Serial estimations of serum albumin levels as a prognostic marker in critically ill patients admitted in ICU in tertiary center: An observational study

Critical illness is a severe condition that poses a significant threat to multiple organ systems and can lead to substantial morbidity and mortality. Serum albumin concentration can serve as an independent predictor of mortality risk in critically ill patients. This study aimed to determine the role of serial monitoring of serum albumin (SA) levels as a prognostic marker of mortality and morbidity. This observational prospective study was conducted at a tertiary hospital over a period from January 1, 2020, to December 31, 2020, among critically ill patients admitted to the intensive care unit. Data collection was performed using a prestructured proforma. Statistical analysis was carried out using Statistical Package for the Social Sciences software version 23, employing appropriate tests. The P-value <.05 was considered statistically significant. The study included 78 patients with 59 (75.6%) were survivors, and 19 (24.4%) were non-survivors. Mean SA levels did not significantly differ between non-survivors (3.30 ± 0.40 g/dL) and survivors (3.42 ± 0.35 g/dL) on admission (day 1) (P = .234). However, on day 3, non-survivors had significantly lower levels (3.02 ± 0.46 g/dL) compared to survivors (3.31 ± 0.29 g/dL) (P = .001). This trend continued on day 5, with non-survivors having significantly lower levels (2.92 ± 0.30 g/dL) compared to survivors (3.31 ± 0.33 g/dL) (P = .003). The decline in SA levels from day 1 to day 3 and from day 1 to day 5 was statistically significant in non-survivors (P = .001). In survivors, a significant decline was observed from day 1 to day 3 (P = .019), while the decline from day 1 to day 5 was not statistically significant (P = .074). Serial estimation of SA levels in critically ill patients can serve as a valuable prognostic marker, aiding in the identification of individuals at a higher risk of mortality and morbidity.

Nanopore sensing: A physical-chemical approach

Protein nanopores have emerged as an important class of sensors for the understanding of biophysical processes, such as molecular transport across membranes, and for the detection and characterization of biopolymers. Here, we trace the development of these sensors from the Coulter counter and squid axon studies to the modern applications including exquisite detection of small volume changes and molecular reactions at the single molecule (or reactant) scale. This review focuses on the chemistry of biological pores, and how that influences the physical chemistry of molecular detection.

Prevalence of Newly Diagnosed End-Stage Renal Disease Patients in a Tertiary Hospital of Central Nepal, Chitwan: A Descriptive Cross-sectional Study

INTRODUCTION

End-stage renal disease patients are in rising trend globally, and they have been found to occur predominantly in developing countries. Many studies have been published before, within and across the countries, to know the clinicodemographic profile of end-stage renal disease patients. However, no such studies were done in Chitwan, Nepal. This study's main objective was to find the prevalence of newly diagnosed end-stage renal disease patients.

METHODS

A hospital-based descriptive cross-sectional study was carried out in the Department of Nephrology from May 2016 to April 2019. Convenient sampling was done, and all the consecutive new end-stage renal disease patients were included in the study. The ethical approval was taken from the Institutional Review Committee (reference number. 2016/COMSTH/IRC/042). The prevalence and demographic profile of new end-stage renal disease patients were studied. The data were analyzed with appropriate statistical tools.

RESULTS

A total of 250 new end-stage renal disease patients were found among 2200 admitted patients. The prevalence of new end-stage renal disease was found to be 250 (11.36%). Out of 250 patients, males were 156 (62.4%), and females were 94 (37.6%). The mean age was 49.6±15.5 years. The commonest cause of the incident end-stage renal disease was Type 2 Diabetes mellitus 89 (35.6%).

CONCLUSIONS

The prevalence of new end-stage renal disease was found to be quite high. The commonest cause of the incident end-stage renal disease was Type 2 Diabetes Mellitus.

Work-related Respiratory Symptoms and Associated Factors among Cement Factory Workers in Rupandehi District, Nepal

Background Cement factory workers are exposed to cement dust at workplace. It leads to a greater prevalence of chronic respiratory signs and symptoms. Objective To identify the prevalence of Work-related respiratory symptoms, its association with various risk factors, and to assess the outcomes like hospitalization and sickness absenteeism. Method Cross-sectional study was conducted in the Argakhanchi Cement factory among 190 workers with minimum work experience of 1 year. Census method was used for data collection. To assess the respiratory symptoms, sputum samples were collected; smears prepared by pick and smear method, and later stained by Leishman and pap stain. Smears devoid of alveolar macrophages were considered unsatisfactory for evaluation. Result The mean age of respondents with standard deviation was 35.56±11.45 years. The prevalence of Work-related respiratory symptoms was 31.6%. Age, no. of years worked, working in the raw materials department, burner and clinker department, cleaning department and wearing mask were the significant risk factors. On cytological analysis of the sputum sample, mild inflammatory cell noticed in 71.6%, moderate inflammation in 23.7%, and dense inflammation in 4.2%. Fungal spores were seen in 3.7%, fungal pseudohyphae in 0.5%, and bacterial colonies in 27% of the sputum samples. Out of 190 participants, 8(4.2%) of them had to be hospitalized and 17(8.9%) were on sick leave due to respiratory symptoms. Conclusion Pre-employment and periodic medical examination, frequent work shift, training on occupational health and safety, use of appropriate personnel protective equipment is recommended to reduce respiratory symptoms.

Prevalence and Associated Factors of Malnutrition in Under Five Children in a Rural Mountainous Area of Nepal: A Community Based Cross Sectional Study

Background Nutrition is believed to be very essential for socio economic development of the country and is an essential component of sustainable development goals. Malnutrition is a major public health problem in Nepal and is more common among under-five year children. Malnutrition among children is complex problem globally, affecting the physical, mental and social development. Objective To estimate the prevalence and explore the associated factors of malnutrition in study population. Method It was a community based cross-sectional study conducted among rural population of Nepal. Wards were selected by simple random sampling technique and household in each ward were selected by systemic random sampling. The mothers of 302 participants aged 12 to 59 months were interviewed for requisite information using pretested questionnaire and anthropometric measurements were taken using standard technique for each participant. Statistical Package for Social Sciences (SPSS) version 16.0 was used for data analysis. Result The prevalence of underweight, stunting and wasting was 36.8%, 37.5%, and 14.6% respectively. We found statistical significant association between underweight and children in lower age group, larger family size, lower level of mother's education and illness in past one month. Factors that are significantly associated with stunting are children in lower age group, lower level of mother's education and illness in past one month and wasting is significantly associated with children in lower age group. Conclusion This study showed the prevalence of malnutrition is high in study population. Factors associated with malnutrition were child's age, family size, mother's education and illness in past one month.

