Journal of Nobel Medical College

Concurrent Eloquent Area Bleeds in a Patient with Uncontrolled Hypertension

2022-12-29T04:35:48+00:00

Uncontrolled hypertension being the most important risk factor for intracerebral hemorrhage (ICH) often leads to solitary hematoma whereas multiple spontaneous simultaneous ICH is not common, and occurrence of bilateral hemorrhage is a rare entity with normal bleeding parameters with very few case reports so far. Here, we report a 67-year-old man with a past medical history of uncontrolled hypertension who was brought to the emergency department due to severe headache, worsening confusion for 1 day. An urgent non-contrast brain Computed Tomography (CT) performed immediately revealed bilateral intracerebral hemorrhage (ICH) of the same age in the right putamen and left thalamus. Our patient had a non-traumatic ICH, with low GCS (5/15) at presentation. He was managed conservatively with antihypertensives and antiedema measures. He was discharged in stable condition GCS 14/15 with left hemiparesis (3/5). At last follow up he was recovering well.Due to the rarity of spontaneous intracranial bleed in patient with normal bleeding parameters, it is particularly interesting to report this rare case presentation.

Research and Publication

2022-12-20T10:15:30+00:00

Research finds out new or additional knowledge or information that needs to be published in order to make it scientifically visible. Publication criteria should meet and manuscript format should be as recommended for the publication.

Patient Age and Outcome in Ischemic Stroke

2022-12-20T10:30:35+00:00

Background: Age is the most important prognostic factor in ischemic stroke. Thisstudy was carried out in patients with ischemic stroke to describe the association of age of the patients with stroke severity at presentation and at three months.

Materials and Methods: The data, which were collected retrospectively from hospital records, we reanalyzed by using the Statistical Package for the Social Sciences (SPSS) version 26. Age was divided into younger (≤ 50 years) and older (> 50 years) based on standard definition. Age was also divided into younger (< 60 years) and older (≥ 60 years) based on the Senior Citizens Act of Nepal. The associations were analyzed by using Chi-square test.

Results: One hundred and fifty-three patients were included in the study. The mean age of the patients was 60.9 years. There was no statistically significant association between baseline stroke severity and the age groups defined both ways. More younger patients had good outcomes (44.4% good outcome vs 25.6% poor outcome in patients ≤ 50 years, p= 0.03; 52.8% good outcome vs 31.6% poor outcome in patients < 60 years, p=0.02). More older patients had poor outcomes (74.4% poor outcome vs 55.6% good outcome in patients > 50 years, p = 0.03; 68.4% poor outcome vs 47.2% good outcome in patients ≥ 60 years, p= 0.02).

Conclusion: There was no significant association between young and old patients and the baseline stroke severity; however, more younger patients had good outcomes compared to older patients at three months, the differences being significant.

Assessment of Cardio Respiratory Fitness of Trained and Non-Trained Young Adult Males

2022-12-21T03:53:38+00:00

Background: Cardio respiratory fitness in terms of maximum oxygen uptake (VO₂ max) reflects the physical fitness of a person. VO₂max determines the capacity of an individual to perform sustained exercise. The present study is to assess and compare the cardiorespiratory fitness in terms of VO₂max between trained and untrained subjects.

Materials and Methods: This cross-sectional study was conducted on 30 young adult males undergoing physical training for more than 3 months to join British army and age-sex matched 30 non-trained controls. VO₂max was estimated indirectly by following the protocol of Queen’s College Step Test (QCT) method.

Results: VO₂ max was found significantly higher in the trained males as compared to non-trained group (68.91± 4.42 vs. 50.31±4.80; p=0.02). On comparison of VO₂ max of our subjects with the standard VO₂ max classification, our trained and non-trained groups fitted into the category of high and average on cardiorespiratory fitness scale respectively.

Conclusion: Physical training improves cardio respiratory fitness by increasing VO₂ max.

