lab and faulty airway maneuvers. The participants' feedback on ISS showed increased skills and confidence level on triaging and protected intubation (p

Purpose Competency to perform cardiopulmonary resuscitation is essential to improve the outcome during an event of cardiac arrest. Medical internship is a "transition phase" beyond which physicians are exposed to the unpreparedness and anxiety while dealing with life-threatening conditions which need rapid actions. Experiential learning, deliberate practice and immediate feedback are the primary advantages of simulation-based medical education. In-situ simulation occurs in a real patient care environment utilizing the available resources. Our aim was to introduce in-situ simulation-based resuscitation skills training for medical interns. Methodology This was a prospective quasi-experimental study with mixed research design conducted in the emergency department. The knowledge score questionnaire, skill-score sheet, post-simulation feedback from the interns and staff were designed, validated through experts, peer-reviewed and pilot tested. All the interns posted in the emergency department participated in the training. Appropriate statistical analyses were applied for quantitative data. Thematic analysis of the data from the open-ended questions was used to identify the themes. Results Six groups of interns (n=35) participated in at least one of the 40 in-situ simulation sessions. The means of the pre- and post-simulation knowledge scores were 5.89± 2.8 SD and 11.74± 1.8 SD, respectively, and the difference was statistically significant [t (35) = 16.705, p

Purpose Point-of-care ultrasound (POCUS) is a quick bedside tool that has the potential to improve emergency care in resource -limited settings due to its relatively low cost and accessibility. Effort to disseminate the knowledge and skills about POCUS is inadequate in low and middle income countries like Nepal. We conducted a two-day interdisciplinary advanced emergency ultrasound workshop that targeted physicians working in emergency department and primary care, especially in rural Nepal. We explored the effectiveness of this training based on validated Kirkpatrick's 4 steps of evaluating training outcomes. Materials and Methods We conducted a prospective quasi-experimental study with mixed research design. Multidisciplinary physicians working in emergency departments participated in the two-day workshop. We assessed and compared the pre- and post-workshop knowledge. We collected on-site and a follow-up feedback to explore pre- and post -workshop confidence level, perceived usefulness and clinical use of ultrasound using a 5 -point Likert scale. The barriers to use POCUS were explored. Results A total of 50 physicians from different parts of Nepal participated in the workshop. The academic level of the participants, duration of their clinical experience and the previous use of POCUS did not have a significant difference in their pre- and posttest knowledge scores. The difference between the median (IQR) pre- and posttest scores [14 (12.75-17.75) and 24.5 (22.25-25.5), respectively] was statistically significant (p

Introduction: Mental health and its related problems are growing concerns over the country. It is challenge to determine the epidemiology of childhood mental disorders. Early detection and effective intervention is necessary for holistic development of the futures citizens. Objectives: To assess the mental health problems and self-esteem of schoolchildren studying in urban Schools of Dharan Sub-metropolitan City. Materials and method: Cross-sectional descriptive research design was followed. The study population included schoolchildren studying in grade 9 and 10 in schools of Dharan (n = 450). Simple random sampling technique was used to select the school and students. Mental health problems were assessed using self-administered Strength and Difficulties Questionnaire and self-esteem level was monitored using self-administered Rosenberg Self-esteem Scale. Data was analyzed by using descriptive and inferential statistics. Results: Majority (55.6%) of the students were male. Among the total students 12.9% had mental health problems. Gender difference was statistically significant as girls had higher (14.5%) mental health problem (p value = 0.027).Girls (15%) were statistically significant more likely to have emotional problems within domain of mental health problem than boys (p value = 0.003).) whereas boys had conduct problem. Self-esteem level was significantly negatively correlated with mental health problems (r = -0.256, p= 0.000). Conclusion: Mental health problem is high prevalent among school children. There was statistically significant negative correlation between mental health problems and self-esteem of the schoolchildren.