Clinicodemographic Profile of Kidney Diseases in a Tertiary Hospital of Central Nepal, Chitwan: A Descriptive Cross-sectional Study

Introduction:

Spectrum of kidney diseases differs significantly in developing and developed countries. However, there is no central registry regarding the nature of such diseases in Nepal and our center either. The study aims to know the clinicodemographic spectrum of kidney disease patients admitted to our hospital.

Methods:

This study was a descriptive cross sectional study done in the department of Nephrology, College of Medical Sciences Teaching Hospital from May 2018 to April 219. Convenient sampling was done and all the consecutive kidney disease patients irrespective of their age, sex, and renal diagnosis were included in the study. Ethical approval was taken from the Institutional Review Committee of the college (reference number. 2016/COMSTH/IRC/049). Clinicodemographic profile of kidney diseases were studied using statistical package for the social sciences version 20 and were represented as mean, standard deviation, number, percentage and ratio.

Results:

Out of a total of 829 patients, the commonest clinical syndrome and the histological patterns were end-stage renal disease 248 (29.9%) and IgA nephropathy 18 (20.7%) respectively. The mean age was 51.4±18.6 years. The commonest reason for hospitalization was sepsis 372 (44.8%). Males were 486 (58.6%) and females were 343 (41.4%).

Conclusions:

The commonest clinical presentation and the reason for admissions were end-stage renal disease and sepsis syndrome respectively.

A Community Based Cross Sectional Study to Estimate the Prevalence and Associated Factors of Hypertension in Rural Nepal

Background Hypertension is a major global public health problem because of its high prevalence as it significantly increases the risk of heart attack, stroke, kidney failure and blindness. Epidemiological shift in prevalence of non-communicable diseases have been observed in Nepal and it is also evident that hypertension and related complications are major contributors to death and disability in Nepal. Objective To estimate the prevalence and explore the associated factors of hypertension in study population. Method A community based cross-sectional study was conducted in rural population of Nepal with multistage sampling design. A total of 422 participants aged 18 to 65 years of age participated in the study. The information was obtained using pretested questionnaire which included demographic information of individuals and other risk factors like alcohol and tobacco use, physical activity. Anthropometric measurements and blood pressure was recorded and hypertension was defined as per JNC VII criteria. Result The overall prevalence of hypertension was 27.7% (male: 32.7%, female: 19.8%). Mean systolic and diastolic BP were 123.79 ± 12.46 mmHg and 81.56 ± 8.32 mmHg, respectively. Age (eldest age group, AOR=4.92: CI: 1.24-19.46), participants with lower level of education (higher education, AOR=0.173: CI: 0.05-0.53), ethnicity (Janajatis, AOR=2.85: CI: 1.44-5.65) and smoking (current smokers, AOR=10.30: CI: 4.39-24.16) are found to be significantly associated with hypertension. Conclusion This study showed the prevalence of hypertension is high in study population. Increasing age, low level of education, ethnicity and smoking were independent risk factors for hypertension.

Clinico-pathological Profile of Kidney Biopsy Patients in a Tertiary Hospital of Central Nepal

Background Kidney biopsy is an important diagnostic tool in Nephrology. As of now, we don't have a central kidney biopsy registry in our country and there are many studies showing heterogeneous patterns of pathologies observed in the country. We thought of looking on the clinico-pathological profile of kidney biopsy patients prevailing in our centre. Objective This study was carried out with an objective to know the clinico-pathological profile of kidney biopsy patients prevailing in our centre. Method This was a hospital based, prospective, observational study carried out in a tertiary teaching hospital of Chitwan over a period of 3 years from May 2016 to April 2019. All the consecutive kidney biopsy patients were included in the study. The indication of kidney biopsies were the standard indication based on clinical presentation and investigations. The patient`s demographic profile, indication of kidney biopsy and histological patterns were studied and analysed using appropriate statistical tools. Result A total of 210 kidney biopsies were analysed over a period of three years, that makes around 5-6 biopsies per month. The mean age of the patient was 35.7 ± 14.9 years. Male were 106 (50.5) and females were 104 (49.5) with male to female ratio of 1.01. The average number of glomeruli was 23.4 ± 11.0. The commonest indication of kidney biopsy and histological pattern were nephrotic syndrome 56 (26.7) and IgA nephropathy 51 (24.2) respectively. Among nephrotic syndrome group, the commonest histological pattern was minimal change disease 21 (37.5). Non-diabetic kidney diseases in diabetes were seen in eight (53.4) diabetic patients making it a significant problem in diabetes and the commonest histological pattern in them were minimal change disease and idiopathic cresentic glomerulonephritis two (13.3) each. Conclusion The commonest indication and histological pattern of the kidney biopsy were nephrotic syndrome 56 (26.7), and IgA Nephropathy 51 (24.2) respectively. Nondiabetic kidney diseases in diabetes were seen in eight (53.4) of the diabetic patient making it a significant problem in diabetes and the commonest histological pattern in them were minimal change disease and idiopathic cresentic glomerulonephritis two (13.3) each.

Complications of Kidney Biopsy in a Tertiary Hospital of Central Nepal, Chitwan

Background: Kidney biopsy is an important diagnostic tool in Nephrology and is said to berelatively a safe procedure.There are limited studies in the complications of kidney biopsy from this region. We therefore thought of looking into the complications of kidney biopsy and its risk factors. Methods: A hospital based analytical cross sectional study was carried out over a period of 3 years. Kidney biopsies were done under ultrasonography guidance. The complications and its risk factors were recorded and were analyzed using mean, standard deviation, ratio, percentage and chi square.   Results: A total of 210 patients were analysed. The mean± standard deviation of 210 patients was 35.7±14.9 years. The commonest minor complication was biopsy site pain not requiring analgesics 136 (64.8%)and the commonest major complication was biopsy site pain requiring analgesics 18(8.6%) followed by perinephric hematoma 10 (4.8%).There was a significant association between low platelet count and the development of complications like pain requiring analgesic (p value 0.04), perinephric   hematoma (p value 0.022) and gross hematuria (p value 0.011). Conclusions: Kidney biopsy is a safe procedure and low platelet count is a significant risk factor for complications (p value <0.05).  Keywords: complications; kidney biopsy; perinephric hematoma; platelet count.  

