Ocular Survey in Kathmandu University Medical Students.

Background Medical students spend long time in academic activities that increases the risk of developing refractive errors and dry eyes that can affect their learning and social abilities. Only a few studies are available regarding ocular problems and its contribution to visual impairment among medical students in Nepal. Objective To evaluate the ocular problems among the medical students in a University hospital. Method An observational, descriptive, cross-sectional study was conducted among five batches undergraduate medical students until 2022 of Kathmandu University School of Medical Sciences, Dhulikhel, Kavre. A self-administered questionnaire was used to obtain demographic data and information on visual problems followed by a detailed ocular examination that included refraction, color vision and Schirmer test. Result Total of 284 medical students (with 568 eyes) with mean age of 22.8 years, 179 males and 105 females were enrolled. Among them, 270 (47.5%) eyes were emmetropic. Simple Myopia was the commonest followed by Compound Myopic Astigmatism. The mean spherical equivalent in right and left eye were -0.914 ± 1.54 and -0.886 ± 1.53 respectively. Approximately 18% students had some form of dry eye. Nineteen students (6.7%) had color vision deficiency and 13 (4.6%) had deuteranomalia, 3(1.1%) had deuteranopia and 3(1.1%) had protanomalia. Conclusion Eye defects, like refractive errors, dry eyes and color blindness, are common among medical students. They need to be advised for frequent eye check up in order to diagnose eye defects timely and arrest visual impairment at early stage.

Nitrobenzene Induced Methemoglobinemia with Paroxysmal Atrial Fibrillation Treated with Single Volume Exchange Transfusions.

Methemoglobinemia is a potentially fatal condition if left untreated. Conventional treatment of nitrobenzene induced methemoglobinemia dictates the use of methylene blue, which is the antidote of choice. However, its availability in our setting is limited only to the laboratory use. We present a case of a 21-year-old female with intentional ingestion of nitrobenzene. Clinical history and supportive investigations revealed methemoglobinemia and it was successfully managed with single volume exchange transfusions in absence of specific antidote. While exchange transfusions are indicated for severe cases, it may be useful as an alternative treatment in acute life-threatening conditions where methylene blue is not available.

Demographics and Awareness of Diabetic Retinopathy among Diabetic Patients Attending Department of Ophthalmology at Dhulikhel Hospital.

Background Diabetes mellitus is considered as a major public health concern globally. Poor management of diabetes may lead to several serious complications including endstage renal disease, diabetic retinopathy, diabetic neuropathy, and cardiovascular complications. Among them diabetic retinopathy is one of the leading causes of visual impairment and blindness in Nepal. Objective To assess the demographics and level of awareness among individuals with diabetes about diabetic retinopathy during their visit to Department of Ophthalmology at Dhulikhel Hospital. Method A descriptive cross-sectional study was conducted involving all consecutive cases of diabetes mellitus who attended eye clinic with the principal investigator and co-investigator from March 2021 to August 2021. Detailed demographics of the participants, their level of awareness regarding diabetic retinopathy and associated complications were documented. This was followed by a detailed ocular examination intending to screen for the presence of features of diabetic retinopathy. Result A total of 260 patients with a mean age of 54 years ± 12.20 (range of 24 - 85 years) were included. The male to female ratio was 2.2:1. Among them, 65.4% of the patients had diabetes mellitus for less than 5 years duration. Diabetic retinopathy was found in 18.46% of the cases. Awareness of diabetic ocular complications was significantly higher among literate population (p = 0.054), among those who have positive family history of diabetes mellitus (p = 0.529) and those who had undergone prior fundus evaluation (p = 0.000). Conclusion From result of this study, we can emphasize that there is a necessity for health education in order to increase the awareness and knowledge about diabetic retinopathy to lower the burden of sight threatening complications related with the issue.

Clinical Characteristics of Cataract Patients and Outcome of Cataract Surgery in Tertiary Care Hospital in Central Nepal.

