Mean Cholinesterase Level among Organophosphorus Poisoning Patients Visiting the Emergency Department in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Acute organophosphorus pesticide poisoning is widespread and the most common in many developing countries, including Nepal. Through the inhibition of acetylcholinesterase, organophosphorus poisoning is characterised by the clinical picture of acute cholinergic crisis. Many researchers have shown increased levels of liver enzymes and decreased levels of serum cholinesterase in organophosphorus poisoning, however, very little work has been done in Nepal that studies the correlation between serum cholinesterase and liver enzymes in organophosphorus poisoning. The aim of the study is to find out the mean cholinesterase level among organophosphorus poisoning patients visiting the Emergency Department in a tertiary care centre. Methods: This was a descriptive cross-sectional study done among 94 organophosphate poisoning cases visiting the emergency department of a tertiary care centre from August 2021 to August 2022 after obtaining approval from the Institutional Review Committee (Reference number: 04102021/06). Convenience sampling was done. Blood workups were done for cholinesterase and liver function tests. Point estimate and 90% Confidence Interval were calculated. Results: The mean cholinesterase level among organophosphorus poisoning patients was 1978.82±1878.22 (1660.17-2297.47, 90% Confidence Interval). Conclusions: The mean cholinesterase level among organophosphorus poisoning patients was similar when compared to other studies done in similar settings. Keywords: cholinesterases; liver function tests; organophosphorus poisoning.

Mean Serum Lactate Levels in Patients with Sepsis Presenting to the Department of Emergency Medicine of a Tertiary Care Center: A Descriptive Cross-sectional Study.

Introduction: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Serum lactate is useful in predicting the prognosis of critically ill patients. Elevated blood lactate levels as well as delayed clearance have been linked to higher mortality in sepsis. Shock index is a simple and effective bedside assessment means of gauging the degree of shock and is an important predictor of identifying high-risk patients. Monitoring lactate levels may aid clinicians in understanding tissue perfusion and detecting unrecognized shock and making prompt therapy adjustments. This study aimed to find out the mean serum lactate levels in patients with sepsis presenting to the Department of Emergency Medicine of a tertiary care centre. Methods: A descriptive cross-sectional study was conducted at a tertiary care centre among the patient with sepsis presenting to the emergency department from 1 September 2022 to 30 November 2022. Ethical approval was obtained from the Institutional Review Committee of a tertiary care centre (Reference number: 26082022/02). History taking and detailed examination were done. Blood was sent for serum lactate and other parameters as proforma was sent. The shock index was calculated. Convenience sampling was done. Point estimate and 95% confidence interval were calculated. Results: Among 53 sepsis patients, the mean serum lactate level in sepsis patients was 2.84+2.02 (male: 2.83+1.70 and female: 2.85+2.42). Conclusions: The mean serum lactate level in patients with sepsis is similar as compared the studies done in similar settings. Keywords: emergencies; lactate; sepsis.

Incidence of typhoid and paratyphoid fever in Bangladesh, Nepal, and Pakistan: results of the Surveillance for Enteric Fever in Asia Project.