Magnetic Stimulus Responsive DDS Based on Chitosan Microbeads Embedded with Magnetic Nanoparticles

In this paper, we have presented a novel Drug Delivery Substrate (DDS) that that is responsive to external stimuli of high-frequency alternating magnetic fields. The DDS is constituted of chitosan crosslinked with PEGDMA (polyethylene glycol dimethacrylate), loaded with Fe₃O₄ magnetic nanoparticles and vancomycin. In another experiment, a 19-hour elution was observed where three magnetic stimuli of 25 mT, 109.9 kHz were given for 60 min to the test samples. The stimuli were separated by several hours. After excitation span, it was observed that the stimulated samples released a significantly higher amount of vancomycin by as much as 21% compared to non-stimulated samples. In another study, preliminary results showing the effect of different PEGDMA chain lengths have been discussed. These results show evidence of a smart, controllable DDS that allows modulation of its normal passive antibiotic elution by applying external stimuli per personalized needs.

Clinicodemographic Profile and Outcome of Maintenance Hemodialysis Patients in a Tertiary Hospital of Central Nepal, Chitwan

Background Maintenance hemodialysis is a popular treatment modality of renal replacement therapy for end stage renal disease patients; however their mortality seemed to be rising in our centre. There were no previous studies regarding the clinicodemographic profile and outcome of maintenance hemodialysis patients from this region. Objective This study was carried out with an objective to know the clinicodemographic profile and outcome of maintenance hemodialysis patients in our centre. Method This study was a hospital based prospective observational study carried out over a period of three year, from May 2016 to April 2019, in the hemodialysis unit of the department of nephrology. All the consecutive end stage renal disease patients on maintenance hemodialysis were included in the study. The patient's demographic profile and outcome were studied and analysed using appropriate statistical tools. Result A total of 156 patients were enrolled in the study. Males were 96(61.5%) and females were 60(38.5%). The mean age of the patient was 52.2±15.6 years. The commonest causes of end stage renal disease and reasons for admission were Type 2 diabetes mellitus 68(43.6%) and volume overload with heart failure 101(64.7%) respectively. At the end of three years, 39(25%) were expired, 14(8.9%) were transferred to other centre and four (2.6%) underwent kidney transplantation. The average duration of hemodialysis was 20.3± 17.5 months. Majority of the patients 154(98.7%) had repeat admission ranging from 1 time 21(13.5%) to 10 times two (1.3%). There was a significant association between age ≥ 40 years and diabetes with mortality (p value < 0.003 and < 0.028 respectively). Conclusion The commonest cause of end stage renal disease and the reason of admission were Type 2 diabetes mellitus 68 (43.6%) and volume overload with heart failure 101 (64.7%) respectively. The overall mortality was 39 (25%) and the commonest cause of mortality was sepsis/health care associated pneumonia 30 (76.9%). There was significant association between age ≥ 40 years and diabetes with mortality (p value < 0.003 and < 0.028 respectively).

Physical Properties and Theoretical Study of NixCo3-xO₄ (0 ≤ x ≤ 1.5) Nanostructures as High-Performance Electrode Materials for Supercapacitors

Study evaluates the electrochemical performance of off-stoichiometric Ni_xCo_3-xO₄ compounds. The off-stoichiometric samples were prepared via hydrothermal technique by systematically varying Co/Ni molar ratio. Physical and electrochemical properties of Ni_xCo_3-xO₄ were observed to be stoichiometry dependent. The increase in Ni/Co ratio in Ni_xCo_3-xO₄ leads to the morphological transformation from fibrous bundles to urchin like nanospheres with a concomitant increase in the surface area reaching up to 132 m2/g. The optimal specific capacitance of 225 F/g at a current density of 1 A/g and 524 F/g at 10 mV/s scan rate was observed of x 1.0 sample, with an increased retention capacity ∼120% measured at 2 A/g current density. The hybrid density functional theory (DFT) calculations of the electronic density of states identified Ni_1.0Co₂O₄ with optimal band-gap of 2.38 eV with an expectation of displaying higher electrocapacitive performance. Experimentally, Ni_0.92Co_2.08O₄ displayed superior electrocapacitive performance among all Ni/Co ratio in Ni_xCo_3-xO₄. The DFT study also predicted Ni preference to the octahedral site, which is in-line with the observed increase in ferromagnetic nature, decreased lattice parameter, and increased structural disorder with increasing Ni/Co ratio. The improved electrochemical performance of Ni_xCo_3-xO₄ (x > 0) is attributed to the mesoporous hierarchical structure, with a high electroactive surface which can effectively improve structural stability, and reduce the ionic and electron diffusion length. Compared to the pure Co₃O₄, the reduction of Co content in Ni_xCo_3-xO₄ is desired due to the high cost and toxicity of Co element.

Electric Stimulus-Responsive Chitosan/MNP Composite Microbeads for a Drug Delivery System

In the last several years, conventional drug delivery systems (DDS) have evolved into DDS that are responsive to exogenous or endogenous stimuli. The objective of this paper is to present a DDS that is responsive to an electric stimulus in the form of bipolar electric pulses. The DDS structure is based on chitosan embedded with magnetic nanoparticles, and crosslinked with polyethylene glycol dimethacrylate to form microbeads. This DDS is loaded with vancomycin as the therapeutic agent of interest. Silver inter-digitated electrodes (IDE) were printed on polyimide substrates with a MEMS-based inkjet material deposition printer, and used to provide 100 Hz pulses of electric current to the DDS for 3 min. The results showed that the stimulated groups released ∼800% more vancomycin than the non-stimulated groups in the excitation duration, but followed a first-order elution profile otherwise. Another significance of our approach is that it does not need complicated or expensive fabrication processes, and can be customized according to the targeted implant site. The IDE system has also been modeled using COMSOL to study the distributed electric fields and ion migration during the stimulus. This paper demonstrates a novel and promising technique of providing stimulus to drug substrates for controllable drug delivery.

