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Background: Risk stratification of Community acquired pneumonia (CAP) is challenging for physicians. Though various biomarkers are available, they are costly or not readily available in all health care settings. This study aimed to analyze the prognostic value of routinely available clinical and blood parameters in relation to the outcome of patients admitted with community acquired pneumonia. Methods: This was a hospital-based observational study of the patients admitted to Chitwan Medical College (CMC), Nepal between August 2021 and December 2021. We enrolled patients 18 years old and above with the diagnosis of CAP in the study and excluded patients with COVID and active pulmonary tuberculosis. The outcomes of the patients were recorded as improved, not-improved, or dead. Fischer exact, Kruskal-Wallis or Mann-Whitney tests were used for analysis wherever appropriate. Results: Total 92 patients with mean age 58.2 years were enrolled in the study. Patients who were not improved or were dead had higher age (p=0.029), respiratory rate (p

Introduction: An acute dyspnea has been a common cause of hospital admission throughout history. When formulating a treatment plan based on limited clinical information, a rapid diagnosis is important. Bedside maneuvers and tests that deliver rapid and reliable results represent a cornerstone of diagnostics medicine. Methods: This was a one-year cross-sectional research conducted at Chitwan Medical College Teaching Hospital. Consecutive patients with acute dyspnea whom were admitted for ≤ 6 hours were included in the study. A 5MHz micro-convex probe was used as the optimal single probe. Data entry and descriptive analysis were done in IBM SPSS version 20.0. Point estimate at 95% confidence interval was calculated along with frequency and descriptive statics. Results: Pneumonia was the most common overall ultrasound diagnosis with combined frequency of 47%. With a Positive Predictive Value of 94.11% and Negative Predictive Value of 97.01%, anterior pneumonia exhibited a sensitivity of 94.11% and specificity of 97.11%. Similarly, Posterior Lateral Alveolar Points (PLAPS) pneumonia had a sensitivity of 94.11% and specificity of 98.08%, with a PPV of 94.11% and NPV of 98.80% respectively. The clinical accuracy for pulmonary edema was the greatest with 96.77%. while COPD/asthma had least accuracy with 81.25%. Conclusions: POCUS of the lung, has a high sensitivity and specificity, especially for evaluation of acute causes of dyspnea such pulmonary edema and pneumonia. It is more sensitive than Chest X ray alone and should be integrated while making clinical diagnosis.

Background: Fiberoptic Bronchoscopy is a valuable tool in current respiratory medicine. This study was aimed to evaluate the diagnostic yield of Fiberoptic Bronchoscopy using a wider diameter bronchoscope. Methods: This was a hospital based cross-sectional study carried out in BP Koirala Memorial Cancer Hospital from January 2021 to March 2021. Consecutive sampling technique was used where 150 patients were enrolled in the study. Data entry and descriptive analysis were done in IBM SPSS version 20.0. Point estimate at 95% confidence interval was calculated along with frequency and descriptive statistics. Results: The overall yield from the wider Fiberoptic Bronchoscope was 70.07% which was slightly higher compared to literature results from conventional bronchoscopy. Lung mass on CT scan was the most common indication for bronchoscopy and upper lobe bronchus was the most common site for biopsy. Bronchial wash yield was highest for Squamous cell carcinoma with 22.78% followed by Pulmonary Tuberculosis with 21.5%. Endobronchial biopsy yield was highest for Squamous cell carcinoma with 41.21% followed by Adenocarcinoma with 31.42%. Temporary hypoxia and mild bleeding were common but life-threatening complications were rare. Conclusions: Overall findings of our study confirm that the diagnostic yield of Fiberoptic Bronchoscopy is high, particularly when a larger diameter bronchoscope is used which can facilitate wider biopsy forceps for larger tissue sampling.