Perception of Self-Esteem among Nursing Students at Nobel Medical College Teaching Hospital

2022-12-21T05:40:09+00:00

Background: Self-esteem is the own judgment of a person about himself or herself and appreciation of his/her value. An individual with high self-esteem has many positive effects and benefits. It is suggested that self-esteem is one of the most influential factors in the occupational behaviors of nursing students. So, the aim of the study was to assess the perception of self-esteem among Nursing Students.

Materials and Methods: A descriptive cross-sectional study was conducted among nursing students at Nobel Medical College Teaching Hospital, Biratnagar, Nepal. The study was started after acquiring approval from the Institutional Review Committee of Nobel Medical College. Data was collected in the classroom through a self-administered questionnaire using the standardized tool Rosenberg Self-Esteem Scale (RSE) from July2021 to November 2021.A total of 238 students were taken as a sample by using the non-probability census method. Data analysis was done by descriptive study.

Results: A total of 238 students participated in this study 79.4 percent had high self -esteem and 21.6 percent had low self-esteem. There was a statistically significant association between perception of self-esteem with the age of respondents, Current nursing programme and current nursing education.

Conclusion: The study concluded that the majority of the respondents had high self-esteem. Acquisition of skill, knowledge, independence and acquire social, cultural and emotional adjustment increase high self-esteem.

Indications and Visual Outcome in Patients Undergoing Penetrating Keratoplasty

2022-12-21T06:10:58+00:00

Background: Penetrating keratoplasty is commonly performed surgery in patients suffering from corneal blindness and visual impairment, where full thickness diseased cornea is replaced with healthy cornea. This study aims to outline indications of Penetrating keratoplasty and visual outcomes following the procedure.

Materials and Methods: This retrospective, hospital-based study included 48 eyes of 48 subjects fulfilling inclusion criteria and underwent Penetrating keratoplasty from January 2017-2020 at Bharatpur Eye Hospital. General ophthalmologic examination was done preoperatively and postoperatively. Indication of the surgery along with demographic outline and requisite investigations were performed.

Results: Mean age of the subjects was 47±1.83 years (13-74 years) where most of them were in 61-70years (23%) age group. Male subjects were more (62.5%) compared to females. Triple procedure was performed in 6.25 percent of patients. The most common indication was infective keratitis (52%) followed by corneal opacity/ scarring, regrafts, keratoconus and bullous keratopathy. Penetrating keratoplasty was performed slightly more for therapeutic purpose (52%) than optical. Intraoperative complications were observed in 16.7% of patients, positive vitreous pressure being the sole cause. Ameliorated visual acuity was observed in 71% of patients with43.75% of patients having VA of ≥3/60

Conclusion: Infective keratitis was the predominant indication followed by corneal opacity/ scarring. Penetrating keratoplasty helps in maintaining integrity of the globe along with restoration of vision

A Comparative Study between Early Versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis in a Tertiary Care Center of Nepal

2022-12-21T06:25:34+00:00

Background: Laparoscopic Cholecystectomy is considered as a gold standard treatment for symptomatic cholelithiasis. The timing of surgery for acute Cholecystitis is still controversial, weather to go early surgery or wait for six to eight weeks after conservative management. Therefore, the aim of this study is to compare the clinical outcomes of early versus delayed laparoscopic cholecystectomy for acute Cholecystitis.

Materials and Methods: A prospective study was conducted in Nobel Medical College Teaching Hospital, Biratnagar, Nepal. Total of 80 patients with the diagnosis of acute Cholecystitis were enrolled in the study. The patients were equally divided in two groups: 40 underwent early laparoscopic cholecystectomy within 72 hours of admission (Group A) and next 40 underwent delayed laparoscopic cholecystectomy after 6-8 weeks of conservative management (Group B).

Results: Out of 80 patients of acute Cholecystitis, mean age of the patients in Group A was 43.40±13.45 years and that in Group B was 44.80±14.36 years. The mean operative time in Group A was 90.22±2.81 minutes whereas in Group B it was 80.97±4.47 minutes. Mean duration of Hospital stay in Group A was 2.02±0.15 days whereas in Group B it was 2.15±0.36 days. Two patients in Group A and one patient in Group B converted to open cholecystectomy. Three patients of Group A and one patient of Group B landed in outpatient department with superficial surgical site infection. Group B patients underwent second hospital admission compared to Group A patients.