BACKGROUND: Precise enteric fever disease burden data are needed to inform prevention and control measures, including the use of newly available typhoid vaccines. We established the Surveillance for Enteric Fever in Asia Project (SEAP) to inform these strategies. METHODS: From September, 2016, to September, 2019, we conducted prospective clinical surveillance for Salmonella enterica serotype Typhi (S Typhi) and Paratyphi (S Paratyphi) A, B, and C at health facilities in predetermined catchment areas in Dhaka, Bangladesh; Kathmandu and Kavrepalanchok, Nepal; and Karachi, Pakistan. Patients eligible for inclusion were outpatients with 3 or more consecutive days of fever in the last 7 days; inpatients with suspected or confirmed enteric fever; patients with blood culture-confirmed enteric fever from the hospital laboratories not captured by inpatient or outpatient enrolment and cases from the laboratory network; and patients with non-traumatic ileal perforation under surgical care. We used a hybrid surveillance model, pairing facility-based blood culture surveillance with community surveys of health-care use. Blood cultures were performed for enrolled patients. We calculated overall and age-specific typhoid and paratyphoid incidence estimates for each study site. Adjusted estimates accounted for the sensitivity of blood culture, the proportion of eligible individuals who consented and provided blood, the probability of care-seeking at a study facility, and the influence of wealth and education on care-seeking. We additionally calculated incidence of hospitalisation due to typhoid and paratyphoid. FINDINGS: A total of 34 747 patients were enrolled across 23 facilitates (six tertiary hospitals, surgical wards of two additional hospitals, and 15 laboratory network sites) during the study period. Of the 34 303 blood cultures performed on enrolled patients, 8705 (26%) were positive for typhoidal Salmonella. Adjusted incidence rates of enteric fever considered patients in the six tertiary hospitals. Adjusted incidence of S Typhi, expressed per 100 000 person-years, was 913 (95% CI 765-1095) in Dhaka. In Nepal, the adjusted typhoid incidence rates were 330 (230-480) in Kathmandu and 268 (202-362) in Kavrepalanchok. In Pakistan, the adjusted incidence rates per hospital site were 176 (144-216) and 103 (85-126). The adjusted incidence rates of paratyphoid (of which all included cases were due to S Paratyphi A) were 128 (107-154) in Bangladesh, 46 (34-62) and 81 (56-118) in the Nepal sites, and 23 (19-29) and 1 (1-1) in the Pakistan sites. Adjusted incidence of hospitalisation was high across sites, and overall, 2804 (32%) of 8705 patients with blood culture-confirmed enteric fever were hospitalised. INTERPRETATION: Across diverse communities in three south Asian countries, adjusted incidence exceeded the threshold for "high burden" of enteric fever (100 per 100 000 person-years). Incidence was highest among children, although age patterns differed across sites. The substantial disease burden identified highlights the need for control measures, including improvements to water and sanitation infrastructure and the implementation of typhoid vaccines. FUNDING: Bill & Melinda Gates Foundation.

Malignant Serous Effusions among Hospital In-patients in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Cell block technique is an adjunct to conventional smears in the diagnosis of malignancy in effusion fluid. It aims at retrieving cellular material and concentrating cells in a small field, with preservation of cytomorphologic details. The objective of this study was to find the proportion of malignant serous effusions using cell block technique among hospital in-patients in a tertiary care centre. METHODS: This was a descriptive cross-sectional study conducted among patients visiting a tertiary care centre between 1st June 2020 to 30th November 2020. Ethical approval was taken from the Institutional Review Committee (Reference number: 305202001). Using a convenience sampling method, 96 hospital in-patients were included in the study. Serous effusions were evaluated by conventional smears and cell block sections. Data was analysed using the Statistical Package for the Social Sciences version 23. Point estimate at 95% Confidence Interval was calculated along with frequency, percentage, mean and standard deviation. RESULTS: Among 96 hospital in-patients, 15 (15.62%) (8.35-22.88 at 95% Confidence Interval) were diagnosed as positive for malignancy by using cell block technique. By conventional smears, 80 (83.33%) cases turned out to be negative for malignancy, 13 (13.54%) were positive for malignancy and three (3.12%) were suspicious for malignancy. Of the three (3.12%) cases suspected for malignancy, two turned out to be positive for malignancy and one was found to be negative for malignancy on cell block technology. CONCLUSIONS: The proportion of malignant serous effusions was similar in comparison to other studies. Cell block technique could be routinely incorporated along with conventional smears for a more accurate diagnosis of malignancy on serous effusion.

Antimicrobial Resistance in Typhoidal Salmonella in Nepal: Surveillance for Enteric Fever, 2016-2019.

BACKGROUND: Enteric fever (caused by Salmonella enterica) has been associated with poor hygiene and is endemic in the South-Asian countries. The increase in resistance to first line antimicrobials has been observed, while the emergence of multi/extremely drug resistance cases have been identified in several countries. The objective of this study is to analyze the current trend of antimicrobial resistance in Salmonella isolates in Nepal, and to identify the status of multi- and extremely- drug resistant isolates. METHODS: We recruited individuals at study hospitals with suspected enteric fever between September 2016 and August 2019 and performed blood cultures. The Salmonella isolates were tested for antimicrobial susceptibility and the antimicrobial resistance trend was evaluated. RESULTS: 1438 positive blood culture isolates were studied for antimicrobial resistance. 88% were culture positive for Salmonella Typhi and 12% for Salmonella Paratyphi. Multidrug resistant S. Typhi cases appeared mostly in December 2018 and January 2019, while there were no multidrug resistant S. Paratyphi cases. Also, extremely drug resistant S. Typhi cases were not observed during the study period. CONCLUSIONS: The Salmonella isolates were mostly susceptible to first-line antimicrobials, cephalosporins and others. Many fluoroquinolones non-susceptible Salmonella were obtained, nevertheless their overall trend seems to be declining. In addition, the S. Paratyphi total cases are reducing since September 2017. Among S. Typhi isolates, only few were multidrug resistant and there were no extremely drug resistant isolates.