Roshana Shrestha,1 Anmol Purna Shrestha,1 Taylor Sonnenberg,2 Janki Mistry,3 Rajeev Shrestha,4,5 Theodore MacKinney3 1Department of General Practice and Emergency Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Nepal; 2Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; 3Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; 4Department of Pharmacology, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Nepal; 5Nepal Pharmacovigilance Unit/Research & Development Division, Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Kavrepalanchok, NepalCorrespondence: Roshana ShresthaDepartment of General Practice and Emergency Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, NepalTel + 977 9841558332Email roshanashrestha@gmail.comPurpose: Acute care of patients with exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department (ED) is crucial, however not studied extensively in Nepal. The purpose of this study is to identify the opportunities for succinct measures to optimize the AECOPD care in ED with a multifaceted bundle care approach in a resource-limited setting.Methods: We conducted a prospective cross-sectional observational study as an initial baseline stage of the quality improvement project. Demographic data, clinical characteristics, the current diagnosis and treatment performances of AECOPD were recorded. The primary outcome measures were 30-day ED revisit and near-fatal events which were compared with other variables and performances with binary and logistic regression. The multidisciplinary team performed the root cause and Pareto analysis to identify the potential gaps in the AECOPD care.Results: The AECOPD performance measures were suboptimal. Written AECOPD emergency management clinical guidelines and advice regarding pulmonary rehabilitation were absent. Among the 249 AECOPD encounters, bilevel positive-airway pressure ventilation was started in 6.4%. At discharge, 11.8% and 39.7% were given oral steroids and antibiotics respectively; 2.2% were advised vaccination. Near-fatal events and 30-day revisit occurred in 19% and 38.2% of the encounters respectively. Those who required domiciliary oxygen had significantly higher 30-day revisits (OR=2.5; 95% CI=1.43– 4.4; P value =0.001) as did those who were previously admitted (OR=1.98; 95% CI 1.11– 3.59; P value =0.022). Those who had a 30-day revisit had increased near-fatal events (OR=2.86; 95% CI=1.362– 6.18; P value =0.006). The opportunities for improving the ED care were identified and feasible interventions and their indicators are summarized for future implementation.Conclusion: The current COPD performance measures were suboptimal with high 30-day revisit and near-fatal outcomes. We suggest the urgent implementation of the enlisted feasible bundles-care involving multifaceted team and protocol-based management plans for AECOPD in a busy resource-limited ED.Keywords: clinical practice guideline, near-fatal outcome, performance measure, quality improvement, resource-limited setting, root cause analysis

Introduction Head injury, a common presentation to the emergency department (ED), is a substantial problem in developing countries like Nepal. The current national institute for health and clinical excellence (NICE) guideline revised in January 2014 focuses on effective clinical assessment and early management of head injuries according to their severity in all age groups. This study assessed the impact of implementing this guideline on the proportions of computed tomography (CT) head scans, guideline adherence, and confidence level of the attending physicians. Methods We consecutively recruited 139 traumatic head injury (THI) patients in this prospective pre-post interventional study conducted in the ED of a tertiary care center. We implemented the NICE guideline into routine practice using multimodal intervention through physicians’ education sessions, information sheets and guideline-dissemination. The pre and post-implementation CT head scan rates were compared. The post-implementation guideline adherence was assessed. Online Google form-questionnaires including 12 validated case scenarios were distributed to the attending physicians at the end of both phases to assess their confidence levels. Results The implementation resulted in a statistically significant decrease in the proportion of CT head scan rates from 92.0% to 70.0% (p-value = 0.005). Following educational interventions, improved guideline adherence of 20.3 percentage points (p-value = 0.001) was observed. Nine ED attending physicians were enrolled in the study who showed statistically significant improvement in their confidence level following the intervention. The NICE guideline showed a sensitivity and specificity of 93.6% and 76.4% with 82.6% accuracy compared to that of clinical judgment (100%, 34.6%, and 58.1% respectively) in detecting intracranial lesions. Conclusion The implementation was successful in satisfying the aim of the NICE guideline by decreasing the proportion of CT head scans, improving guideline adherence and increasing the confidence of the attending physicians.

BackgroundThe COVID-19 pandemic is a global challenge that is not just limited to the physical consequences but also a significant degree of a mental health crisis. Self-harm (SH) and suicide are its extreme effects. The aim of this study was to provide an overview of the impact of the COVID-19 pandemic on the occurrence and clinical profile of suicide and SH in our ED.MethodsThis is a cross-sectional observational study conducted in the ED of a tertiary care center. Records of all fatal and nonfatal SH patients presenting to the ED during the lockdown period (March 24-June 23, 2020; Period1), matching periods in the previous year (March 24-June 23,2019; Period 2) and 3 months period prior (December 24 2019-March 23, 2020; Period 3) was included by searching the electronic medical record (EMR) system. The prevalence and the clinical profile of the patients were compared between these three periods.ResultsA total of 125 (periods 1=55, 2=38, and 3=32) suicide and SH cases were analyzed. The cases of suicide/SH had increased by 44% and 71.9% during the lockdown period in comparison to the period 2 and 3. Organophosphate poisoning was the most common mode. Females were predominant in all three periods with a mean age of 32 (95%CI: 29.3-34.7). There was a significant delay in arrival of the patients in period 1 (p-value=0.045) with increased hospital admission (p-value =0.009) and in-hospital mortality (18.2% vs 2.6 % and 3.1%) (p-value=.001).ConclusionWe found an increase in patients presenting with suicide and SH in our ED during the pandemic which is likely to reflect an increased prevalence of mental illness in the community. We hope that the result will prime all mental health care stakeholders to initiate mental health screening and intervention for the vulnerable population during this period of crisis.