Conclusion: Early Laparoscopic cholecystectomy for acute cholecystitis is almost comparable with delayedLaparoscopic cholecystectomy. However, early laparoscopic cholecystectomy reduces the morbidity of patients as well as it is cost-effectiveness.

Study of Left Ventricular Mass in Normal Nepalese Population

2022-12-21T06:38:58+00:00

Background: A prospective study was conducted to find distribution of the left ventricular mass in normal adult Nepalese population in order to establish the upper reference limit.

Materials and Methods: A total of 100 consecutive male and 100 female participants of age 18 years and above visiting for cardiac checkup were enrolled prospectively in this study. Participants with hypertension, diabetes, obesity and significant cardiovascular disease were excluded.

Results: Mean age of study population was 43 years. Mean left ventricular mass in total, male and female population was 127.45±29 gm, 136.48±30.64gm and 118.43±24.24 gm respectively. Mean left ventricular mass index (LVMI) in total, male and female population was 74.52±15.78 gm/m2, 80.04±16.5 gm/m2 and 69.17±13.05 gm/m2 respectively. Left ventricular mass and left ventricular mass index increased with age, Body Mass Index, Systolic and Diastolic Blood Pressure, and were statistically significant (p-value <0.05).

Conclusion: Normal left ventricular mass in Nepalese Population was found to be lesser in female compared to male. Left ventricular mass increased with increasing Age and Body Mass Index.

Sensitivity and Specificity of High Resolution Computed Tomography Chest in Diagnosing Corona Virus Disease 2019: A Retrospective Correlation with Reverse Transcriptase Polymerase Chain Reaction

2022-12-21T07:11:31+00:00

Background: Corona Virus Disease 2019came into existence in December 2019, as a sudden outbreak inthe city of Wuhan, China. Early identification of the patient is vitalto control disease transmission.This study is aimed at estimatingthe sensitivity, specificity, and practicability of Highresolution computed tomography chest in detecting Corona Virus Disease 2019 compared with a Reverse transcriptase-polymerase chain reaction.

Materials and Methods: This was a retrospective single-center analytical study conducted at Nobel Medical Collegefor5 months during the second wave of Covid 19 from Feb 2021 to June 2021 after ethical approval from the Institutional Review Committee of Nobel Medical College Teaching Hospital. All clinically suspected patients who had undergoneHigh-resolution computed tomography chest and Reverse transcriptase-polymerase chain reaction within a 1-week time difference were included. High-resolution computed tomography chest scan was reported before Reverse transcriptase-polymerase chain reaction results became available.

Results: Among 342 consecutive patients (195 male and 147 females, mean age 64), Reverse transcriptase-polymerase chain reaction was positive in 183 (53.5%) cases. Common High-resolution computed tomography chest features significantly more common in Reverse transcriptase-polymerase chain reaction positive patients were bilateral subpleural and peripheral ground-glass opacities with septal thickening(crazy paving). In comparison with Reverse transcriptase-polymerase chain reaction, the sensitivity was 91.8% and specificity 67.2%.

Conclusion: This study revealed the high sensitivity of high-resolution computed tomography chest scansin accurately diagnosingCorona Virus Disease 2019.

Procalcitonin Level and Organ Dysfunction in Children with Sepsis: A Prospective Observational Study

2022-12-21T07:17:31+00:00

Background: Procalcitonin is produced in response to endotoxin or mediators released in response to bacterial infections and are reported to be sensitive predictor of sepsis and multiple organ failure. The main aim of this study was to correlate procalcitonin levels with the severity of organ dysfunction in children with sepsis.