Background: Respiratory distress (RD) in mechanically ventilated patients may signify life-threatening complications which may be potentially reversible. The aim of the study was to determine the signs and etiologies of respiratory distress in patients under mechanical ventilation. Methods: A hospital-based cross-sectional study was done on adult patients on mechanical ventilation (MV) with Respiratory distress admitted at Chitwan Medical College, Nepal from January 2021 to June 2021.We studied various signs and etiologies of RD in different days on MV. Descriptive analysis was carried out using IBM SPSS version 20. Results: Total 66 patients were included in the study with mean ± SD of age was 55.3 ± 15.8 years with equal proportion of male and female. Out of total 154 occurrences of 11 signs in 66 patients, agitation was the most common one occurring 29.3% of times followed by use of accessory muscle in 15.9%. Most common cause of respiratory distress was interstitial syndrome of increased extra-vascular lung water or density on ultrasound was present more in patients on MV for ≥ 5 days. Most patients (74.2%) had multiple RD signs and 25.8% had only a single sign. Gasping was more common in patients on MV ≥ 5 days and agitation and delirium more in early days of MV. Conclusions: More than half of the conditions associated with RD on MV are relatively reversible and as the patients can develop RD any time or any day after being put on MV, a continued vigilance system is essential for their timely assessment and management.

INTRODUCTION: Antimicrobial therapy is the main stone in treatment. Gram negative bacilli are common cause of sepsis, pneumonia and urinary tract infections in ICU patients. Their treatment becomes more challenging due to the evolution of multiple drug resistant strains. The findings of this study would be useful in the formation of effective diagnostic approaches and policy of antimicrobial therapy for the treatment of infections in a similar intensive care hospital setting. MATERIALS AND METHODS: A Laboratory based descriptive cross-sectional study was conducted at the department of clinical microbiology of the Chitwan Medical College Teaching Hospital based on the reports of 129 bacterial isolated of various clinical specimens from different ICUs of hospital between April 2018 to September 2018. RESULTS: Among the 129-gram bacilli isolated mono bacterial growth were 116(89.92%) while remaining 13(10.08%) had poly bacterial or mixed organisms isolated. The most frequently isolated organisms were Acinetobacter spp. 51(39.55%), Escherichia coli 25(19.37%), Klebsiella spp. 27(20.93%), Pseudomonas aeruginosa 17(13.95%) and Enterobacter spp. 8(6.2%). Antibiotic resistance was observed in many organisms with multidrug resistance 97(75.2%) among them. High level of resistance was observed to Cefotaxime (98.04%), Ceftriaxone (96.08%), Imipenem (80.39%), Ampicillin/sulbactam (72.55%) and Amikacin (70.59%). Ciprofloxacin (68.63%), Levofloxacin (27.45%) and Meropenem (28.21%) were found to be relatively effective against Acinetobacter spp. Isolated. CONCLUSIONS: Most of the frequently isolated organisms are multi drug resistant.

Background: The oxygen crisis globally during the Corona virus disease-19 (COVID-19) pandemic reflected the need of appropriate and economic use of oxygen in its management. There is scarce report of the use of different oxygen delivery methods (ODMs) in COVID-19 patients in our region. Methods: This was a hospital-based observational study conducted from July 2021 to October 2021. We studied various ODMs used by 100 COVID-19 patients, aged 18 years or above admitted to Chitwan Medical College and Teaching Hospital during July to October 2021 and the trend of how the ODMs changed during the hospital stay. Data analysis was done by SPSS version 20 for Windows. Fisher’s exact and Kruskal Wallis tests were used to analyze the data of the participants. Results: In our study, oxygen supplementation at presentation using nasal cannula was required by 74% of patients, face mask by 13%, Venturi mask 34%, non-rebreathing mask 25%, high-flow nasal cannula 27%, non-invasive ventilation 6%, and invasive mechanical ventilation by 21%. There was significant difference in the use of ODMs at presentation among the moderate, severe and critical COVID-19 groups (P

Background: The full extent of pulmonary damage and long-term prognosis due to severe COVID-19 pneumonia is still unclear. This study was aimed to characterize and compare changes in the radiological pattern of HRCT chest in severe COVID-19 pneumonia patients from admission to that of follow-up. Methods: This was a one-year prospective study done at Chitwan Medical College from April 2020 to April 2021. Total 56 patients with severe COVID-19 pneumonia who had at least one HRCT chest during admission and another during follow-up within 5 weeks. Based on the total number of days on systemic steroids, patients were separated into three follow-up groups. Statistical Package for Social Science version 20 was used for data input and descriptive analysis. Point estimate at 95% Confidence interval was calculated along with frequency and descriptive statistics. Results: The median CT severity index scores of follow-up HRCT chest improved from 14.5 to 10.0 in the 3rd week and from 16.0 to 11.5 in the 5th week. Ground Glass Opacity resolved early and steadily. The prevalence of bronchiectasis and fibrosis was considerable, with no meaningful improvement up to 5th week. Conclusions: Significant radiological improvement can be seen as early as 3rd week from recovery phase of severe COVID-19 pneumonia where systemic steroids have a key contributory role. High frequency of bronchiectasis and fibrosis from in-patient HRCT chest may be due to acute COVID-19 pneumonia lesions on the preexisting undiagnosed lung diseases which may be falsely ascribed to the post-COVID.