Background Depression is prevalent but poorly recognized in the Emergency Department (ED). We aimed to determine the prevalence of geriatric depression and its possible determinants in the ED using the 15-item geriatric depression scale (GDS). We also aimed to explore the performance of the shorter, five-item GDS as compared to the 15-item GDS. Methods This was a cross-sectional study with convenience sampling of the ED patients ≥ 60 years. The previously validated Nepali version of GDS-15 screened the sample into “no”, “mild-moderate” and “severe" depression using cutoff values of 4/5, and 8/9 respectively. Demographic and socioeconomic factors, comorbidities and health seeking behaviour were studied and the relation was assessed with binary (Chi-square and Kruskal-Wallis test) and multinomial regression analysis. The performance of GDS-5 was compared with the GDS-15 as standard. Cronbach’s alpha was calculated to investigate reliability. Validity was assessed by calculating sensitivity, specificity, positive predictive value, negative predictive value, Spearman’s correlation, receiver operating characteristic curve, and kappa coefficient. Results 280 patients were enrolled with an overall prevalence of depression of 45.7% [104 (81.3%) mild-moderate depression, and 24 (18.8%) severe depression]. The mean age of the sample was 71.36 with female predominance (61%), and 82.5% were illiterate. In the binary analysis, those who had more pain, visited the ED more often, had musculoskeletal diseases and sleep problems, mobility problems, visited local healers previously, and who reported self-perceived “heart and mind” disease showed statistically significant differences among the three categories. In multinomial regression analysis, visits to local healers, sleep problems and frequency of pain were significantly related to depression. The sensitivity, specificity, area under curve and Spearman’s correlation of GDS-5 were 75.8%, 96%, 0.919, and 0.827 respectively. Cronbach's alpha for GDS-5 was low (0.416), therefore a new version was proposed which improved the sensitivity to 90.6% and Cronbach’s alpha to 0.623. Conclusions Geriatric depression was highly prevalent which urges the need for ED-based interventions for screening and referral. The proposed brief GDS-5 correlated well with the GDS-15 with better validity and internal reliability and offers a more expeditious form of screening for geriatric depression in emergency settings in Nepal.

Background: Sepsis is a leading cause of death in emergency department. Serum lactate level assessment can play an important role for risk assessment and prognostication in critically ill septic patient.Objective: The objective of this study is to determine the relevance of initial serum lactate measurement after the implementation of sepsis protocol in emergency department, based on guidelines of Surviving Sepsis Campaign.Methods: This was a cross sectional descriptive study conducted at Patan Hospital from January 2014 to January 2015 among 94 sample of serum lactate who had clinical suspicion of sepsis as per established sepsis emergency department protocol. Data of serum lactate sent from emergency department was noted from the registry book of department of biochemistry, Patan Academy of Health Sciences. Based on clinical practice the obtained lactate results were stratified intothreerisk groups: high (> 4 mmol/L), intermediate (2.5 to 3.99 mmol/L) and low (< 2.5 mmol/L).Result: Out of the total 94 samples, 56 (59.6%) were male and 38 (40.4%) were female. Mean lactate level in males was 5.73 mmol/L and that in females was 5.47 mmol/L. Abnormal lactate level was predominantly high 85 (80%) out of which 31 (29%) had intermediate whereas more than half 54 (50.76%) had high lactate level.Conclusion: This study tells that clinically diagnosed sepsis do have higher serum lactate level. So, in our context, this needs to be explored to be used for early diagnosis of sepsis.Journal of Kathmandu Medical CollegeVol. 5, No. 2, Issue 16, Apr.-Jun., 2016, page: 49-51