Materials and Methods: A prospective observational study was done among children aged >1 month - 18 years admitted for sepsis in level 4 pediatric intensive care unit at Rainbow children Hospital, Hyderabad from July 2018 to January 2020. Children with sepsis due to burns and trauma were excluded. Procalcitonin levels were assessed on days 1 and 5 and were analyzed using descriptive statistics. P value of < 0.05 was considered significant wherever applicable.

Results: Among 369 cases, procalcitonin levels showed positive correlation with severity of illness and multiorgan failure as evidenced by pediatric risk of mortality III score (mean score 6.44 ± 3.79) and worst sepsis-related organ failure assessment score (mean score 7.11 ± 4.27) respectively. Duration of non-invasive ventilation, invasive ventilation, pediatric intensive care unit stay, and mortality were significantly high in children with higher procalcitonin level. Mean procalcitonin level were significantly higher in culture positive cases (65.79 ± 77.10) compared to culture negative cases (37.99 ± 45.81).

Conclusion: In this study, positive correlation was observed between procalcitonin level and multiple organ dysfunctions in sepsis and septic shock.

Latent Tuberculosis Infection in Potential Renal Transplant Recipients and Live Donors in a Tertiary Level Transplant Center in Nepal

2022-12-21T08:28:06+00:00

Background: Active tuberculosis in transplant recipients can result from latent infection with Mycobacterium Tuberculosis in the transplant recipients, donor tissue, or de novo post-transplant infection. This study aimed to determine the prevalence of latent tuberculosis infection in potential renal transplant recipients and live donors at a tertiary-level transplant center.

Materials and Methods: This observational study was conducted from July to October 2020 among 72 potential kidney transplant recipients and their potential donors from the Department of Nephrology, Tribhuvan University Teaching Hospital. The biochemical parameters and health behaviors were measured to find the association with latent tuberculosis infection.

Results: The prevalence of latent tuberculosis infection according to Mycobacterium tuberculosis-specific interferon-gamma release assays was 20.8% in potential recipients and 16.6% in potential donors, whereas the prevalence with tuberculin skin test was 9.7% in potential recipients and 33.3% in potential donors. Low levels of hemoglobin, calcium, albumin, vitamin D and history of smoking were associated with the development of latent tuberculosis infection among potential recipients. Alcohol drinking was significantly associated with the development of latent tuberculosis infection among donors.

Conclusion: Potential renal transplant recipients and donors have a significant burden of latent tuberculosis in the pre-transplantation phase. Diagnosis and treatment of latent tuberculosis before transplantation can prevent ominous complications.

Sepsis Screen Parameters in Blood Culture Positive Neonatal Sepsis

2022-12-21T08:41:47+00:00

Background: Neonatal sepsis is a clinical syndrome of bacteremia characterized by systemic signs and symptoms of infection in the first 28 days of life. Although, Positive blood culture is the gold standard for the diagnosis of neonatal septicemia, definitive culture results take at least 48–72 h, resulting in treatment delay. Hence certain rapid diagnostic tests such as C-reactive protein, micro erythrocyte sedimentation rate, total white blood cell count, absolute neutrophil count, and immature/total neutrophil count ratio collectively termed as the “Sepsis Screen” is used. The aim of this research is to study the relation between sepsis screen parameters and blood culture proven neonatal sepsis and to assess the clinical profile of neonates with culture-proven sepsis.

Materials and Methods: This was a descriptive observational study conducted on 97 clinically suspected neonatal sepsis cases in the neonatal intensive care unit.. Sepsis screen tests were evaluated for sensitivity, specificity, positive predictive value and negative predictive value. The culture results were correlated with sepsis screen tests and p-value<0.05 was considered significant.

Results: Early-onset sepsis was seen in 47.4% cases, while late-onset sepsis accounted for 52.6% cases. Immature to total neutrophil ratio was the single best reliable sepsis screen test with a high specificity, PPV, and negative predictive values of 93.8%, 85.7%, and 88.4% respectively.