Background: Acute febrile illness (AFI) is defined as a fever lasting less than 14 days with no evidence of organ-specific symptoms or signs of infection. Our aim was to determine the most common etiology of AFI with transaminitis and to find the relationship between clinical and laboratory investigation profile, as well as outcomes of illness. Methods: This is a hospital based prospective study conducted in Chitwan Medical College and Teaching Hospital (CMC-TH) from 17 April 2021 to 18 October 2021. All patients >15 years of age admitted with acute febrile illness and elevated transaminases under Pulmonary and Critical Care Medicine (PCCM) Unit of CMCTH were enrolled consecutively. Results: The mean age of the patients (n=103) was 45.1 ± 16.8 years. There were almost equal proportion of males and females. The most common presenting symptom (besides fever) was headache, followed by myalgia, with a median duration of 5 days. Scrub typhus was the commonest diagnosis (60, 58.3%). A diagnosis of Acute Undifferentiated Febrile Illness (AUFI) was given in (39, 37.9%) patients. The three transaminitis severity groups (mild, moderate and severe) were not significantly different by age, gender and comorbidity status. Acute kidney injury and multi-organ dysfunction syndrome (MODS) were significantly associated with severe transaminitis (P

Background: Corona virus disease 2019 (COVID-19) has become a global public health issue with significant impacts upon the healthcare delivery systems. Previous studies have consistently found elevated levels of C-Reactive Protein and D-dimer with disease severity. In this study, we aimed to investigate the relationship between C-Reactive Protein, D-dimer level and Computed Tomography severity score in patients with SARS-COV-2 pneumonia. Methods: Our study included 76 patients with COVID-19, admitted in COVID Unit of Chitwan Medical College and Teaching Hospital from June 2020 to December 2020. We included COVID-19 cases confirmed by a RT-PCR test and those undergoing High resolution Computed Tomography of chest and having C-Reactive Protein and D-dimer levels done on admission. A semi-quantitative CT score was calculated based on the extent of lobar involvement (0:0%; 1, < 5%; 2:5–25%; 3:26–50%; 4:51–75%; 5, > 75%; range 0–5; global score 0–25. Results: Overall the median CTSS was 15. Mild, moderate and severe CT severity scoring was reported in 5.3%, 60.5% and 34.2% respectively and D-dimer progressively increased across the CTSS severity groups. The difference was significant for CRP, P = 0.007 but not for D-dimer, P = 0.42. Moreover, higher CTSS scores were significantly associated with higher ICU stay, lower recovery rate and higher O2 requirement at discharge. Conclusions: Radiological severity of COVID-19 pneumonia has significant association with elevated C-Reactive Protein level but not with D-dimer level and other routine laboratory parameters.

Background: Clinical assessment, chest X-ray (CXR) and high-resolution computed tomography (HRCT) are used in the Corona virus disease-19 (COVID-19) management. The aim of the study was to determine the clinical characteristics and CXR and HRCT findings in COVID-19 patients with different clinical severity. Methods: This was a hospital-based cross-sectional study conducted at Chitwan Medical College, Department of Pulmonary and Critical Care Medicine from September to December 2020. Data from sixty adult patients with moderate (non-severe), severe, and critical COVID 19 disease having both CXR and HRCT were collected and were analyzed using SPSS version 16. Results: Median age of patients in our hospital-based study was 59.9 years and 76.7% were male, 30% had diabetes, and 35% had hypertension. Respiratory rate (p=0.001) and shortness of breath (p= 0.011) significantly increased and oxygen saturation (SpO2) (p0.05). Conclusions: There was no difference in CXR and HRCT findings across moderate, severe and critical clinical severities of COVID-19; future study performing CXR whenever HRCT is done for any indication may similarly indicate the situation in mild COVID-19 disease.

