Z_{3} Parafermion in the Double Charge Kondo Model.

Quantum impurity models with frustrated Kondo interactions can support quantum critical points with fractionalized excitations. Recent experiments [W. Pouse et al., Nat. Phys. (2023)NPAHAX1745-247310.1038/s41567-022-01905-4] on a circuit containing two coupled metal-semiconductor islands exhibit transport signatures of such a critical point. Here, we show using bosonization that the double charge-Kondo model describing the device can be mapped in the Toulouse limit to a sine-Gordon model. Its Bethe-ansatz solution shows that a Z_{3} parafermion emerges at the critical point, characterized by a fractional 1/2ln(3) residual entropy, and scattering fractional charges e/3. We also present full numerical renormalization group calculations for the model and show that the predicted behavior of conductance is consistent with experimental results.

Heart Failure: Past, Present, Future.

There are 23 million people with heart failure in the world. Heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) need to be identified before advising treatment of heart failure. Coronary artery disease, dilated cardiomyopathy, valvular heart disease, and hypertension are the common causes of heart failure. Diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and neprilysin receptor blockers have been found to reduce mortality in heart failure. Natural compensatory mechanisms such as release of various vasoconstrictors and vasodilators in heart failure come into action to improve symptoms for some time. Ultimately compensatory mechanisms fail to work and patients reach end-stage heart failure. Mechanical circulatory support devices are recommended as a bridge treatment before heart transplant. The only option at this stage is heart transplant which is not feasible easily in the low and middle-income countries. Though end-stage heart failure treatment with inotropic drugs improves symptoms for a short period, various trials have shown increased mortality with their uses. On-going research on heart failure is expected to come out with more effective treatment of heart failure in future.

Prevalence of White Coat Hypertension among the Patients Visiting in a Tertiary Care Center, Kathmandu, Nepal.

Background Hypertension is a major cardiovascular risk factor. White coat hypertension refers to elevated office blood pressure but normal out of office blood pressure. White-coat hypertension has a risk of cardiovascular events more than normotensives. Objective To identify the prevalence of white coat hypertension among patients presented in the cardiology department. Method The descriptive cross-sectional study was conducted among 165 patients who visited the cardiology outpatient department of Kathmandu Medical College and Teaching Hospital from December 2017 to November 2018. Blood pressure was measured at the hospital, and ambulatory blood pressure device was used to monitor 24hrs pattern. Hypertension is classified as per recent guideline. Data were entered and analysed using Statistical Package for social sciences version 20. Result Out of 165 ambulatory blood pressure monitoring conducted patients, 140 participants were enrolled in the study based on inclusion criteria. Among them 55% (77) were male, and 45% (63) were female. Age ranged from 18-78 years with a mean of 43.82 ± 12.31 years. Overall among 140 participants 14.28% had white coat hypertension, however, after excluding twenty-two high normal group, among 118 participants who were hypertensive according to office BP, 16.9% (20) had white coat hypertension, and 33.57% of patients did not have nocturnal dipping of blood pressure. Conclusion The white coat hypertension is prevalent among around one-sixth of hypertensive patients visiting tertiary care centre, and one third have non-dipping which needs to be considered in the management of hypertension.

Prevalence of Diastolic Dysfunction in Type 2 Diabetes Mellitus.

Background Diastolic dysfunction is an inability of the ventricle to fill to a normal end-diastolic volume, both during exercise as well as at rest. Diabetes mellitus increases the risk of heart failure even in the absence of other co-morbidities. Objective To find the prevalence of diastolic dysfunction in patients with type 2 diabetes mellitus and its association with age, gender, duration, glycosylated hemoglobin levels, dyslipidemia, tobacco smoking and alcohol consumption. Method Ninety patients with type 2 diabetes mellitus of both genders, aged 30 to 60 years, were included in this study. Doppler echocardiography was performed to evaluate diastolic dysfunction. Result The mean age of the study population was 46.21 ± 9.20 yrs. The overall prevalence of diastolic dysfunction in the study population was 47.8%. The prevalence of diastolic dysfunction increases with age: 23.1% in patients of age 30 - 39 yrs to 65.8% in patients of age 50 - 60 yrs (adjusted OR 0.16, 95% CI 0.04 - 0.64, P = 0.010) and with the duration of diabetes: 32.8% in patients with diabetes for <5 yrs to 75% in patients with diabetes for >10 yrs (adjusted OR 0.31, 95% CI 0.08 - 1.00, P = 0.05). There was no significant association between diastolic dysfunction and dyslipidaemia, BMI, tobacco smoking, alcohol consumption, HbA1c and gender. Conclusion Prevalence of diastolic dysfunction in type 2 diabetes mellitus was 47.8% in our study. A rising trend of prevalence of diastolic dysfunction with the duration of diabetes and increasing age of patients was observed.