Background Cataract remains the leading cause of avoidable blindness in low-income countries such as Nepal. Despite the availability of surgical interventions for cataract in leading institutions, still a large number of patients from remote areas delay or have difficulty in getting treatment, present late or with complications. Objective To determine the clinical characteristics and visual outcome of patients undergoing cataract surgery in Tertiary Care Hospital in Central Nepal. Method We retrospectively reviewed the medical records of 138 patients who underwent cataract surgery at a tertiary care hospital from January 2018 to September 2022. R version 4.0.3 was used for the data analysis. Categorical variables are presented as frequency (percentages) and the numerical ones are presented as mean (standard deviation). Result During follow-up visits between one to three weeks, 91.9% out of 135 patients had normal/near normal presenting visual acuity and with best correction it was 96.9% out of 131 patients. About 1.6% out of 124 operated eyes still had moderate visual impairment after best correction when they visited for follow-up at 12 weeks. Conclusion The study findings underline the ongoing gap in increasing access to cataract treatment, given the large proportion of individuals who still presented extremely late.

Retinal Haemorrhage in Newborns in Tertiary Care Hospital.

Background Retinal haemorrhage in new-born is a clinically common neonatal fundus condition. Although, it usually does not affect the development of visual function, entities like macular haemorrhages may lead to amblyopia causing deterioration of visual function. Such scenario leads to downgrade in quality of life of the affected child. Objective To explore the underlying clinical factors associated with retinal haemorrhage in term new-borns. Method A cross sectional study was conducted involving 136 term neonates admitted in the neonatal intensive care unit of Dhulikhel Hospital. Fundus examination was performed within 2 weeks of delivery. Retinal haemorrhage was graded according to their location in three retinal zones. Result Out of 136 cases examined, 44 (32.35%) of the cases had one of the eyes with retinal haemorrhage. Where grade 1 retinal haemorrhage was accounted in majority of the cases. Birth weight, gestational age, mode of delivery, poor Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) Score in 1 and 5 minutes, birth asphyxia, neonatal sepsis and heavy work in antenatal period had statistically significant correlation with occurrence of retinal haemorrhage. Conclusion Our results suggest that spontaneous vaginal delivery, larger birth weight, higher gestational age, birth asphyxia, low Appearance, Pulse, Grimace, Activity, and Respiration score, are risk factors for occurrence of neonatal retinal haemorrhage. It is recommended that in neonates with above high-risk factors should undergo targeted fundus screening for early identification and needful interventions.

Awareness and Knowledge of Glaucoma and their Associated Factors among People Visiting a Tertiary Level Hospital in Central Nepal.

Background Glaucoma is one of the major causes of irreversible blindness globally. Almost 60 million people globally are affected by glaucoma making it the second leading cause of blindness worldwide. Diagnosis of glaucoma early on is vital for timely management and prevention of blindness. However, it is challenging to diagnose it early because it is asymptomatic in the initial stage, and there is also the dearth of appropriate screening tools. Awareness, knowledge, and beliefs are believed to influence the treatment-seeking behavior of people as well as their uptake of services. Objective To assess the awareness and knowledge about glaucoma among general patients and patient attendants visiting Dhulikhel Hospital. Method We conducted a cross sectional quantitative study among general patients visiting Dhulikhel Hospital. We collected data using face-to-face interviews with semistructured questionnaires. We analyzed data in R version 4.0.3 (2020-10-10). We presented numerical variables as mean and standard deviation whereas categorical variables as frequency and percentage. We determined factors associated with awareness and knowledge of glaucoma using logistic regression analysis and estimated adjusted odds ratio (AOR) with 95% confidence interval. Result Of 379 participants, a total of 214 (56.5%) participants had heard about glaucoma. Out of the participants who heard about glaucoma, the mean knowledge score was 48.3±21.7 and 53.3% had good knowledge on glaucoma. The odds of having heard about glaucoma were two percent lower (AOR=0.98; 95%CI: 0.97-0.99; p-value 0.036) in the older participants compared to one year younger participant, 1.98 (95%CI:1.01-3.86; p-value 0.046) times higher among literates and 2.79 (95%CI: 1.76- 4.41; p-value < 0.001) times among participants with previous ocular examination. The odds of having good knowledge was 1.94 (95%CI: 1.10-3.42; p value 0.021) times among participants with previous ocular examinations. Conclusion The knowledge and awareness regarding glaucoma in a hospital-visiting population in central Nepal was low. Half of the participants were unaware of the disease glaucoma and half of the participants who heard of the glaucoma had poor knowledge on glaucoma.

Awareness and Knowledge of Glaucoma and their Associated Factors among Staffs in a Tertiary-level Hospital in Central Nepal.