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

Background: Point of care ultrasonography (POCUS) by non-cardiologist is a safe and rapidly evolving diagnostic modality for the assessment of left ventricular ejection fraction (LVEF). This study aims to correlate the eyeball estimation of LVEF (EBEF) with modified Simpson’s method and linear measurement in M-mode parasternal long axis view (PLAX). Methods: A descriptive cross-sectional study was conducted at Chitwan Medical College. POCUS was performed in all ICU patients on the day of admission with optimal image acquisition and LVEF was estimated by three different methods and correlation of results were analyzed. Results: Out of total 52 patients studied, median age was 58.38 ± 17.58 years (range: 24 – 89 years). There were 28 males (53.8%) and 24 females (46.2%) in this study. LVEF measured by eyeballing method and modified Simpson’s method had excellent correlation (Pearson’s correlation coefficient (r) = 0.956, P

Background: Age and serum creatinine are known to be predictors of mortality in scrub typhus patients admitted in intensive care unit. This study aimed to explore the factors predicting mortality in patients with scrub typhus requiring both ventilator and vasopressor support in our set up.Methods: A retrospective analysis of 43 patients with scrub typhus (ELISA IgM positive, optical density ?0.5) admitted in Medical Intensive Care unit of Chitwan Medical College Teaching Hospital between April 2016 to September 2017 was performed considering recovery or death (poor outcome) as outcome measurement. Potential variables (p

Background: Fiberoptic bronchoscopy is an important and relatively safe procedure for evaluation of various pulmonary diseases. Endobronchial forceps biopsy is commonly performed sampling technique for visible lesions in tracheobronchial tree. Diagnostic yield of biopsy depends upon lesion type and the number of biopsy samples taken. This study aimed to evaluate the complications and diagnostic yield of endobronchial forceps biopsy in visible lesions and correlate the number of biopsy samples taken with the yield. Methods: This was an observational study conducted at two tertiary care hospitals in Chitwan; Chitwan Medical College Teaching Hospital and B P Koirala Memorial Cancer Hospital. One hundred and forty patients who underwent endobronchial forceps biopsy of bronchoscopically visible lesions were included. Complications and diagnostic yield of the biopsy samples and its correlation with number of biopsies taken were evaluated. Results: The common complications observed were transient drop in saturation > 4% (22%) and mild bleeding (9.9%). The net diagnostic yield was 67.4% that significantly improved with an increase in the number of biopsies taken. The yield was better for exophytic growths compared to submucosal/ mucosal lesions (83.7% vs. 57%, OR = 8.1 (2.2 – 29.9), P

Critical Care Medicine is a specialty dealing with the comprehensive management of patients having, or at risk of developing, acute, life threatening organ dysfunction The glaring need of critical care services and human resources for critical care have become more evident in the face of the current COVID-19 Pandemic At this juncture, when the world is facing threat to humanity with an increasing number of deaths due to COVID 19 pandemic, the discussion about the need for ICU beds and human resources for critical care management has re-surfaced and is being increasingly realized In Nepal, as of 15supth/sup April, 2020, there are 194 hospitals with ICU facilities The total ICU bed strength is 1595 in 194 hospitals (which is approximately 6% of all hospital beds) and only around 50% of them are equipped with ventilators (840) These figures indicate that Nepal has approximately 2 8 ICU beds per 100,000 population As Nepal braces to contain a major COVID-19 outbreak, the hospital capacities of the country have already come under huge pressure If the number of confirmed cases of COVID-19 continue to rise at the current pace, the shortage of critical care facilities will become more glaring than ever before The current pandemic is a tremendous opportunity for health planners to accelerate action and ensure that the country is well-equipped to contain the COVID-19 pandemic We need to be working towards infrastructure and human resource strengthening and expansion in critical care, in order to efficiently contain the pandemic Copyright © 2020, Nepal Medical Association All rights reserved