Size-dependent magnetic and inductive heating properties of Fe3O4 nanoparticles: scaling laws across the superparamagnetic size

An efficient heat activating mediator with an enhanced specific absorption rate (SAR) value is attained via control of the iron oxide (Fe₃O₄) nanoparticle size from 3 to 32 nm.

Eco-Friendly and High Performance Supercapacitors for Elevated Temperature Applications Using Recycled Tea Leaves

Used tea leaves are utilized for preparation of carbon with high surface area and electrochemical properties. Surface area and pore size of tea leaves derived carbon are controlled by varying the amount of KOH as activating agent. The maximum surface area of 2532 m2 g-1 is observed, which is much higher than unactivated tea leaves (3.6 m2 g-1). It is observed that the size of the electrolyte ions has a profound effect on the energy storage capacity. The maximum specific capacitance of 292 F g-1 is observed in 3 m KOH electrolyte with outstanding cyclic stability, while the lowest specific capacitance of 246 F g-1 is obtained in 3 m LiOH electrolyte at 2 mV s-1. The tea leaves derived electrode shows almost 100% capacitance retention up to 5000 cycles of study. The symmetrical supercapacitor device shows a maximum specific capacitance of 0.64 F cm-2 at 1 mA cm-2 and about 95% of specific capacitance is retained after increasing current density to 12 mA cm-2, confirming the high rate stability of the device. An improvement over 35% in the charge storage capacity is seen when increasing device temperature from 10 to 80 °C. The study suggests that used tea leaves can be used for the fabrication of environment friendly high performance supercapacitor devices at a low cost.

Magnetic stimulus responsive vancomycin drug delivery system based on chitosan microbeads embedded with magnetic nanoparticles

Local antibiotic delivery can overcome some of the shortcomings of systemic therapy, such as low local concentrations and delivery to avascular sites. A localized drug delivery system (DDS), ideally, could also use external stimuli to modulate the normal drug release profile from the DDS to provide efficacious drug administration and flexibility to healthcare providers. To achieve this objective, chitosan microbeads embedded with magnetic nanoparticles were loaded with the antibiotic vancomycin and stimulated by a high frequency alternating magnetic field. Three such stimulation sessions separated by 1.5 h were applied to each test sample. The chromatographic analysis of the supernatant from these stimulated samples showed more than approximately 200% higher release of vancomycin from the DDS after the stimulation periods compared to nonstimulated samples. A 16-day long term elution study was also conducted where the DDS was allowed to elute drug through normal diffusion over a period of 11 days and stimulated on day 12 and day 15, when vancomycin level had dropped below therapeutic levels. Magnetic stimulation boosted elution of test groups above minimum inhibitory concentration (MIC), as compared to control groups (with no stimulation) which remained below MIC. The drug release from test groups in the intervals where no stimulation was given showed similar elution behavior to control groups. These results indicate promising possibilities of controlled drug release using magnetic excitation from a biopolymer-based DDS. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 2169-2176, 2018.

Cardiovascular complications in end stage renal disease in a tertiary hospital in Nepal

Background & Objectives: The cardiovascular complications including morbidity and mortality remains alarmingly high in all stages of chronic kidney disease. Although patients with chronic kidney disease share many of the similar risk factors for cardiovascular disease as the general population, there are a number of uremia related risk factors, such as anemia and alterations in calcium/phosphorus metabolism that also play a role in promoting cardiovascular disease. The objective of the study was to study the cardiovascular complications in end stage renal disease patients on maintenance hemodialysis.Materials & Methods: It is a hospital based cross-sectional observational study conducted at College of Medical Science - teaching Hospital. Hundred patients (n=100) with a diagnosis of end stage renal disease (irrespective of the underlying cause), and those who were on hemodialysis support were studied over a period of one year.Results: One hundred end stage renal disease patients were analyzed. Cardiovascular disease was present in 74% (n=74). the mean age of the patient who had cardiovascular disease was 59.36+14.337 years. The three major causes of end stage renal disease in the study population were hypertension (35%) followed by diabetes(31%) and chronic glomerulonephritis (14%). On electrocardiogram, left ventricular hypertrophy was a major finding 64% (n=64) followed by arrhythmias 30% (n=30). On echocardiography, left ventricular hypertrophy was found in 49% (n=49) followed by left ventricular diastolic dysfunction 38% (n=38). On subgroup analysis, left ventricular hypertrophy was found statistically significant with calcium and phosphorus product > 55 mg2/dl2 (p=0.01). Similarly left ventricular systolic dysfunction, regional wall motion abnormalities and st-t changes was found statistically significant with anemia; p=0.006, p=0.0004 and p=0.02 respectively.Conclusion: Prevalence of cardiovascular complications were common in end stage renal disease patients receiving maintenance hemodialysis. Anemia, calcium and phosphorus product > 55 mg2/dl2 were their independent risk factors.

Prevalence of Peripheral Arterial Disease (PAD) in End Stage Renal Disease (ESRD) Patients on Hemodialysis: A Study from Central Nepal