Background: Renal colic is a common clinical presentation in emergency. The goal of this study was to describe the epidemiology, current diagnostic and treatment strategies of ureteric colic in our emergency department.Methods: This is a retrospective study performed over a six months period of patients with clinically suspected renal colic. Data collected included age, sex, urine analysis, ultrasound studies regarding size, site of the stone and presence of hydronephrosis. Comparative statistical analysis was performed using SPSS 12.2 software.Results: Among the total 201 cases, 134(67%) had ultrasound performed which yielded ureteric stone in 61/134 (45.5%) cases, out of which 52.5% (32/61), 32.8% (20/61) and 14.8% (9/61) had stones measuring 5-9.9mm, ≤ 4.9mm and ≥ 10mm respectively. The mean age was 31.6±11 with male: female of 3:1. Hydronephrosis was strongly correlated with the presence of ureteric stone (sensitivity -85.2%, specificity-94.5%, positive predictive value-92.9% and negative predictive value of 88.5%) and was significantly more common with larger stones (p=0.05). Hematuria and pyuria was present among 44.3% (27/61) and 31.1% (19/61) of the ultrasound confirmed ureteric stones respectively. Nonsteroidal antiinflammatory drugs and smooth muscle relaxants were the most common drug offered.Conclusions: Ultrasound to detect hydronephrosis, which is the most significant finding, may help to establish the probability of obstruction due to clinically important stone. Absence of hydronephrosis probably suggests small or passed out calculus requiring no immediate urological intervention or may indicate alternate diagnosis. Presence or absence of hematuria cannot be reliable diagnosing and excluding ureteral stones.

Background: Internationally emergency medicine is a relatively young specialty that is increasingly recognized for its potential for growth. In low middle-income countries (LMICs) like Nepal resources are quite limited and the development of new specialties such as emergency medicine can be slow to evolve. Specific areas of emergency care, including pediatric critical care have significant challenges due to clinical and educational limitations in countries like Nepal. Countries with robust healthcare systems like the United States can play a significant role in bridging this education and clinical divide in LMICs. In 2018 and 2019 the University of Toledo Medical Center in collaboration with Dhulikhel Hospital-Kathmandu University Hospital School of Medicine developed adult and pediatric critical emergency care workshops and educational sessions in an effort to improve the development of emergency medicine in Nepal. These sessions included hands-on workshops, educational lectures, and simulation participation environments in critical care procedures and decision making for both adult and pediatric emergencies. In these two workshops a total of 71 participants, including Nepalese emergency care providers ranging from pre-hospital personnel to faculty, engaged in these sessions. Results: Pre and post-workshop surveys were provided and this subjective data showed significant improvement in confidence levels along with procedural skills technique and knowledge as a result of the educational sessions provided. Conclusion: Multidisciplinary education and workshops to LMIC are necessary for development of emergency medicine and pediatric critical care. Simulation education and workshop training are highly valuable “hands on” methods to educate these healthcare providers. Highly developed healthcare systems in emergency and critical care must assist in the world wide development acute care management in these poorly resourced countries

Background Simulation is well established as an effective strategy to train health care professionals in both technical and nontechnical skills and to prevent errors. Despite its known efficacy, adequate implementation is restricted due to the financial burden in resource-limited settings like ours. We therefore pursued to introduce cost-effective in situ simulation (ISS) in the emergency department (ED) to explore its impact on perception and learning experience among multidisciplinary health care professionals and to identify and remediate the latent safety threats (LST). Methods This is a prospective cross-sectional study with a mixed method research design, which was conducted in the ED of Dhulikhel Hospital-Kathmandu University Hospital. The pretest questionnaire was used to determine baseline knowledge, attitude, and confidence of the staff. The ISS with minimal added cost was conducted involving multidisciplinary healthcare workers. The LSTs were recorded and appropriate remediation was performed. Voluntary post simulation feedback was collected after the sessions. Results Overall 56 staff participated in at least one of the 35 simulation sessions, among which 45 (80%) responded to the questionnaires`. Twenty participants (45.5%) were reluctant to use the defibrillator. The self-reported confidence level of using defibrillator was low 29 (64.6%). The knowledge score ranged from 0 to 8 with the median score of 3 and a mean of 3.29 ± 1.8. There was no statistically significant difference in knowledge scores among participants of different occupational backgrounds, previous training, duration of work experience, and previous use of a defibrillator. A total of 366 LSTs {individual (43%), medication (17%), equipment (4%), and system/team (36%)} were identified (10.45 LST per ISS). The overall feedback from the participants was positive. Eighty percent of participants reported increased skills to use a defibrillator, and 82% reported increased confidence for managing such cases. They also agreed upon the need and continuity of such type of simulation in their workplace. Conclusions The baseline knowledge score and the confidence level of the staff were low. Self-reported feedback suggested increased confidence level and teamwork skills after ISS. It promoted identification and remediation of latent safety threats. ISS serves as a cost-effective powerful educational model that can be implemented even in settings where finances and space are limited.