The COVID-19 pandemic is unfolding at an unprecedented pace. The unprecedented threat provides an opportunity to emerge with robust health systems. Nepal has implemented several containment measures such as Rapid Response Team formulation; testing; isolation; quarantine; contact tracing; surveillance, establishment of COVID-19 Crisis Management Centre and designation of dedicated hospitals to gear up for the pandemic. The national public health emergency management mechanisms need further strengthening with the proactive engagement of relevant ministries; we need a strong, real-time national surveillance system and capacity building of a critical mass of health care workers; there is a need to further assess infection prevention and control capacity; expand the network of virus diagnostic laboratories in the private sector with adequate surge capacity; implement participatory community engagement interventions and plan for a phased lockdown exit strategy enabling sustainable suppression of transmission at low-level and enabling in resuming some parts of economic and social life.

Introduction: Medical thoracoscopy has recently gained renewed interest due to its minimal invasive nature and high yield diagnostic outcome. This study aims to observe diagnostic yield and safety of medical thoracoscopy in undiagnosed exudative pleural effusion. Methods: This is a descriptive cross-sectional study conducted in two tertiary care hospitals in Chitwan from March 2018 to May 2018. Ethical approval from the Institutional Review Board was obtained. Convenient sampling was done that included all the patients who met criteria for undiagnosed exudative pleural effusion after diagnostic thoracocentesis. Patients having contraindication to procedure and who refused consent were excluded. Statistical analysis was performed using IBM SPSS Statistics 20 and data are presented as mean (±SD) and frequency (percentage). Results: A total of 14 patients underwent rigid medical thoracoscopy. All 14 patients had unilateral pleural effusion. The overall diagnostic yield was 100%. Malignancy was the most frequent histopathology diagnosis seen in 11 (78.57%) patients, the commonest being metastatic adenocarcinoma in 8 (57.1%). Pleural tuberculosis and acute-on-chronic pleuritis were seen in 2 (14.3%) and 1 (7.1%) patients, respectively. Pleural deposits and hemorrhagic pleural fluid were the two commonest findings, seen in 10 (70.1%) and 9 (64.3%) patients, respectively. Two (14.3%) patients clinically treated as tuberculous pleural effusion was re-diagnosed to have metastatic adenocarcinoma. Common procedure-related minor complications observed were mild to moderate pain and mild bleeding, observed in 3 (21.4%) and 2 (14.3%) patients, respectively. Conclusions: Medical thoracoscopy is a safe, well-tolerated and high yield procedure in undiagnosed exudative pleural effusion. This art of medicine should be promoted in daily medical practice.

Background: This study was conducted to elucidate the clinical features, laboratory parameters and management outcome of dengue patients admitted in a tertiary care center of Nepal. Methods: This was a retrospective descriptive study in dengue patients aged 12 years or more who were admitted in Tropical Wards and Intensive Care Unit of Chitwan Medical College Teaching Hospital (CMCTH), Chitwan, Nepal from November 2016 to December 2017. Diagnosis of dengue was confirmed by positive NS1 antigen or ELISA IgM or both. The required data were retrieved from patient’s medical records and laboratory data base. Data analysis was performed by using IBM-SPSS 20. Results: Of 60 patients, majority (65%) were male. Forty-one (68.33%) patients were diagnosed by positive NS1 and 18 (30%) were ELISA IgM positive. In the year 2017, highest numbers of cases (20, 33.33%) were in the month of November, followed by 14 cases (23.33%) in October. Similarly, in the year 2016, dengue cases peaked in the month of November. All patients had fever as a presenting complaint. Other common presenting features were myalgia 42 (70%) and headache 32 (53%). Thrombocytopenia was observed in 52 (86.66%) patients followed by leucopenia in 41 (68.33%) cases. Elevation of AST and ALT were found in 45 (75%) and 38 (63.33%) patients respectively. Only 2 patients (3.3%) had dengue with warning signs. Four (6.8%) patients needed platelet transfusion. No mortality was observed. Conclusions: Majority of dengue patients had thrombocytopenia, leucopenia, and elevated AST and ALT. Only two patients had dengue with warning signs. Hospital mortality was not documented.