Prevalence of Early Repolarization Patterns in Adults.

Background The finding of persistent Junction point elevation of 1 mm or more in adjacent leads in electrocardiogram is considered to be due to early repolarization. This condition was considered benign in the past but presently it is believed to be the rare cause of idiopathic ventricular fibrillation and sudden death. Objective The main objective of the study is to find out the prevalence of early repolarization pattern in subjects having electrocardiogram at Kathmandu Medical College Teaching Hospital. Method Twelve lead electrocardiograms of patients attending Kathmandu Medical College Teaching Hospital were studied. Data was collected for patient particulars. Electrocardiograms were analyzed for the type of early repolarization. Result The overall prevalence of early repolarization pattern of electrocardiogram was 2.82 %. It's prevalence in male and female was 4.95 % and 0.77 % respectively. The prevalence of different types of early repolarization electrocardiography pattern was 0.70 %, 1.25% and 0.63% of the population studied for type I, II, and III early repolarization patterns. Type IV or Brugada pattern was not detected in our study. Conclusion The commonest pattern observed was type II that is early repolarization pattern in inferior or inferolateral leads. Having knowledge of early repolarization and its type helps to counsel the physicians about the risk of arrhythmia and sudden cardiac death.

Prevalence of Sensory Neuropathy in Type 2 Diabetes Mellitus and Its Correlation with Duration of Disease.

Background Peripheral neuropathy is one of the most common and distressing late complication of diabetes mellitus. Ignorance of the complications may develop foot ulcers and gangrene requiring amputation. Objective The main objective of this study is to find out the prevalence of sensory neuropathy in type 2 diabetes mellitus and to compare it with the duration of disease. Method Two hundred seventy one patients with type 2 diabetes mellitus of both gender age 30 years and above willing to participate were included in this study. Patients having hypothyroidism, rheumatoid arthritis, B12 deficiency, cerebrovascular disease, chronic musculoskeletal disease, Parkinson's disease, alcohol abuse, chronic renal or liver failure and cancer were excluded from the study. Touch, pin prick and vibration sensation were tested. Vibration perception threshold was recorded from six different sites of the sole of each foot using Biothesiometer. Result Two hundreds seventy one type 2 diabetic outpatients were studied. The mean age was 59.81±22.85 years. The overall prevalence of diabetic sensory neuropathy in the study population was 58.70%. A rising trend of diabetic sensory neuropathy with increasing age and duration of diabetes was observed. Neuropathy was found more in patients having urinary microalbuminuria. Burning and pins and needles sensation were most common symptoms. Conclusion The overall prevalence of diabetic sensory neuropathy in the study population was 58.70% (mean age 59.81±22.85 yrs), and its prevalence increased with duration of diabetes and increasing age. Its prevalence was found more in patients having microalbuminuria.

Measurement of right atrial volume and diameters in healthy Nepalese with normal echocardiogram.