Extensive Drug Resistant Acinetobacter Species Isolates in Sputum Sample of Patient Admitted in Intensive Care Unit of a Tertiary Care Centre: A Descriptive Cross-sectional Study.

INTRODUCTION: Increasing antibiotic resistance has created a global public health threat worldwide. Acinetobacter species is one of the important pathogenic organisms in the hospital setting due to its ability to persist in the hospital environment for long. Its resistance to commonly used antibiotics can prolong hospital stay, increase financial burden, and increase morbidity and mortality. This study aims to find the prevalence of extensive drug resistant Acinetobacter species in the sputum sample of Intensive Care Unit patients admitted in a tertiary care center. METHODS: A descriptive cross-sectional study was conducted in a tertiary care center among the hospital records from May 2017 to May 2021, after ethical approval (Reference number: 2104202101). All the Intensive Care Unit patients with isolated acinetobacter species in their sputum samples within the past four years were collected and Statistical Package for Social Sciences version 25 was used for analysis. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: Of the total 409, 196 (47.9%) (95% Confidence Interval= 43.06-52.74) of Acinetobacter species in the sputum sample had extensive drug resistance. Of these, 193 (98.5%) and 1 (0.5%) of the extensive drug resistant Acinetobacter species were resistant to carbapenem and polymyxin respectively. CONCLUSIONS: Prevalence of extensive drug resistant acinetobacter was found higher compared to other studies.

Benign Histopathologic Findings of Endometrium among Perimenopausal Women presenting with Abnormal Uterine Bleeding: A Descriptive Cross-sectional Study.

INTRODUCTION: Abnormal uterine bleeding is the most common presenting complaint in the perimenopausal age group. Endometrial biopsy obtained by dilatation and curettage is the preferred modality of investigation to determine the causative pathology of abnormal uterine bleeding. The objective of this study was to find out the prevalence of the benign histopathological findings in perimenopausal women presenting with abnormal uterine bleeding. METHODS: This descriptive cross-sectional study was conducted among patients between 1st June 2020 to 30th September 2021. Ethical approval was taken from the Institutional Review Committee of Kathmandu Medical College (reference number: 305202002). Using the convenience sampling method, 96 cases of endometrial biopsies were studied under light microscopy. Data was analyzed using the Statistical Package for the Social Sciences version23.0. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: Among the 96 specimens, the prevalence of benign findings was 93 (96.9%) (93-100 at 95% Confidence Interval). Among them, the commonest benign histopathologic spectrum was hormonal imbalance pattern in 40 (41.7%) followed by normal menstrual pattern 35 (36.5%). Five (5.2%) cases showed chronic endometritis. Six (6.2%) cases of endometrial hyperplasia without atypia were identified. Three (3.1%) cases showed endometrial atrophy. Four (4.1%) cases showed endometrial polyp. CONCLUSIONS: The prevalence of benign histopathological findings among endometrial biopsies in the study was similar to other studies.

Spatial Heterogeneity of Enteric Fever in 2 Diverse Communities in Nepal.

BACKGROUND: Typhoid fever is endemic in the urban Kathmandu Valley of Nepal; however, there have been no population-based studies of typhoid outside of this community in the past 3 decades. Whether typhoid immunization should be prioritized in periurban and rural communities has been unclear. METHODS: We performed population-based surveillance for enteric fever in 1 urban catchment (Kathmandu) and 1 periurban and rural catchment (Kavrepalanchok) as part of the Surveillance for Enteric Fever in Asia Project (SEAP). We recruited individuals presenting to outpatient and emergency departments at 2 study hospitals with suspected enteric fever and performed blood cultures. Additionally, we conducted a household survey in each catchment area to characterize care seeking for febrile illness. We evaluated spatial heterogeneity in febrile illness, care seeking, and enteric fever incidence. RESULTS: Between September 2016 and September 2019, we enrolled 5736 participants with suspected enteric fever at 2 study hospitals. Among these, 304 (5.3%) were culture positive for Salmonella Typhi (249 [81.9%]) or Paratyphi A (55 [18.1%]). Adjusted typhoid incidence in Kathmandu was 484 per 100 000 person-years and in Kavrepalanchok was 615 per 100 000 person-years. While all geographic areas for which estimates could be made had incidence >200 per 100 000 person-years, we observed spatial heterogeneity with up to 10-fold variation in incidence between communities. CONCLUSIONS: In urban, periurban, and rural communities in and around Kathmandu, we measured a high but heterogenous incidence of typhoid. These findings provide some support for the introduction of conjugate vaccines in Nepal, including outside urban areas, alongside other measures to prevent enteric fever.