Background Children with emergency conditions require immediate life-saving intervention and resuscitation. Unlike adults, the pediatric emergency drug dose, equipment sizes, and defibrillation energy doses are calculated based on the weight of the individual child. Broselow tape is a color-coded length-based tape that utilizes height/weight correlations for children. However, in low-income countries like Nepal, due to factors like undernutrition, the Broselow tape may not accurately estimate weight in all ranges of pediatric age group. Methods This study was conducted in the Department of Pediatrics of Dhulikhel Hospital, Kathmandu University Teaching Hospital, in children less than 15 years of age. Our study aims to prospectively compare the actual weights of urban and rural Nepalese children with the estimated weights using the Broselow tape (2017 edition) and the updated APLS formula. The errors in the selection of endotracheal tube size and adrenaline dose using the Broselow tape were also explored. Results This study included 315 children with male to female ratio of 0.63:1. They were divided into 3 groups according to their estimated weight by the Broselow tape into 18 kg. There was a total agreement of the estimated color zone according to the Broselow tape with the actual weight in the gray zone (p = 0.01). There was a positive relationship between the actual body weight and the estimated body weight (correlation (r = 0.970, p = 0.01) and accuracy (r2 = 0.941)). Our analysis showed that the accuracy of estimated weight with the Broselow tape decreases with increasing weight of children. The precision of the tape was relatively high in the lower length zones as compared to the higher length zones. The estimated size of the endotracheal tube (p = 0.01) and adrenaline dose (p = 0.08) by the Broselow tape was in agreement with that estimated using PALS formula in weight group of less than 18 kg, but decreases as the estimated weight increases further. Conclusions The accuracy of the Broselow tape in estimating the weight of a child, endotracheal tube size, and dose of adrenaline is higher in weight group of less than 18 kg, and accuracy decreases as the weight of child increases. The Broselow tape should be avoided in children weighing more than 18 kg. Hence, PALS age-based formula for ET tube size estimation and weight-based formula for adrenaline dose calculation are recommended for children weighing more than 18 kg.

IIntroductions: Clinical profile of patient presenting with shock is important in early recognition and intervention to improve outcome especially in resource limited setup. This study is designed with an objective to evaluate history, clinical findings, laboratory findings and provisional diagnosis of patient presenting with shock. Methods: This was cross sectional observational study conducted at Patan Hospital emergency department from September to November 2014. All consecutive patients presenting with shock were included in this study during that period of time. Patient’s demography, clinical profile, provisional diagnosis and treatment were analyzed. Results: In two month period, 40 patients presented with shock to the emergency. Out of them 21(53.3 %) were female and 17(47.7%) were male. Commonest presenting complain was fever and shortness of breath 12(31.6%) each, shortness of breath followed by diarrhea 6(13.4%) and shortness of breath 5(13.2%). The diagnosis was as follows; septic shock 17(44.7%), hypovolaemic shock 10(26.3%), cardiogenic shock 7(18.4%) and unclassified 4(10.5%). Out of 17 patients with septic shock, 12 patient had pneumonia. Mean duration of stay in emergency was 100.6 minutes, minimum 30 minutes and maximum 225 minutes. Mean fluid given in emergency was 2328.9 milliliters, minimum 1000 millilitres and maximum 5000 millilitres. Conclusions: Sepsis was an important cause of shock in the emergency department. Pneumonia was common cause of sepsis and chronic obstructive pulmonary disease was common underlying condition. Keywords: emergency, lactate, shock