BACKGROUND: The size of right atrium is expected to be different in diverse healthy ethnic groups. It is important to know the normal size of right atrium in our healthy population. OBJECTIVE: The study aimed to find out the normal values of right atrial volume, right atrial short axis diameter and right atrial long axis diameter in healthy Nepalese population with normal echocardiographic findings. It also looked at correlations between right atrial dimensions and the right atrial volume. METHOD: Verbal consent was taken from all the participants. One hundred participants between the age of 18 and 60 years with normal echocardiographic findings and without any chronic disease were included in this study. Right atrial volume was measured by using area length method. Right atrial short axis diameter and Right atrial long axis diameter were measured in the four chamber view. RESULT: The mean right atrial volume was 23.64±5.36 ml (range 11.30-40.00 ml).The range of right atrial short axis diameter and right atrial long axis diameter were 1.34-3.80 cm and 2.4-4.7 cm respectively. CONCLUSION: The size of right atrium in the Nepalese population is smaller compared to western population. Male right atrial volume size is greater than female in Nepalese population similar to western population. The findings of normal value of right atrial volume and right atrial diameter in Nepalese population will help the physician to assess patients with various conditions affecting the right atrium.

64-slice CT scan in Kathmandu Medical College Teaching Hospital.

64-slice CT scan is a versatile newly introduced imaging technology, which is capable of diagnosing various diseases from head to toe. The 64-slice CT coronary angiography has a negative predictive value of 100%. Virtual images of bronchi, stomach and colon can provide definite diagnosis. Coronary artery calcification score which predicts coronary artery disease can be calculated by 64-slice CT scan.

Changing spectrum of antibiotic sensitivity in enteric fever.

AIMS AND OBJECTIVES: The study was designed to analyze clinical profile and Antibiotic sensitivity pattern in case of culture positive typhoid fever and compare response of quinolones in vitro and in vivo. METHODOLOGY: Forty eight cases of culture positive enteric fever presented in outpatient and emergency department of Kathmandu Medical College, Sinamangal, and Kathmandu were included in the study. Sensitivity pattern of isolates from blood culture was done by antibiotic disc diffusion method and this was compared with clinical response. RESULTS: Response was based on Fever Clearance Time (FCT) and it was found that mean FCT was 3.58 days with standard deviation of 1.84 .Comparison was made separately for FCT >or=5 days and it was found that vomiting as the symptom and stool occult blood positive as the investigation to predict prolong FCT. Nalidixic acid as compared with other quinolones showed that other quinolones (ciprofloxacin, ofloxacin) are effective even in Nalidixic acid resistant cases when FCT was taken as the criteria of response, and it doesn't include the relapse rate. CONCLUSION: Enteric fever is one of the leading causes of fever in Nepal. The diagnosis in most of the cases is done empirically by clinical features, but culture and sensitivity of blood or bone marrow is the gold standard way of diagnosis and providing treatment. The antibiotic sensitivity pattern is changing and resistance cases are emerging with indiscriminate use of drugs.

Retinopathy in a diabetic population.

AIMS AND OBJECTIVES: The study was conducted with the aim to find out the prevalence of diabetic retinopathy among diabetics on treatment, to find out the presence of associated risk factors and to determine the knowledge of diabetic retinopathy among patients with diabetic mellitus. METHODOLOGY: Cross sectional screening of 316 diabetic patients on treatment presenting to Kalimati Diabetic Clinic and Kathmandu Medical College was done over a period of 8 months for the presence of diabetic retinopathy, associated risk factors and the knowledge of diabetic retinopathy. RESULTS: 21% of the known diabetics had evidence of various grades of diabetic retinopathy although 75.3% of the enrolled patients had history of diabetes mellitus of less than 10 years. Associated risk factors were present in 66.46%. However, only 50% diabetics had the knowledge of diabetic retinopathy. CONCLUSION: As 21% of the diabetic patients on treatment had various grades of diabetic retinopathy and 50% of the diabetic patients were not aware of diabetic retinopathy, emphasis has to be given for the awareness of ocular involvement in diabetes mellitus such that blindness from retinopathy can be prevented. The responsibility lies on treating physicians or Diabetic Centres for referral of diabetic patients for ophthalmic evaluation. Similarly, control of associated risk factors like hypertension, hyperlipidemia is equally important.

Visual outcome of laser treatment in diabetic retinopathy.