Background Peripheral arterial disease is a common condition in the hemodialysis population with an estimated prevalence ranging from 17-48%. Many studies have been conducted to know the prevalence of peripheral vascular disease in hemodialysis population. However no such study has been conducted so far in Nepal.Objective This study was carried out with an objective to assess the prevalence of Peripheral Arterial Disease in End Stage Renal Disease Patients on Hemodialysis.Method Fifty patients with a diagnosis of End Stage Renal Disease (irrespective of the underlying cause), and those who were on hemodialytic support for more than 3 months were studied over a period of one year. Peripheral arterial disease was diagnosed on the basis of the ankle –brachial index, which was the ratio of the resting systolic blood pressure in the arteries of the ankle to that of the brachial artery, measured by using a standard mercury manometer with a cuff of appropriate size and the Doppler ultrasound. Patients with ankle –brachial index ?0.9 were considered positive for peripheral arterial disease.Result A total of 50 End Stage Renal Disease patients were analyzed. The mean age of the patient was 49.81±12.63 years. The age range was from 18- 79 years. Majority of them were males 64% (n=32). Peripheral arterial disease defined by ankle –brachial index ?0.9 was present in 30% (n=15) of patients. The three major cause of End Stage Renal Disease in the study population was Chronic Glomerulonephritis 40 % (n=20), Type 2 Diabetes Mellitus 28 % (n=14) and Hypertension 24 % (n=12). Type 2 Diabetes Mellitus was the commonest cause 53% (n=8) of End Stage Renal Disease in patients with peripheral arterial disease followed by hypertension 33% (n=5). On univariate analysis, peripheral arterial disease was found to be significantly associated with age >40 years (p value= 0.003; OR=14.8; CI=1.75-125.27), Type 2 Diabetes Mellitus (p value= 0.009; OR=5.4; CI=1.44-21.14), parasthesia of lower limbs (p value= 0.001; OR=10; CI-2.31-43.16), and intact PTH >300 ng/ml (p value =0.006; OR=5.7; CI=1.55-21.50). However on multivariate analysis only parasthesia of lower limbs and intact PTH >300 ng/ml were significantly and independently associated with peripheral arterial disease, while other variables were not significant.Conclusion Peripheral arterial disease was common occurrence in End Stage Renal Disease patients on hemodialysis. Ankle –brachial index needs to be included as a routine assessment in End Stage Renal Disease patients to detect peripheral arterial disease at its earliest.Kathmandu University Medical Journal Vol.12(3) 2014; 181-184

Intradialytic Muscle Cramp and its Association with Peripheral Arterial Disease in End Stage Renal Disease Patients on Hemodialysis

Introduction: Muscle cramp is a common intradialytic complication observed in hemodialysis patients. Similarly Peripheral arterial disease is a common condition in the hemodialysis population. No study on intradialytic muscle cramp and its association with Peripheral arterial disease is yet reported from Nepal. Methods: Fifty patients with a diagnosis of End Stage Renal Disease who were on hemodialysis were studied over a period of one year. Muscle cramp was defined clinically as contractions of a large muscle group and Peripheral arterial disease was diagnosed on the basis of the ankle –brachial index. Chi square (X2) test was used to determine the association between Intradialytic Muscle cramps and Peripheral Arterial Disease. Results: A total of 50 End Stage Renal Disease patients were analyzed. The mean age of the patient was 49.81±12.63 years. The major causes of End Stage Renal Disease in the study population was Chronic Glomerulonephritis 40 % (n=20). Muscle cramps were present in 26% (n=13) cases. Peripheral arterial disease was present in 30% (n=15) of patients. However there was no statistically significant association between the presence of Intradialytic Muscle cramps and peripheral arterial disease (p value =0.18) Conclusions: Intradialytic Muscle cramps and peripheral arterial disease were common occurrence in end stage renal disease patients on hemodialysis patients, however there was no association between the presence of intradialytic Muscle cramps and peripheral arterial disease.  Keywords: end stage renal disease; intradialytic muscle cramps; peripheral arterial disease.

Intradialytic Muscle Cramp and its Association with Peripheral Arterial Disease in End Stage Renal Disease Patients on Hemodialysis

INTRODUCTION

 Muscle cramp is a common intradialytic complication observed in hemodialysis patients. Similarly Peripheral arterial disease is a common condition in the hemodialysis population.

METHODS

 Fifty patients with a diagnosis of End Stage Renal Disease who were on hemodialysis were studied over a period of one year. Muscle cramp was defined clinically as contractions of a large muscle group and Peripheral arterial disease was diagnosed on the basis of the ankle -brachial index (ABI).

RESULTS

 A total of 50 End Stage Renal Disease patients were analyzed. The major causes of End Stage Renal Disease in the study population was Chronic Glomerulonephritis 40 % (n=20). Muscle cramps were present in 26% (n=13) cases. Peripheral arterial disease was present in 30% (n=15) of patients. However there was no statistically significant association between the presence of Intradialytic Muscle cramps and peripheral arterial disease (p value =0.18) CONCLUSIONS: Intradialytic Muscle cramps and peripheral arterial disease were common occurrence in end stage renal disease patients on hemodialysis patients, however there was no association between the presence of intradialytic Muscle cramps and peripheral arterial disease.

Hymenoptera stings: a study of clinical profile, complication and outcome from a teaching hospital of central Nepal

Background Hymenoptera sting is a common health hazard in the tropics. Wasp and Bee stings can produce symptoms ranging from local allergic reactions to serious complications including anaphylaxis and multiple organ dysfunction syndromes.Objective To evaluate the clinical profile, management and early outcome of patients with gallbladder cancer.Methods We prospectively analyzed all the consecutive patients with Hymenopterid sting (Wasp and Bee stings), who were admitted in Nephrology Unit in college of Medical Sciences Teaching hospital over a period of two year; from June 2010 to May 2012. Data including demographic profile, clinical profile, complications and outcomes associated with the Hymenopterid stings were entered in a designated profroma and were analyzed.Results A total of 15 cases with Hymenopterid stings (Wasp and Bee stings) were analyzed. Majority of the cases were females (n=8). The male to female ratio was 0.88. The mean age of the case was 37.1± 17.38years. Most of the cases (n=11) were younger subjects d"45 years and majority of them felt in the age group of 21-30 years; (n=4). Mean number of stings (Wasp or Bee stings), were 46 ± 18.4 (12-74) and the mean time to reach the hospital from the bite time was 78.23±82.24 hours (30 minutes-13 days). Black Wasps were the commonest species to inflict the stings in (n=10) cases and Bees in (n=5) cases. The Hymenoptera stings were observed more frequently in the month of July to September in (n=8). The commonest site of bite was head and face seen in (n=11) cases. Among the clinical presentations the commonest clinical presentation was local burning pain and pruritus which was present in all the cases (n=15) followed by nausea (n=10). The commonest clinical sign was bipedal edema which was seen in (n=7) cases. Low Hb (defined as Hb <10gm/dl) was seen in (n=5) cases of Hymenopterid stings. Low platelet (defined as Platelet < 100X109/L) was documented in (n=10) cases. Serum creatinine >1.5mg /dl was seen in (n=7) cases. Low serum albumin (defined as Serum Albumin (<3.5gm/dl) was seen in (n=6) cases. Among the complications, the most common complication was Hepatitis which was seen in (n=9) cases, followed by Acute Kidney Injury. There was no mortality associated with Hymenopterid stings in our study. However 1 patient left against medical advice.Conclusion Black Wasps were the commonest species to inflict the stings in (n=10) cases. The most common complication of Hymenoptera sting was Hepatitis, which was seen in (n=9) of cases, followed by Acute Kidney Injury. Majority of complications were seen in Wasp stings which caused significant morbidity. No mortality was observed in our study except one case; that left hospital against medical advice. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-3, 17-24   