Conclusion: Most of the individual sepsis screen parameters showed statistical correlation with blood culture status, yet Immature to total neutrophil ratio had highest sensitivity, specificity, positive predictive value and proved to be a sensitive and responsive indicator of neonatal sepsis.

Thyroid Dysfunction Associated with Depressive Disorder: A Descriptive Cross-Sectional Study Done in a Tertiary Care Center of Eastern Nepal

2022-12-21T08:57:37+00:00

Background: Depression is one of the most common psychiatric disorders with substantial morbidity and mortality. It is known to be associated with changes in the hypothalamic-pituitary-thyroid axis, thus may be accompanied by subtle thyroid dysfunction. Thus, our study aims to determine the prevalence and characteristics of thyroid dysfunction in newly diagnosed depressive patients.

Materials and Methods: A prospective descriptive cross sectional study was conducted among 130 patient diagnosed as depression from December 2020 to June 2022 after taking the ethical approval. The patients in the symptomatic phase and above 18 years was recruited in our study. Thyroid profile consisting of free tri-iodothyronine (FT3), free thyroxine (FT4) and thyroid-stimulating hormone (TSH) was estimated by chemiluminescence immunoassay in the central laboratory of Nobel Medical College Teaching Hospital.

Results: Out of 130 depressive patients recruited in our study, 44 patients had abnormal thyroid function test showing a prevalence of 33.84%. The most common form was moderate depression which was 39.99% of our study population. The commonest thyroid abnormality was subclinical hypothyroidism (15.38%) followed by overt hypothyroidism (14.61%). Thyroid abnormality was more common among the severe form of depression (46.66%). The comparison of means of fT3, fT4 and TSH between different grades of depression was statistically significant for fT3 (p=0.048) and TSH (p=0.001).

Conclusion: Thus, the most common thyroid function abnormalities in our study include subclinical and overt hypothyroidism, with associated lower level of fT4 and higher level of TSH.

Phenotypic Characterization of Candida species in Tertiary Care Hospital of Eastern Nepal

2022-12-21T09:11:08+00:00

Background: Candida albicans is one of the most frequently isolated yeast in clinical laboratories and studies have shown that it accounts for up to 80% of the yeast recovered from the site of infection. Candida species have emerged as significant opportunistic fungal pathogens and the conventional methods of yeast identification are reported to be cumbersome with delayed diagnosis and initiation of treatment. Thus rapid identification and speciation of Candida species is essential in clinical laboratories.

Materials and Methods: A hospital based cross sectional study was carried out in the department of microbiology, Nobel medical college from January 2020 to December 2020. Approval was acquired from the Institutional Review Committee. Various clinical specimens were obtained and identification as per the standard microbiological procedures. Data were analyzed by SPSS, version 20.

Results: A total of 62 Candida species were isolated out of which 65% were from male and 35% were from female patients. Candida albicans was found to be the most common species with 68%. The highest incidence was seen in the age group below 20 years and 21 – 40 years with 32.25% cases each followed by 41-60 years with 20.96% cases. Among 62 specimens, urine samples yielded the highest number of Candida species 48.38% followed by sputum samples with 29.03% Candida species. High vaginal swab (HVS) yielded 12.9% Candida species and blood samples yielded 9.67% Candida species.

Conclusion: Candida albicans is still the most significant clinically but other non albicans are also emerging significant pathogens and warrant routine discrimination in clinical laboratories.

A Study on Comparison of Two Benzodiazepines in Treatment of Alcohol Dependence Syndrome in Nepal

2022-12-21T09:21:41+00:00

Background: Benzodiazepines are regularly prescribed to treat patients in alcoholic withdrawal. After analyzing pharmacology of benzodiazepines, diazepam is faster metabolized and concentrated in the liver, as an active metabolite whereas lorazepam is metabolized in liver by conjugation and excreted in urine. lorazepam being a drug of choice used in patients with deranged liver functions is needed to be compared with that of diazepam. The objective of the study is the comparasion of two benzodiazepines in treatment of alcohol dependence syndrome in Nepal.