Background Since glaucoma-related blindness may only be prevented with early identification and treatment, finding asymptomatic individuals in the target population is critical. It is thus important to determine the awareness and knowledge on glaucoma. Objective To determine the knowledge and awareness on glaucoma among the staff of a tertiary level hospital in central Nepal. Method This was a cross sectional study among the staffs of Dhulikhel Hospital who participated voluntarily in the study. The data was collected through the administration of semi-structured questionnaires. R version 4.0.3 (2020-10-10) was used for the data analysis. Categorical variables are presented as frequency (percentages) and the numerical ones are presented as mean (standard deviation). Adjusted odds ratio (AOR) with 95% confidence interval were estimated through logistic regression analysis for determining factors associated with awareness and knowledge of glaucoma. Result A total of 107 (89.2%) participants had heard about glaucoma of which 93 (86.9%) had good knowledge and 14(13.1%) had poor knowledge on glaucoma. The mean score of knowledge was 64.1±16.9. Only 47.7% of the participants said that glaucoma also has an asymptomatic course. We could not find an association of awareness and knowledge of glaucoma with any of the selected sociodemographic variables. Conclusion Although there was a fairly good glaucoma related awareness and knowledge among hospital staff, we found lack of understanding on some critical issues on glaucoma, mainly related to its asymptomatic nature. There is thus room for improvement in educating about glaucoma even in healthcare settings. Given the necessity of expanding glaucoma awareness in the public, hospital staff might potentially serve as messengers to the communities.

Rickettsial Infection amongst Febrile Illness Patient in a Tertiary Care Hospital: A Retrospective Cross-sectional Study.

Background Rickettsial infection is an emerging neglected tropical disease in the Southeast Asia. In past few years Nepal is also reporting escalating prevalence of rickettsia. The under evaluation is resulting it as undiagnosed or are simply labeled as pyrexia of unknown origin. Objective To find out the prevalence of rickettsia in a hospital setting, assess the sociodemographic and other relevant clinical features of the rickettsia patients. Method This is a hospital based retrospective cross-sectional study from October 2020 to October 2021. This study reviewed the medical records of the department. Result The study included 105 eligible patients and the prevalence rate was 4.38 per 100 patients. The mean age of the participants was 42 years, and the mean hospital stay was 3 (SD ±2.06) days. More than 55% of the participants had fever for less than or equal to 5 days and 9% had Eschar present. Vomiting, headache, and myalgia were the most common symptoms and hypertension, and diabetes were the common comorbidities. Pneumonia and the acute kidney injury were the two complications of the patients as stated in the study. The severity of the thrombocytopenia deducted from admission time to discharge, and the case fatality was 4%. Conclusion The future studies shall consider on collaborative clinical and entomological research. This would help in better understanding of the etiology of supposedly unknown febrile illness and the under-investigated field of emerging rickettsia in Nepal.

Correlation between Invasive Intracranial Pressure Monitoring and Optic Nerve Sheath Diameter in Patients with Traumatic Brain Injury.

Background In management of patients with traumatic brain injury, intracranial pressure holds an important place. Any untoward rise in intracranial pressure portends dreaded complications. Hence, any delay in detecting the issue is considered unacceptable. Objective This study focuses on analyzing the correlation between ultrasound derived optic nerve sheath diameter and intracranial pressure values derived from invasive intracranial pressure monitoring system in a neurosurgical patient with severe traumatic brain injury. Method A prospective observational study was performed using a convenience sample technique including all adult patients with traumatic brain injury who had invasive intracranial monitors placed as part of their clinical care. Ocular ultrasound was performed with 5 - 7.5 MHz linear probe of ACUSON X300 ultrasound system while simultaneous intracranial pressure readings were obtained directly from an invasive intracranial pressure monitoring system. The association between optic nerve sheath diameter and invasive intracranial pressure reading was assessed with the Pearson's correlation coefficient and a receiver operator characteristic curve was created to determine the optimal optic nerve sheath diameter cutoff to detect intracranial pressure > 15 cm H2O. Result One hundred and fifteen ocular ultrasounds were performed on 30 individual patients. The mean age of the population involved in this study is 42.13 years ± 1.89 with male preponderance in the ratio of 6:1. Pearson's correlation coefficient of optic nerve sheath diameter and intracranial pressure was found to be 0.844 (p < 0.000) demonstrating a significant positive correlation. The area under the receiver operating characteristic curve was found to be 0.961 (95% confidence interval = 0.93 to 0.99). Based on analysis of the receiver operating characteristic curve, optic nerve sheath diameter > 4.85 mm performed best to detect intracranial pressure > 15 cm H2 O with a sensitivity of 93.5% and specificity of 83%. Conclusion Optic nerve sheath diameter is a dependable screening tool to evaluate for elevated intracranial pressure among patients with traumatic nerve injury.