OBJECTIVE: To determine the visual outcome of laser treatment in diabetic retinopathy. DESIGN: Prospective, non-comparative case series. MATERIALS AND METHODS: A total of 80 eyes of 50 patients with diabetic retinopathy in different stages were photocoagulated using diode green laser. Focal laser only was given in 46 eyes and pan retinal photocoagulation only was given in 29 eyes while 3 eyes received focal laser and pan retinal photocoagulation. One eye was given grid laser only and one eye received both grid and focal laser. The best corrected visual acuity was noted and fundus examination was carried out prior to laser therapy and at the last follow-up and results were compared. RESULTS: Non- proliferative diabetic retinopathy was present in 76%. Following laser treatment, best corrected visual acuity improved in 52.50%, remained static in 35% and deteriorated in 12.5%. Maculopathy improved in 52%, remained static in 6% and deteriorated in 2% in right eyes while there was no maculopathy in 40% in right eyes. Similarly, maculopathy improved in 38% and remained same in 10% while 52% had no maculopathy in left eyes. After laser treatment, NVD (OD) regressed in 6% and remained unchanged in 4%. Similarly, NVE (OD) regressed in 18% and remained unchanged in 4% and NVE (OS) regressed in 18% and remained unchanged in 2% following laser therapy. CONCLUSION: Timely and adequate laser treatment helps in saving the vision in patients with diabetic retinopathy.

Enteric fever: diagnostic value of clinical features.

OBJECTIVES: to evaluate the diagnostic value of clinical symptoms and signs in enteric fever and to propose a clinical diagnostic criterion. DESIGN: Prospective observational study. SETTING: Kathmandu Medical College, Teaching Hospital, Kathmandu, Nepal. MATERIALS AND METHODS: febrile patients with clinical diagnosis of enteric fever were included in the study with the aim of confirming diagnosis with blood culture, or bone marrow culture and evaluating the diagnostic accuracy of various clinical signs and symptoms. RESULTS: 64% of the clinically diagnosed cases had blood/ bone marrow culture positive. The diagnostic accuracy of the various symptoms and signs excluding fever was between 42%-75.5%. Majority of the symptom and sign did not have very high diagnostic accuracy. Hence a diagnostic criterion was proposed and clinical features with diagnostic accuracy more than 50% were taken into consideration. Major criteria included fever with diagnostic accuracy of 64%, headache with accuracy of 75.5% and relative bradycardia with an accuracy of 66%. Minor criteria included vomiting, diarrhoea, Splenomegaly, chills and abdominal pain /discomfort with diagnostic accuracy of 57%, 55%, 55%, 53% and 51% respectively. Finally after combination of various major and minor criteria a final diagnostic criterion was proposed having an accuracy of 66% and including both major and minor clinical symptom and sign. CONCLUSION: clinical diagnosis of enteric fever will be very helpful in a country like ours. Though none of the clinical symptoms and sign have very high diagnostic accuracy a diagnostic criteria may be helpful. Criteria including both major and minor signs and symptoms would be the most appropriate diagnostic tool as it includes the important abdominal symptoms and signs of enteric fever.

Clinico-radiological profile of stroke in eastern Nepal: a computed tomographic study.

AIM: Stroke is a frequent cause of death and disability in elderly patients. This study was carried out to establish the pattern of various types of cerebrovascular accident (CVA) in eastern Nepal and to correlate the clinical data and radiological findings in cases of stroke. MATERIALS AND METHODS: All the patients clinically diagnosed as stroke and referred to the radiology department for Computed tomography (CT) of the brain over a period of 1 year were included. RESULTS: There were 150 patients with stroke (104 males and 46 females), aged 7 to 91 years in which infarction (58%) was more common than haemorrhage (42%) in both group of age (< or = 40 years and > 40 years). Smoking was the commonest risk factor noted in 40.66% cases followed by hypertension (40%). Excessive meat consumption (more than 4 times a week) was seen in 69.1% cases. In early Middle Cerebral Artery (MCA) territory infarction presenting within six hours of onset, positive CT findings were seen in 40% cases among which, obscuration of the lentiform nuclei was diagnostic. CONCLUSION: In this part of Nepal, infarction is more common than haemorrhage as the cause of stroke and in contrary to western population; hemorrhagic stroke constitutes a significantly higher proportion of stroke. Smoking is the commonest risk factor followed by hypertension and it is also seen in combination with alcohol in many cases. Excessive meat consumption could be an additional risk factor for stroke in this part of Nepal. In younger age group (< or = 40 years), haemorrhage is more common than infarction and alcohol consumption is the commonest risk factor.