Material and Methods: This was a prospective, open label study carried out in Department of Psychiatry, Nobel Medical College and Teaching Hospital, Biratnagar. 50 patients (25 in each) aged between 25 to 65 years diagnosed as alcohol dependent admitted and grouped in either diazepam or lorazepam alternatively. The doses prescribed to the diazepam group and lorazepam group are 30 mg/day and 8 mg/day respectively in divided doses. For both the treatment groups, the dose was tapered every alternate day for 10 days. The Clinical Institute Withdrawal Assessment Alcohol Scale Revised (CIWA-Ar) scale was used for withdrawal symptoms scoring on the baseline and day 10. Lab Investigations were performed but were not a part of the study.

Results: Out of the Fifty patients included in the study, at day 0, the mean CIWA-Ar scores were similar in both the treatment groups: 24.38±5.03 in the diazepam group and 24.79±6.42 in the lorazepam group. There was a significant intragroup decrease in the CIWA-Ar scores measured from Day 0 to the end of 10 days (p<0.0001) in both treatment groups; there was no significant difference between the two groups

Conclusion: Diazepam and lorazepam are equally effective in alcohol withdrawal detoxification.

Snakebite Incidence, General Awareness and Belief of Snakebite Management at a Rural Municipality of Eastern Nepal

2022-12-27T06:39:52+00:00

Background: Understanding people’s awareness on snakebite management would be highly beneficial to develop strategic program at local levels of Nepal. We aimed to identity snakebite incidence, general awareness and beliefs of people regarding snakebite management in rural communities.

Materials and Methods: A community-based cross-sectional study was conducted at Budhiganga Rural Municipality from September to November 2022 among 245 households. Ethical clearance was taken from institutional review committee of Birat Medical College. Microsoft Excel 2019 and SPSS software ver. 2025 were used for data analysis.

Results: Annual snakebite incidence rate was 2332 per 100000 populations. Majority (71%) could not identify biting snake and attended traditional healers (70%). Among study participants, 25% had false belief that banded krait is not poisonous. Various false beliefs on snakebite first aid management were reported such as use of tourniquet (81%), washing bite sites (53.47%), cutting bite site (52%) and so on. Further, prevalent false beliefs on food-related practices were snake drinks milk (85.31%), giving victim water following the snakebite was beneficial (47%), giving chilly to those bitten was beneficial (41.63%) and so on.

Conclusion: Despite the existing burden of snakebites, people are not aware about the correct ways to manage them and were still attending traditional healers as a means of treatment. The mis beliefs about snakebite first aid management are very much prevalent.

Profiles and Inhospital Outcomes of Patients with Acute Upper Gastrointestinal Bleeding in a Tertiary Care Center

2022-12-29T04:14:06+00:00

Background: Acute upper gastrointestinal bleeding is one of the common and life threatening condition presenting in emergency. The aim of the present study was to determine the clinical profile and in-hospital outcomes in these patients admitted at a tertiary care center in Kathmandu, Nepal.

Materials and Methods: This is a descriptive, observational study conducted over 9 months (October 2021– July 2022). All consecutive patients aged 16 years and above admitted in the hospital ward with the history of acute bleeding were included in the study after informed consent. Demographic data, clinical, laboratory and endoscopic data were noted during the hospital stay. Statistical analysis was done used SPSS v.24.

Results: The mean age of our study population (N = 132) was 46.92 years. Among 132 patients who underwent endoscopy, 43.9% had portal hypertension related bleeding, 41.7% had ulcer related bleeding, 5.3% had malignancies, 3% had corrosive intake. No etiology was found in 3 patients. Hematemesis with melena was the most common mode (53.8%) of presentation to the hospital.Shock was preset in 25% of patients at presentation to the hospital. In-hospital re-bleeding rate and mortality were 12.7% and 9.8% respectively.

Conclusion: Portal hypertension related bleeding followed by ulcers related bleeding is the common cause of acute upper gastrointestinal bleeding. In-hospital mortality was 9.8%.