Clinical Dilemma of Diabetic Ketoacidosis and COVID-19 Infection.

The COVID-19 Pneumonia with diabetic ketoacidosis is a dreadful health condition. Diabetic ketoacidosis is one of the severe metabolic complications and it can be precipitated by infection. We presented a case of 48 years female with no known comorbidities who presented with COVID-19 symptoms and with Diabetic Ketoacidosis. The case presented with elevated inflammatory markers, high anion gap metabolic acidosis with type I respiratory failure. During admission, the oxygen saturation had marked drop, later her improvement was steady followed by gradual tapering of the oxygenation. Marked improvement was noticed in the subsequent follow-up. COVID-19 infection can be precipitated by preexisting diabetes or newly diagnosed diabetes and the severity of COVID-19 infection is more pronounced in patients with diabetes mellitus, thus should be managed timely and accordingly. The scarce studies among the COVID-19 cases with diabetic ketoacidosis reflect the need for further studies for the availability of a wider range of information.

Knowledge, Attitude and Practice towards COVID-19 among Private School Teachers of Chitwan, Nepal.

Background The coronavirus disease (COVID-19) pandemic has brought life to a standstill across the world, with nearly 178 countries reporting school closures. As the schools have started reopening slowly, precautions are utmost necessary to prevent the potential spread of COVID-19 in school and community settings. Objective To assess knowledge, attitude and practice towards COVID-19 among private school teachers. Method A web based cross-sectional analytical study design was undertaken. Currently working private school teachers of Chitwan District were included as a unit of analysis. The snowball sampling technique was employed to identify the eligible participant. Collected data was entered in SPSS version 20 and analyzed using the Chi-square test, Pearson correlation, and binary logistic regression. Result Of 344 participants, the majority were male (52.9%), most of the participants were from age group 26-30 years (38.4%). Regarding knowledge, attitude and practice, 57% had good knowledge, 53.2% had favorable attitude and 51.7% had good practice towards COVID-19. Logistic regression analysis demonstrated gender (OR 0.475, 95% CI: 0.256-0.818) and COVID-19 training (OR 25.687, 95% CI 5.354-123.226) were significant with good knowledge. Conclusion Knowledge about COVID-19 among private schools teacher was good, attitudes have been mostly favorable, and the practices were mostly adequate. However, good knowledge is not the only factor for better attitude and good practices. It is necessary to implement massive education campaigns, trainings and information via school authorities and health authorities by developing and adopting appropriate guidelines on COVID-19.

Laparoscopic Surgeries in Urology: Initial Burgeoning Experience at National Transplant Centre, Nepal.

Background This study focuses on experience of laparoscopic surgery at Shahid Dharma Bhakta National Transplant Centre (SDNTC), Nepal; which could enable us to gain knowledge regarding its benefits over conventional surgery. The present study revealed the frequency of various forms of laparoscopic surgeries done at our centre. Moreover, this study accomplishes laparoscopic donor nephrectomy "a historical milestone achieved in Nepal for kidney transplantation on 18th November 2018" which was the first Laparoscopic donor nephrectomy done in Nepal by Nepalese team. Objective The present study assesses the feasibility and safety of laparoscopic surgery at government hospital of Nepal. Method This hospital based cross-sectional study included all patients of age group 10 to 60 years, coming to outpatient department of SDNTC and those having indications for nephrectomy. We excluded patient having previous history of open surgeries of kidney, bleeding disorders, uncontrolled Diabetes Mellitus and uncontrolled Hypertension. The study duration was 15 months from November 2017 to January 2019. The total number of patients enrolled in the study was fifty where transperitoneal laparoscopic surgery was performed in all 50 patients. The demographic data, indications for surgery, duration of surgery, complications of surgery and perioperative outcomes were analyzed. Result Out of 50 cases, 34 (68%) underwent simple lap nephrectomy, 6 (12%) were lap pyeloplasty, 6 (12%) lap nephrectomy along with ureterectomy of long segment of diseased ureter, 1 (2%) lap radical nephrectomy, 1 (2%) lap donor nephrectomy for kidney transplantation, 1 (2%) lap heminephrectomy and 1 (2%) lap nephrectomy for hydronephrotic non functioning left crossed ectopia. Amongst all nephrectomies, 27 (54%) patients were operated on right side while 23 (46%) patients on left. The median age of the patient was 38.56 years. Out of total cases 32 (64%) were male and 18 (36%) female. The median operative time and hospital stay was 122.3 minutes and 5 days respectively. The median estimated blood loss was 74.1 cc. Only one patient required blood transfusion intra-operatively. 2 (4%) patients were converted to open surgery. Conclusion Laparoscopic surgery is feasible and safe procedure in government setup hospital with less cumbersome procedure and minimum complications associated with it.