BackgroundThoracoabdominal trauma presents a diagnostic challenge for the emergency physician. The introduction of bedside ultrasonography (USG) provides a screening tool to detect hemoperitoneum, hemothorax, pneumothorax and pericardial effusion in torso injuries.AimTo evaluate the accuracy of extended focused assessment with sonography for trauma (EFAST) for chest and abdominal injuries performed by first responders in a tertiary care hospital of Nepal.MethodsThis was a prospective study including all trauma patients who obtained either an Injury Severity Score ≥15 or direct trauma to the trunk in 1 year period in the emergency department (ED) of Dhulikhel Hospital-Kathmandu University Hospital. The results of the EFAST were then compared with contrast-enhanced CT (CECT), radiology ultrasound (USG)/chest X-ray, or intraoperative findings when the EFAST was positive. The negative EFAST cases were observed for a minimum of 4 hours in the ED. Descriptive statistics and sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated.ResultsOut of 267 cases, 261 patients underwent an EFAST examination. The sensitivity and specificity were 94.8% and 99.5%, respectively. The negative predictive value was 98.53% whereas the positive predictive value was 98.21%. The overall accuracy was 99.4%.ConclusionThe results of this study suggest that EFAST examination performed by first-line healthcare providers is a useful method for assessment of thoracic and abdominal injuries. EFAST was found to have a high specificity (99.5%) and positive predictive value (98.21%) which indicates that it is an effective technique for detecting intra-abdominal or thoracic injuries. However, the effectiveness of EFAST is limited by its being operator dependent, and thereby human error. For negative EFAST cases, we recommend a monitoring period of at least 4 hours, serial fast scan, or further investigation through other methods such as a CECT.Level of evidenceLevel I

Emergency medicine (EM) is a young but prestigious medical discipline worldwide.1 However, in Nepal, it is in preliminary phase.2 EM is not only restricted to urban emergency departments but also a multifaceted discipline.3 Several EM training modules are currently practiced fragmented with different curriculum and duration.4,5 Pre-hospital emergency medical services (EMS), hospitals, trauma centres, and public health are working in silos and most of them devoid of proper emergency facility.2 This brought us to the realization of an urgent need of bringing all the stakeholders together in a symposium like this. The symposium was arranged into four different sessions as listed below: To familiarize with the history and current state of EM from Global Emergency Medicine perspective. To highlight the different clinical experiences and advancements in EM in Nepal. To emphasize the importance and possibilities in EM education and research in Nepal. To discuss the roadmap to develop and establish EM as a recognized medical speciality in Nepal. The overall objectives of the symposium were to discuss the challenges faced by current Emergency Medicine providers and identify the opportunities for the future development and recognition in Nepal. The most important current task for Nepal’s emergency physicians of advocating for policies, programs, and funding to support further development of the specialty was realized. Rural and urban emergency service providers from academic and non-academic institutions, governmental/non-governmental organizations and international medical institutions attended the symposium. General Practice (GP) residents, medical officers, medical students, interns and paramedics were among active participants.

Introduction: There are numbers of epidemiological studies that shows clear correlation between obesity and cardiovascular risk factors like systemic hypertension, diabetes, dyslipidemia. The primary aim of this study was to assess the absolute cardiovascular risk (ACR) and cardiovascular risk factors in obese patient. Methods: A descriptive cross sectional study was conducted at this hospital in a population who came for preventive health checkup package. The study was done over a period of 2 years from April 2011 to march 2013. Hypertension was defined as per JNC-7 guidelines. Lipid profile was assess following the criteria of Third report of National Cholesterol Education. Cardiovascular risk assessment was done by Farmingham risk assessment calculator 2008. Result: Total 197 people: male 95(55.5%), female 75(44.5%) participated in this study. Out of which 101 (59.4%) had high BMI with equal prevalence among gender. There was significant relation of BMI with high cholesterol and high triglyceride with p-0.021 and p-0.004 respectively. However there was no statistically significant relation with alcohol use, smoking, hypertension and diabetes .The study also revealed that 22% of population had moderate and 18% had high ACR but correlation between ACR and BMI was not significant statistically (p=0.091). .However in routine ultrasound finding there was strong association of fattyliver with high BMI 59% in overweight and in 22% obese which was statistically significant P