Kidney Biopsy: An Experience from Tertiary Hospital

Introduction: Kidney Biopsy is an important diagnostic tool in Nephrology. It is useful in Nephrology in terms of diagnosis, prognosis and management. There is little information on renal biopsy data from central Nepal. We describe our center`s experience in kidney biopsy in term of histological patterns, complications and outcomes.Methods: We prospectively analyzed the biopsies data of patients over a period of one and half year. All kinds of kidney disease patients were included for kidney biopsy, irrespective of their clinical syndromes and underlying diagnosis.Results: A total of 75 biopsies were analyzed. Majority of them were females; 56% (n=42). Most of the biopsies; 84% (n=63) were from younger subjects ≤ 45 years and majority of them fell in the age group 11-20 years. Most common clinical renal syndrome to undergo biopsy was Sub Nephrotic range Proteinuria in 53.3% (n=40). Among comorbid conditions, 53.3% (n=40) had Hypertension. The most common histological pattern seen was Mesangial proliferative Glomerulonephritis (MesPGN) seen in 24% (n=18). Among complications associated with the procedure, macroscopic hematuria was seen in 6.7% (n=5) cases and clinically significant perinephric hematoma causing pain was seen in 5.3% (n=4). There was no mortality associated with biopsy procedure.Conclusions: Sub Nephrotic range Proteinuria was the commonest clinical renal Syndrome observed. In terms of renal histology, Mesangial Proliferative Glomerulonephritis (MesPGN) was the commonest histological pattern observed. Kidney biopsy is a safe procedure without any significant adverse events.Keywords: Kidney biopsy, sub nephrotic range proteinuria, mesangial proliferative glomerulonephritis

Kidney Biopsy: An Experience from Tertiary Hospital

INTRODUCTION

Kidney Biopsy is an important diagnostic tool in Nephrology. It is useful in Nephrology in terms of diagnosis, prognosis and management. There is little information on renal biopsy data from central Nepal. We describe our center`s experience in kidney biopsy in term of histological patterns, complications and outcomes.

METHODS

We prospectively analyzed the biopsies data of patients over a period of one and half year. All kinds of kidney disease patients were included for kidney biopsy, irrespective of their clinical syndromes and underlying diagnosis.

RESULTS

A total of 75 biopsies were analyzed. Majority of them were females; 42 (56%). Most of the biopsies; 63 (84%) were from younger subjects ≤ 45 years and majority of them fell in the age group 11-20 years. Most common clinical renal syndrome to undergo biopsy was Sub Nephrotic range Proteinuria in 40 (53.3%). Among comorbid conditions, 40 (53.3%) had Hypertension. The most common histological pattern seen was Mesangial proliferative Glomerulonephritis seen in 18 (24%). Among complications associated with the procedure, macroscopic hematuria was seen in 5 (6.7%) cases and clinically significant perinephric hematoma causing pain was seen in 4 (5.3%). There was no mortality associated with biopsy procedure.

CONCLUSIONS

Sub Nephrotic range Proteinuria was the commonest clinical renal Syndrome observed. In terms of renal histology, Mesangial Proliferative Glomerulonephritis (MesPGN) was the commonest histological pattern observed. Kidney biopsy is a safe procedure without any significant adverse events.

Clinicomicrobiological profile of infective endocarditis in a tertiary care center of Nepal

Background Infective endocarditis is a common problem and data regarding its clinical and microbiological pattern from developing countries are sparse. We studied clinical features and the microbiological pathogens in patients with Infective Endocarditis in our Hospital. Objective To study the clinical profile and microbiological pathogens involved in patients with Infective Endocarditis, admitted under Department of Internal Medicine of B.P Koirala Institute of Health Sciences. Materials and methods A total of 54 patients with history of fever and underlying heart disease were studied. It was a hospital based cross sectional descriptive study done in patients with infective endocarditis presented to us from March 2007 to February 2008 in B.P Koirala Institute of Health Sciences. Results Out of 54 patients, 11 (20.4%) had Dukes definite IE. The male: female ratio was 1.2:1. The mean age of the study group was 27.3 years (range=16-55). In IE group, fever was present in 100% cases (n=11) as it was the inclusion criteria of the study, followed by SOB 81.8% (n=9). History of antibiotic therapy prior to the presentation was present in 36.7 % (n=4) patients. Pallor was the most common sign 63.6% (n=7). Splenomegaly was seen in 18.2% (n=2). Anaemia (Hb<10gm %) in 36.4% (n=4) and microscopic haematuria in 72.3% (n=8) cases. Blood culture positivity was seen in 36.4 %. The most common pathogens were Staphylococcus aureus in 27.3% (n=3) and Acinetobacter species in 9.1% (n=1). Conclusion In our study we found that the clinical spectrum of IE was different from the west in that the majority of patients being young in our study. However, RHD still is the commonest underlying heart disease and Staphylococcus aureus being the commonest isolate. Journal of College of Medical Sciences-Nepal, 2012, Vol-8, No-4, 34-41 DOI: http://dx.doi.org/10.3126/jcmsn.v8i4.8698  

Acute Coronary Syndrome in an Intensive Care Unit of a Tertiary Referral Centre in Central Nepal: The Spectrum and Coronary Risk Factors