Majority of patients with diabetes mellitus (DM), who are on insulin therapy, use insulin pen for convenience, accuracy, and comfort. Some patients may require two different types of insulin preparations for better glycemic control. We have reported a case of poor glycemic control as a consequence of inappropriate insulin injection technique. A 57-year-old man with type 2 DM had been using premix insulin 30 : 70 for his glycemic control for the last 12 years. On follow-up visit, his blood sugar level (BSL) had increased; therefore the treating physician increased the dose of premix insulin and added basal insulin with the aim of controlling his blood sugar level. Despite these changes, his BSL was significantly higher than his previous level. On investigation, the cause of his poor glycemic control was found to be due to inadequate delivery of insulin (primarily premix) as a consequence of lack of priming and incompatibility of single insulin pen for two cartridges. His basal insulin was discontinued and the patient along with his grandson was instructed to administer insulin correctly. After correction of the errors, the patient had a better glycemic control.

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

Acute exacerbations pose a very high economic burden on Chronic Obstructive Pulmonary Disease (COPD) patients and are commonly infective in nature. Gram’s staining and bacterial cultures are baseline investigations for sputum examination for COPD. This study evaluated these techniques for characterization and identification of various organism involved in acute infective exacerbations of COPD. Sodium Chloride (3%) induced sputum samples from 122 severe and very severe COPD subjects presenting in acute exacerbation who had history of frequent exacerbations and frequent antibiotics use were evaluated. The sputum samples were evaluated by Gram’s staining and bacterial culture from January 2013 to March 2014. Induction technique was able to obtain adequate samples from 86 (70.48% of 122) subjects. Gram’s stain showed 30 samples of Gram positive cocci (34.88%), 23 samples (26.74%) of Gram Negative Cocci and 50 samples (58.13%) of Gram Negative Bacilli. Bacterial culture showed predominant growth of Gram negative organisms including Pseudomonas sp, Acinetobacter sp, Klebsiella pneumoniae and Citrobacter Freundii. Gram negative bacilli are the most common isolated pathogens responsible for the acute exacerbation in severe and very severe COPDs with history of frequent exacerbations and hospital visits.

Arterial blood gas (ABG) sampling is an essential investigation for assessment of acid-base status, oxygenation and ventilation in critical care practice. Arterial puncture to obtain arterial blood is more invasive procedure than venous and has more potential complications. To find out the correlation between arterial and peripheral venous blood gas values for pH, PCO2 and bicarbonate. Patients admitted in ICU requiring arterial blood gas analysis to determine their acid-base status or ventilatory status was included in the study. One milliliter of venous blood was obtained in a heparin flushed syringe within 5 minutes of getting arterial blood sample. Both labeled samples were processed immediately. Data were analyzed by student’s t-test. A total of 50 paired samples from 36 patients were evaluated. The mean differences between arterial and venous blood gas values for pH, PCO2 and bicarbonate were 0.02 units, -2.37 mmHg and -0.45 mEq/L respectively. Similarly, the correlation coefficients between arterial and venous parameters were 0.964, 0.881 and 0.906 for pH, PCO2 and bicarbonate respectively, which were statistically significant (p

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

Introduction.This study aimed to explore the predictors of mortality from scrub typhus infection in patients requiring intensive care unit (ICU) admission.Materials and Methods.A retrospective study was conducted on 120 patients with serum ELISA IgM positive for scrub typhus (optical density ≥ 0.5) admitted at the medical ICU of Chitwan Medical College Teaching Hospital between April 2016 and September 2017. Data was extracted from patient medical records and electronic database of the hospital. The outcome measurement was mortality (Yes/No) due to the infection. A multivariate binary logistic regression analysis (p<0.10) using potential variables from bivariate analysis (p<0.25) was adjusted to predict the mortality.Results.The mortality rate was 20% (24/120). Factors associated with mortality, as found using bivariate analysis, were heart rate > 100/minute (p<0.001), systolic blood pressure < 90 mmHg (p=0.025), diastolic blood pressure < 60 mmHg (p=0.032), serum creatinine > 1.4 mg/dl (p<0.001), acute kidney injury requiring dialysis (p=0.029), acute respiratory distress syndrome (p<0.001), and shock requiring vasopressor (p<0.001). Regression analysis showed age (odds ratio [OR] = 1.063; 95% CI = 1.010–1.118;p=0.019) and serum creatinine (OR = 1.063; 95% CI = 1.010–1.118;p=0.019) as significant predictors of poor outcome.Conclusion.Older age and high serum creatinine were found to be independent predictors of poor outcome in patients with scrub typhus admitted in medical ICU.