Aim: To determine the prevalence of H. pylori based on endoscopic biopsy and to investigate the association between H. pylori and endoscopy diagnosis and histopathological diagnosis. Materials and Methods: Over a period of two years, 228 endoscopic biopsies were included. Endoscopy diagnosis, histopathological diagnosis, and colonization with H. pylori were recorded and compared using appropriate statistical tests. Results: The overall prevalence of H. pylori was 68%; 69.6% in males and 66.7% in females. Duodenal and gastric ulcers were seen more in males (63.2% and 60%) compared with females (32.1% and 40%) (P < 0.001). The total rate of colonization of H. pylori in duodenal ulcer and gastric ulcer (85.7% and 84%, respectively) was significantly higher than those in gastritis, duodenitis, and gastric cancer (61.8%, 69.2%, and 60%, respectively) (P = 0.046). Histologically, chronic active gastritis and chronic follicular gastritis was significantly higher in duodenal ulcer and gastric ulcer (57.1%, 44% and 21%, 40%) in comparison to chronic persistent gastritis (21.4%, 16%) with P value < 0.001. Similarly, chronic active gastritis and chronic follicular gastritis had higher prevalence of H. pylori infection in comparison to chronic persistent gastritis (85.3%, 83.3% vs. 41.4%) with P value < 0.001. Conclusion: This study reveals that the overall prevalence of H. pylori infection is high in our setting with no significant difference in gender. Peptic ulcers were common in males. Those with peptic ulcers had higher rates of H. pylori colonization. Chronic active gastritis and chronic follicular gastritis were common histological findings in ulcerative diseases with significantly higher H. pylori positivity.

Background Eosinophilia in children is commonly caused by or parasitic, allergic and immunologic problems. Objectives To study clinical and laboratory profile of patients with eosinophilia and to identify possible causes. Method A prospective and descriptive study was conducted from January 2009- December 2011. All the cases of eosinophilia with symptoms and signs of single or multiple organ were included. The known caused of eosinophilia like allergy, asthma and drugs were excluded. Results During three years period, 84(2.41%) cases had eosinophilia with single or multiple organ involment. 14.3%, 39.3% and 46.4% had mild, moderate and severe eosinophilia respectively, with cases of hypereosinophilia comprising 85.7%. Eosinophilia is seen predominantly in tamang caste with overall age ranging from 1-14 years. Most common symptoms and signs are abdominal pain (67.9%) hepatomegaly (59.5%) respectively. Gastrointestinal system was most commonly involved organ followed by respiratory system. Nineteen percent had polyserositis involving pleural, pericardial effusion and ascites at presentation. Out of 84 patients only nine serum samples were able to be sent for parasitological analysis. sixteen had identifiable and/ or possible causes. Serum sample for parasitological analysis revealed fascilosis, filariasis, strongylosis stercoralis and toxocariasis. Conclusion Eosinophilia is more common among tamang poulation in our study. Most common symptoms and signs are abdominal pain and hepatomegaly respectively. Parasitic infection seems to be the most common cause however further study has to be done to reach final conclusion. Kathmandu University Medical Journal | Vol.10 | No. 2 | Issue 38 | Apr – June 2012 | Page 58-62 DOI: http://dx.doi.org/10.3126/kumj.v10i2.7346

Pain in the emergency department (ED) is common but undertreated. The objective of this study was to examine the efficacy and safety of intranasal (IN) ketamine used as an analgesic for patients with acute injury with moderate to severe pain.This study was a cross sectional, observational study of patients more than 8 years old experiencing moderate to severe pain [visual analog score (VAS)50 mm]. The initial dose of IN ketamine was 0.7 mg/kg with an additional dose of 0.3 mg/kg if VAS was more than 50 mm after 15 minutes. Pain scores and vital signs were recorded at 0, 15, 30 and 60 minutes. Side-effects, sedation level and patient's satisfaction were also recorded. The primary outcome was the number of patients achieving ≥ 20 mm reductions in VAS at 15 minutes. Other secondary outcome measures were median reduction in VAS at 15, 30 and 60 minutes, changes of vital signs, adverse events, satisfaction of patients, and need for additional ketamine.Thirty-four patients with a median age of 29.5 years (IQR 17.5-38) were enrolled, and they had an initial median VAS of 80 mm (IQR 67-90). The VAS decreased more than 20 mm at 15 minutes in 27 (80%) patients. The reduction of VAS from baseline to 40 mm (IQR 20-40), 20 mm (IQR 14-20) and 20 mm (IQR 10-20) respectively at 15, 30 and 60 minutes (P0.001). No critical changes of vital signs were noted and adverse effects were mild and transient.This study showed that IN ketamine is an analgesic choice for patients with acute injury in moderate to severe pain in an overcrowded and resource limited ED.