Introduction: Acute coronary syndrome is the major leading cause for coronary care unit admission. Its spectrum comprises a variety of disorders including unstable angina, non ST elevation and ST elevation myocardial infarction.Methods: An observational study was designed to study the spectrum of acute coronary syndrome and associated coronary heart disease risk factors in subjects admitted in intensive care unit from August 2009 to September 2010. Details including coronary risk factors and the categories and outcomes of acute coronary syndrome were analyzed.Results: A total of 57 subjects were included in the study. The majority (63.1%) were males. The mean age was 64.54±13.8 years.  Five (8.8%) patients were ≤45 years and 29 (50.88%) patients were ≥65 years. Majority of the patients were smokers (50.87%). The other major coronary heart disease risk factors were diabetes (43.85%), hypertension (36.87%), dyslipidemia (26.32%) and previous history of coronary heart disease (31.58%). Coronary heart disease figured prominently in the family history as well (26.32%). ST elevation myocardial infarction was the major category (42.11%) followed by non-ST elevation myocardial infarction and unstable angina (31.58% and 26.32% respectively). Myocardial infarction complicated with cardiogenic shock had very high mortality (83.33%).  Conclusions: The ST elevation myocardial infarction was the major clinical form of acute coronary syndrome admitted in intensive care unit. Prevention should be targeted on modifiable risk factors such as the management of risk factors. In addition, the improvement in cardiology service with the establishment of CCU and cathlab might alter the mortality and morbidity in ACS management.Keywords: acute coronary syndrome; coronary risk factors; intensive care unit.

Acute coronary syndrome in an intensive care unit of a tertiary care centre: the spectrum and coronary risk factors

INTRODUCTION

Acute coronary syndrome is the major leading cause for coronary care unit admission. Its spectrum comprises a variety of disorders including unstable angina, non ST elevation and ST elevation myocardial infarction. Its spectrum and incidence is crucial as a part of need assessment of cardiac catheterization laboratories.

METHODS

An observational study was designed to study the spectrum of acute coronary syndrome and associated coronary heart disease risk factors in subjects admitted in intensive care unit of College of Medical Sciences Teaching Hospital, Bharatpur, Nepal from August 2009 to September 2010. Details including coronary risk factors and the categories and outcomes of acute coronary syndrome were analyzed.

RESULTS

A total of 57 subjects were included in the study. The majority 36 (63.16%) were males. The mean age was 64.54±13.8 years. Five (8.8%) patients were ≤45 years and 29 (50.88%) patients were ≥65 years. The major coronary heart disease risk factors were smoking 29 (50.88%), diabetes 25 (43.85%), hypertension 21 (36.87%), and previous history of coronary heart disease 18 (31.58%). ST elevation myocardial infarction was the major category 24 (42.11%) followed by non-ST elevation myocardial infarction and unstable angina 18 (31.58%) and 15 (26.32%), respectively. Myocardial infarction complicated with cardiogenic shock had very high mortality (83.33%).

CONCLUSIONS

The ST elevation myocardial infarction was the major clinical form of acute coronary syndrome admitted in intensive care unit. Prevention should be targeted on modifi able risk factors such as the management of hypertension, dyslipidemia, diabetes and obesity. In addition, the improvement in cardiology service with the establishment of CCU and cathlab might improve the mortality and morbidity in such cases.

Kinship care at community is better model to ensure psychosocial and economic security to orphans living with HIV than from care homes

BACKGROUND

There were about 24,000 children affected by AIDS living in Nepal in 2010; of these 5,000 AIDS orphans were in need of immediate support. The objective of this study was to investigate which model of care and support is more appropriate for improving psychosocial and economic security of AIDS orphans.

METHODS

With the documented 5200 cases of AIDS orphans from 42 districts at National Association of People Living with HIV, we purposively selected five districts - one from each development region, based on the highest number of AIDS orphans reported. From five districts, 56 HIV positive double orphans aged 8-18 years and their 42 caregivers were interviewed to find their psychosocial and economic situation.

RESULTS

Thirty nine (70%) orphans were found living in kinship care, while 17(30%) were living in institutional care homes. Orphans living in kinship were more optimistic, as they were backed by their close relatives 35 (90%), had birth certificates 35 (90%), ensured inherent family property 21 (54%), obtained basic needs like food, education and shelter from grandparents 23 (59%), and had more than five friends who visited their homes 26 (67%). While, the orphans living in institutional care homes 17(30%) had no birth certificates, fewer contacts with siblings 2 (12%), and none had friends outside the care homes.

CONCLUSIONS

Kinship care is better model for psychosocial and economic security for AIDS orphans in Nepal, rather than institutional care. Families can provide good protection to AIDS orphans if government provides minimum support to them.

Pneumonia in South-East Asia Region: public health perspective

Globally, pneumonia is the leading cause of death in young children and burden of disease is disproportionately high in South-East Asia Region of WHO. This review article presents the current status of pneumonia disease burden, risk factors and the ability of health infrastructure to deal with the situation. Literature survey was done for the last 20 years and data from country offices were also collected. The estimated incidence of pneumonia in under five children is 0.36 episodes per child, per year. Risk factors are malnutrition (40% in India), Indoor air pollution, non-breast feeding, chronic obstructive pulmonary disease, etc. Strengthening of health care delivery system for early detection and treatment and as well as minimization of preventable risk factors can avert a large proportion of death due to pneumonia.

Preventing renal and cardiovascular risk by renal function assessment: insights from a cross-sectional study in low-income countries and the USA

OBJECTIVE

To assess the prevalence of microalbuminuria and kidney dysfunction in low-income countries and in the USA.

DESIGN

Cross-sectional study of screening programmes in five countries.

SETTING

Screening programmes in Nepal, Bolivia, the USA (National Health and Nutrition Examination Survey (NHANES) 2005-2008) Bangladesh and Georgia.

PARTICIPANTS

General population in Nepal (n=20 811), Bolivia (n=3436) and in the USA (n=4299) and high-risk subjects in Bangladesh (n=1518) and Georgia (n=1549).

PRIMARY AND SECONDARY OUTCOME MEASURES

Estimated glomerular filtration rate (eGFR)<60ml/min/1.73 m(2) and microalbuminuria (defined as urinary albumin creatinine ratio values of 30-300 mg/g) were the main outcome measures. The cardiovascular (CV) risk was also evaluated on the basis of demographic, clinical and blood data.