Introduction. Proper insulin injection practice is essential for better diabetic control. This study aims to assess the insulin injection practice of patients with diabetes. Materials and Methods. A cross-sectional study was conducted at Chitwan Medical College Teaching Hospital, Bharatpur, Nepal, from February 2017 to May 2017. Patients injecting insulin through insulin pens (n=43) for a minimum of 4 weeks were consecutively recruited. Patients’ baseline characteristics, current insulin injection technique, insulin transportation practice, complications of insulin injection, disposal practice of used needle, and acceptability of insulin were recorded. Descriptive statistics were performed using IBM-SPSS 20.0. Results. The insulin injection technique of patients and their relatives was inadequate. The majority of patients and their relatives (25, 58.1%) mentioned that they transport their insulin cartridge without maintaining cold chain. Thirteen patients (30.2%, n=43) reported complications of insulin injection and the most common complication among those patients was bruising (10, 76.9%, n=13). Almost all patients disposed the used needle improperly, and the common method was disposing the needle in a dustbin and then transferring to municipal waste disposal vehicle. Insulin was accepted by just 16 (37.2%) patients. Conclusion. There was a significant gap between the insulin delivery recommendation through insulin pen and current insulin injection practice.

Background & objectives: Tuberculosis is a transmissible disease mainly due to inhalation of infected droplet nuclei. The burden of drug resistant tuberculosis is very high in our neighboring countries India and China. Prevalence of primary drug resistant disease is difficult to estimate in our country because culture and sensitivity is not done routinely. This study was an attempt to find out the prevalence of drug resistant in newly diagnosed tuberculosis patients serving in the Nepalese Armed Forces. Methodology: Medical records of patients serving in the Nepalese Armed Forces who had the provisional diagnosis of pulmonary tuberculosis for the first time from July 2012 to June 2014 were analyzed. They had their sputum subjected for both smear and culture with sensitivity testing. Out of 134 patients, 62 had culture positive for Mycobacterium tuberculosis and drug sensitivity was done for the first line 4 antitubercular drugs. Results: Drug resistant strains were found in 5 cases (8.1%) of which 2 (3.2%) were resistant to 4 first line drugs - rifampicin, isoniazid, ethambutol and streptomycin. Prevalence of isoniazid resistance was the highest, found in 3 cases (4.8%). Conclusion: Primary drug resistant tuberculosis in newly diagnosed cases was high even in young healthy adults, and isoniazid resistant strains were the commonest.DOI: http://dx.doi.org/10.3126/jcmc.v4i4.11970

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

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

Introduction: To determine the changes in oxygen saturation, blood pressure and pulse rate during endoscopic procedure and to evaluate – oesophagogastroduodenoscopy (OGD) related discomfort assessed by the patient. Methods:It is observational case control study. Baseline pulse, blood pressure and oxygen saturation were monitored before procedure, at one minute of procedure, at fi ve minute and soon after procedure. Patients were randomly selected according to lottery system (1: without sedation and 2: with sedation) and divided into two groups; without and with sedation. Before leaving department they were asked about level of discomfort during and after procedure. Results:Patient’s mean age ± SD: 36.65, ± 11.42 years and 53.3% were men. Base line mean oxygen saturation among sedated patient were 96.77 ±1.56 % and 97.23, ± 2.26 % respectively (P=0.358). Mild to moderate hypoxia was noted more in sedated patient than in non sedated patient. Severe hypoxia was noted in 3.3% of sedated patient. No statistically signifi cant change was noticed in pulse and blood pressure in both the group. None or only slight discomfort was experienced by 9.4% in non sedated group and 90.6% in sedated group. Severe discomfort by 96.4% in non sedated group and 3.6% in sedated group . Conclusions:There is slight more incidence of mild hypoxia in sedated group than in non sedated group but no change in pulse and blood pressure. However, sedated patient have significant less level of discomfort than in non sedated group. Though routine use of pulse oxymeter is not necessary, routine use of sedation during endoscopy is recommended. Key Words: discomfort, gastroscopy, oxygen saturation, pulse oximeter