The ultrastructure of the primordial blood cells in the first and second hematopoietic lobes of the late second and third instar larva and prepupa of Drosophila melanogaster was compared with the ultrastructure of the blood cells found freely in the larval hemolymph. Within the hematopoietic lobes two principal cell-types were detected: (i) the prohemocytes and proplasmatocytes, and (ii) different developmental stages of crystal cells., Prohemocytes are characterized by a ribsome-rich cytoplasm, showing small amounts of mitochondria, rough ER and Golgi complexes and few primary lyosomes. Prohemocytes differentiate into proplasmatocytes. When released into the hemolymph they transform further into plasmato-, podo-, and lamellocytes. This differentiation pathway is characterized by a gradual, numerical increase of cytoplasmic organelles, the development of the lysosomal system and the aquisition of the capacity for phagocytosis and melanin formation. The differentiation of a procrystal cell into a crystal cell involves a number of intermediate stages, during which the crystalline material is produced, accumulated, and crystallized. Primary and secondary lysosomes in the primordial blood cells of the hematopoietic organs as well as the free blood cells in the hemolymph were identified cytochemically with the help of the acid phosphatase test. The capacity for melanin synthesis was studied with the phenol- and polyphenol oxidase test.

The fine structure and histochemistry of the neoplastic primordial blood cell-types in the larval hematopoietic organs and the mature cell-types in the hemolymph of the blood tumor mutant lethal (1) malignant blood neoplasm (l(1)mbn) of Drosophila melanogaster were investigated. In this mutant the cell-types of the plasmatocyte-line are neoplastic while the cell-types of the crystal-cell-line are not and are much reduced in numbers (1, 2). In contrast to the wild-type the mutant hematopoietic organs are enlarged and contain, in addition to primordial blood-cells, large numbers of mature plasmato-, podo-, and lamellocytes. All cell-types of the plasmatocyte-line differ in their fine structure and behavior from their wild-type counterparts. The mutant blood cells show generally a numerical increase of cell organelles and acid phosphatase positive primary and secondary lysosomes. In the phenol oxidase test they showed a vigorous melanization reaction. Plasmato- and podocytes invade into the tissues of the larva and show high phagocytic activity.

In the recessive mutant lethal(3)malignant blood neoplasm, (l(3)mbn), the precursors of the plasmatocytes, the proplasmatocytes, are malignantly transformed. The hypertrophied hematopoietic organs produce excessive amounts of plasmatocytes which are released into the hemolymph throughout the third larval instar. As a result, their number in the hemolymph increases up to 15-fold compared with that in the wild-type hemolymph. Most free blood cells in the mutant hemolymph are plasmatocytes. Podocytes and lamellocytes of normal size are rare. Approximately 10–12% of the blood cells are giant plasmato-, podo-, and lamellocytes which show numerous primary and secondary lysosomes in their cytoplasm. Furthermore, the malignant plasmatocytes invade all larval tissues which become histolyzed by a yet unknown process. The high level of polyphenol oxidase expression, coupled with the inability of the cells to distinguish between their own and foreign tissue, leads to the formation of melanotic masses and eventually to the melanization of the entire larva.

Background The International Labour Organization (ILO) defines child labour as “work that deprives children of their childhood, their potential and their dignity, and that is harmful to physical and mental development. The ILO has estimated that in 2004, almost 218 million children (almost 1 in 7) aged 5-17 were involved in child labour worldwide, about 126 million under hazardous conditions. In Asian-Pacific region, 122 million children aged 5-14 were working as child labourers. It is imperative to know why the children are engaged in labour and what kind of effect child labour has in their health, education as well as the economy of their family. Methods This is a descriptive study which interviewed 313 child labourers working in different industries. It specially tried to assess the reasons why children joined the labour force, their family demographics, education and their general hygienic condition. Results 83.4% of child labourers joined labour because of poverty, 36.1% of them earned less than thousand rupees a month. 23.6% of them come from a big family with more than eight members. 30% (94) of them have not received even the primary level of education. Their overall hygienic condition is not satisfactory. Conclusion In Nepal, poverty is the most common cause of child labour and child labourers do not have a good hygienic condition. Key words: Child labour; Poverty; Earnings; Hygiene pressure DOI: http://dx.doi.org/10.3126/nje.v1i3.5573 Nepal Journal of Epidemiology 2011;1(3) 90-94

In Drosophila genetic factors cause malignant and benign neoplasms (Gateff, 1978a,b,c). In addition, compactly growing lethal tumors have been obtained from eye-antennal imaginal discs during serial subculture in the abdomens of female flies (Gateff, 1978a,b). The following tumor types have been found: (1) lethal-benign imaginal disc neoplasms, (2) malignant neuroblastomas, (3) malignant blood cell neoplasms, and (4) a benign gonial cell neoplasm. The fine structure of some of the above tumors has been studied and compared to the fine structure of corresponding wild-type cells. These will be discussed below.