Typhoid and Paratyphoid Cost of Illness in Nepal: Patient and Health Facility Costs From the Surveillance for Enteric Fever in Asia Project II.

BACKGROUND: Enteric fever is endemic in Nepal and its economic burden is unknown. The objective of this study was to estimate the cost of illness due to enteric fever (typhoid and paratyphoid) at selected sites in Nepal. METHODS: We implemented a study at 2 hospitals in Nepal to estimate the cost per case of enteric fever from the perspectives of patients, caregivers, and healthcare providers. We collected direct medical, nonmedical, and indirect costs per blood culture-confirmed case incurred by patients and their caregivers from illness onset until after enrollment and 6 weeks later. We estimated healthcare provider direct medical economic costs based on quantities and prices of resources used to diagnose and treat enteric fever, and procedure frequencies received at these facilities by enrolled patients. We collected costs in Nepalese rupees and converted them into 2018 US dollars. RESULTS: We collected patient and caregiver cost of illness information for 395 patients, with a median cost of illness per case of $59.99 (IQR, $24.04-$151.23). Median direct medical and nonmedical costs per case represented ~3.5% of annual individual labor income. From the healthcare provider perspective, the average direct medical economic cost per case was $79.80 (range, $71.54 [hospital B], $93.43 [hospital A]). CONCLUSIONS: Enteric fever can impose a considerable economic burden on patients, caregivers, and health facilities in Nepal. These new estimates of enteric fever cost of illness can improve evaluation and modeling of the costs and benefits of enteric fever-prevention measures.

Histopathological Study of Skin Lesions in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Skin diseases are much common in developing countries. The spectrum varies according to geographic distribution, gender, age, and coexisting disorder. We conducted this study to find out the prevalence of different skin lesions and to evaluate their frequency and site of distribution. METHODS: A descriptive cross-sectional study was done in the pathology department of Kathmandu Medical college from June 2019 to November 2019 after ethical clearance. The skin biopsies were processed, sectioned and stained with Haematoxylin and eosin and evaluated. A convenience sampling method was used. Data was collected and entry was done in Statistical Packages for Social Services version 20.0, point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: Among 133 skin biopsies examined, noninfectious vesicobullous and vesicopustular disease were found in 42 (46.6%) cases followed by microbial disease in 22 (24.5%) and noninfectious erythematous papular and squamous disease in 21 (23.4%) cases. Spongiotic dermatitis was the most common vesicobullous disease seen in 26 (28.9%) cases. Leprosy was the commonest microbial disease found in 7 (7.8%) cases. The commonest noninfectious erythematous papular and squamous disease was erythema dyschromicum perstans seen in 7 (7.8%) cases. The commonest neoplastic lesion was keratinocytic tumor seen in 12 (32.5%) cases. The commonest tumor of the skin was intradermal nevus seen in 6 (16.3%) cases. CONCLUSIONS: Spongiotic dermatitis is a predominating non-neoplastic and overall skin lesion which was similar to the other studies done. Histopathological examination is the gold standard for the proper diagnosis as histomorphological features distinguish various skin lesions.

Prevalence of different types of gallstone in the patients with cholelithiasis at Kathmandu Medical College, Nepal.

BACKGROUND: Gallstone disease known as cholelithiasis is the most common digestive surgical disorder and account for an important part of health care expenditure. Attempt was made to analyse the gallstone for typing depending upon the composition. AIMS & OBJECTIVES: The main objective of this study was to see the prevalence of different types of gallstone in Nepal and to correlate them with the clinical findings. MATERIALS & METHODS: Gallstones of 80 different patients who underwent cholecystectomy for cholelithiasis were collected from 20th January 2005 to 16th May 2006 in Department of Pathology, Kathmandu Medical College Teaching Hospital. Detailed history was taken. Stones were analyzed with chemical and enzymatic methods using clinical spectrophotometer. RESULTS & CONCLUSION: The most commonly involved age group for cholelithiasis (32.5%) is found to be 30-39 years with a female predominance (M: F=1:3.2). Cholelithiasis was found more commonly among non-vegetarian with the vegetarian: non-vegetarian ratio 1:9. Mixed type stone was found to be the most common type of stone comprising 78.75%, followed by cholesterol stone 12.5%, Brown pigment stone 7.5% and Black pigment stone 1.25%.