Magnetic Resonance Imaging Findings in Lumbar Disc Degeneration in Symptomatic Patients.

BACKGROUND: The sequel of disc degeneration is one of the leading causes of functional incapacity that leads to chronic disability. The study aims to evaluate the MRI findings of degenerative changes in symptomatic patients. METHODS: The study was a retrospective study for the duration of 3 years. Symptomatic patients undergoing MRI of LS spine were included in the study. Patients undergoing MRI for neurological symptoms alone and acute trauma or suspected infection or tumor were excluded from the study. MRI of patients was evaluated for degenerative changes and their sequel. Data was entered in a predesigned proforma and analysis was done with SPSS version 19.0. RESULTS: A total of 2037 MRIs of LS spine of symptomatic patients were included in the study. Degenerative changes were demonstrated in 1906 (93.8 %) patients, which comprised 1039 (54.5 %) males and 867 (45.4 %) females. Disc bulge along with disc desiccation was the most common degenerative findings noted in 1667 (81.8 %). Disc herniation was seen in 1032(50.6%), neural foraminal stenosis in 1220 (59.8 %), central spinal canal in 1136 (55.8%) and nerve root compression in 650 (31.9%). Disc bulge, neural foraminal stenosis, central spinal canal stenosis was significantly more common in patients older than 40 years. Disc herniation was however significantly more frequent in patients younger than 40 years. CONCLUSIONS: Degenerative changes are common in symptomatic patients and increase in frequency with aging. Disc herniation is however more common in younger patients.

Magnetic Resonance Imaging Findings in Degenerative Disc Disease of Cervical Spine in Symptomatic Patients.

BACKGROUND: The pathophysiological findings demonstrated in cervical spine in Magnetic Resonance Imaging (MRI) can explain only partly the occurrence of neck and shoulder pain. This study aims to evaluate the occurrence of cervical degenerative disc pathologies in symptomatic patient with neck pain and radiculopathy. METHODS: The study was a retrospective and institutional record based descriptive study carried out for the duration of 3yrs in a well-equipped imaging center. Only MRI performed for neck pain with or without radiculopathy with complete clinical form was included in the study. MRI findings were entered in SPSS spread sheet and analyzed using SPSS 19.0. RESULTS: A total of 750 MRI was reviewed among which 571(76.13%) had cervical degenerative disc pathology. Disc degeneration and disc bulge was the most common finding, followed by neural foramina stenosis, disc herniation and myelopathic changes. Disc degeneration and disc bulge was seen more frequently in patients older than 40 years than those less than 40 years. Disc herniation was rare in extremes of age and noted predominantly in productive population between 3 rd and 6 th decade of life. CONCLUSIONS: Disc degeneration and global disc bulge were predominant findings in symptomatic patients increasing with the age. Disc herniation and neural foraminal stenosis were common changes seen associated with neck pain with or without radiculopathy and were predominant in productive age group.

Field investigaton of an outbreak of epidemic dropsy in eastern Nepal.

About 17 cases with clinical syndrome suggestive of epidemic dropsy attended to the B P Koirala Institute of Health Sciences, Dharan, for treatment. These cases were from three villages of Saptari district in eastern Nepal. Some of the mustard oil samples were tested positive with Nitric acid test. In the wake of this, an extensive field investigation was conducted covering a wider area in these villages.

Crossed Testicular Ectopia.

Crossed testicular ectopia also known as transverse testicular ectopia is a rare anomaly of the testis which is ectopically located in contralateral hemiscrotum with absent testis in the ipsilateral hemiscrotum. Most case are incidentally discovered intraopeartively during operation of inguinal hernia and few case reports are available which have reported preoperative diagnosis of crossed testicular ectopia. We report a case of crossed testicular ectopia in 12 year old boy who presented with right undescended testis diagnosed preoperative on Ultrasound and Magnetic Resonance Imaging as crossed testicular ectopia.