RESULTS

The prevalence of eGFR<60ml/min/1.73 m(2) was 19%, 3.2% and 7% in Nepal, Bolivia and the USA, respectively. In Nepal, 7% of subjects were microalbuminuric compared to 8.6% in the USA. The prevalence of participants with predicted 10-year CV disease (CVD) risk ≥10% was 16.9%, 9.4% and 17% in Nepal, Bolivia and in the USA, respectively. In Bangladesh and Georgia, subjects with eGFR<60 ml/min/1.73 m(2) were 8.6% and 4.9%, whereas those with microalbuminuria were 45.4% and 56.5%, respectively. Predicted 10-year CVD risk ≥10% was 25.4% and 25% in Bangladesh and Georgia, respectively.

CONCLUSIONS

Renal abnormalities are common among low-income countries and in the USA. Prevention programmes, particularly focused on those with renal abnormalities, should be established worldwide to prevent CVD and progression to end-stage renal disease.

Peritonitis in Continuous Ambulatory Peritoneal Dialysis

INTRODUCTION: Access to hemodialysis is limited in Nepal due to geographical terrain and hemodialysis centers being mostly limited to major city. Therefore, continuous ambulatory peritoneal dialysis is likely to be a better option in Nepal. In 1998, CAPD was initiated in Nepal without success. High rate of peritonitis was cited for failure. Hot tropical climate and poor sense of hygiene among patients was thought to be responsible for the high rate of peritonitis. A new CPD program was started in 2002 in our institute. We reviewed the incidence of peritonitis and factors predisposing. METHODS: All chronic renal failure patients on CAPD since 2002 to 2007 were included in the study. They were followed up for complications and treatment outcome. Patients complicated with peritonitis (N=19) and patients without peritonitis (N=31) were compared. RESULTS: A total of 50 patients were enrolled and mean duration of dialysis was 12 month per patients (Total patients month=600). Twenty six episodes of peritonitis in 19 patients were recorded during this period. Fourteen episode of peritonitis were culture positive. Culture sterile peritonitis was recorded in 12 episodes. Low serum albumin was predisposing factors for peritonitis and peritonitis rate was higher in end stage disease related due to diabetes mellitus. CONCLUSION: Peritonitis rate was comparable in our new program. Thus peritonitis is not a limiting factor for growth of CAPD in Nepal. Hypoalbuminemic and diabetic patients are prone for CAPD related peritonitis.  KEYWORDS: continuous ambulatory peritoneal dialysis, Peritonitis, Peritonitis rate.

Peritonitis in Continuous ambulatory peritoneal dialysis

INTRODUCTION

Access to hemodialysis is limited in Nepal due to geographical terrain and hemodialysis centers being mostly limited to major city. Therefore, continuous ambulatory peritoneal dialysis is likely to be a better option in Nepal. In 1998, CAPD was initiated in Nepal without success. High rate of peritonitis was cited for failure. Hot tropical climate and poor sense of hygiene among patients was thought to be responsible for the high rate of peritonitis. A new CPD program was started in 2002 in our institute. We reviewed the incidence of peritonitis and factors predisposing.

METHODS

All chronic renal failure patients on CAPD since 2002 to 2007 were included in the study. They were followed up for complications and treatment outcome. Patients complicated with peritonitis (N=19) and patients without peritonitis (N=31) were compared.

RESULTS

A total of 50 patients were enrolled and mean duration of dialysis was 12 month per patients (Total patients month=600). Twenty six episodes of peritonitis in 19 patients were recorded during this period. Fourteen episode of peritonitis were culture positive. Culture sterile peritonitis was recorded in 12 episodes. Low serum albumin was predisposing factors for peritonitis and peritonitis rate was higher in end stage disease related due to diabetes mellitus.

CONCLUSION

Peritonitis rate was comparable in our new program. Thus peritonitis is not a limiting factor for growth of CAPD in Nepal. Hypoalbuminemic and diabetic patients are prone for CAPD related peritonitis.

Skin disease is common in rural Nepal: results of a point prevalence study

BACKGROUND

Skin problems are the commonest reason for people accessing healthcare services in Nepal but there is little information about the prevalence of skin disease.

OBJECTIVES

To perform a point prevalence study of skin disease in the Terai region of Nepal.

METHODS

Five villages were randomly selected in Bara District in the Terai region of Nepal, and 878 people were examined.

RESULTS

The number of individuals identified as having a skin disease was 546. The point prevalence of identifiable skin abnormalities was 62.2% (546 of 878) (with 95% exact confidence intervals 58.9-65.4%). A wide range of dermatoses was identified. The six most prevalent were dermatophyte infections (11.4%), followed by pityriasis versicolor (8.9%), acne (7.7%), melasma (6.8%), eczema (5.6%) and pityriasis alba (5.2%). Overall, treatable skin infections and infestations were by far the commonest skin diseases identified.

CONCLUSIONS

Our study has demonstrated a very high point prevalence (62.2%) of skin disease in rural Nepal. This study represents the first formal survey of skin disease in Nepal and demonstrates a large burden of disease, in particular treatable infections.

Placebo-controlled trial of co-trimoxazole for Cyclospora infections among travellers and foreign residents in Nepal

Cyclospora is a coccidian (previously referred to as cyanobacterium-like bodies) that has been implicated in cases of prolonged diarrhoea. The average duration of symptoms is more than three weeks, and no specific treatment has been shown to shorten the illness. A case report suggested that co-trimoxazole may be effective. Expatriate persons with gastrointestinal complaints and cyclospora detected on examination of faeces were recruited from two clinics in Kathmandu, Nepal, between May and August, 1994. Participants were assigned in a randomised, double-blinded manner to receive either cotrimoxazole (160 mg trimethoprim, 800 mg sulphamethoxazole) or placebo tablets twice daily for 7 days. Of 40 patients included in the study, 21 received cotrimoxazole and 19 placebo. There were no significant differences between these two groups in age, sex, time in Nepal, duration or severity of illness, or presence of other enteric pathogens. After 3 days, 71% of patients receiving co-trimoxazole still had cyclospora detected, compared with 100% of patients receiving placebo (p = 0.016). After 7 days, cyclospora was detected in 1 (6%) of 16 patients treated with co-trimoxazole who submitted stool specimens compared with 15 (88%) of 17 patients receiving placebo (p < 0.0001). Eradication of the organism was correlated with clinical improvement. There was no evidence of relapse of infection among treated patients followed for an additional 7 days. Treatment with co-trimoxazole for 7 days was effective in curing cyclospora infection among an expatriate population in Nepal.