Comparison between Simple and Classical Techniques to Create Closed Pneumoperitoneum.

Background Closed method of pneumoperitoneum using Veress needle is an established technique. Classical closed technique is popular. Simple technique is a modified closed technique. Objective To compare the classical and simple techniques of closed pneumoperitoneum. Method This study was conducted in the department of urology, Bir hospital from August 1st 2019 to March 30th 2021. Total 114 patients were randomized into simple and classical technique of creating closed pneumoperitoneum. Time taken for creation of pneumoperitoneum, complications and failure of creating pneumoperitoneum in each group noted and analyzed. Chi square test, Fischer exact test and student t test were used and p < 0.05 considered significant. Result Among 114 patients, 61 in simple and 53 in classical technique allocated. In simple technique, mean age was 42.98±18.21 years, BMI was 21.84±2.57 kg/m2 , mean time for pneumoperitoneum creation was 108.07±21.14 seconds. In classical technique, mean age was 40.15±17.58 years, BMI was 21.94±2.54 (kg/m2 ), mean time for pneumoperitoneum creation was 189.70±32.21 seconds. Mean time was less in simple technique than classical technique (p < 0.001). Complication rate observed was 6% in each technique (p=0.797) with cumulative rate of 10%. Omental injury was seen in 3.2% in simple technique and 5.6% in classical technique (p=0.662). Retroperitoneal insufflation was seen in 6.5% in simple technique and 5.6% in classical technique (p=0.842). No failed pneumoperitoneum was observed in both groups. Conclusion Simple technique is as effective, reproducible and safe method as classical technique of creating closed pneumoperitoneum.

Prevalence of Refractive Error and Ocular Pathologies among School Children: Finding from the School Eye Program of Dhulikhel Hospital.

Background Childhood blindness and visual impairments could lead to the onset of blindness among children and adolescents. New cases appear particularly between the ages of 6-15 years and if uncorrected, runs a risk of developing Amblyopia, strabismus. There exists a mounting need to strengthen and modify established school eye health programs in Nepal as per the local needs and conditions. Objective To determine the prevalence of refractive error and ocular pathologies among school children in rural Nepal. Method This cross-sectional study was conducted in nine schools of Kavrepalanchowk and Bhaktapur district with 953 students screened from December 2018 to February 2020. The team of optometrist, ophthalmic assistants and ophthalmologist applied a standard protocol for screening of refractive error as a part of the school eye program of Dhulikhel Hospital. Other standard eye examinations were performed to note the ocular pathologies. The association of socio-demographic factors of students having refractive errors with that in emmetropes was identified using logistic regression analysis. Result A total of 953 students were screened in nine study sites, age ranged from 5-19 years. There were 183 students (19.2%) with refractive errors. Blurred vision was the common complaint reported by 2.5% of students. Multivariate logistic regression analysis showed higher age group children (aOR=2.93; 95% CI: 1.62-5.29; P=0.01) and urban area children (aOR=4.37; 95% CI: 0.87-21.98; P=0.07) to have higher odds of refractive error. Conclusion Refractive error is the major eye problem among school children. Despite its high prevalence, there is still a major gap in timely diagnosis and treatment. Regular vision screening and timely treatment is required for better addressing refractive error among school-going children.

Digital Subtraction Angiography a Door Opener for Neurosurgical Residents who want to Perform Neurointerventional Procedures.

Digital subtraction angiography (DSA) has been a fluoroscopic golden investigative tool to know the vascular angiography of the brain and spinal cord. The technique in performing this procedure exposes residents in accessing the major vessels, branches of the arch of aorta, selective angiography and diagnosing different vascular anomalies of brain and spine. They are also exposed to the knowledge of different diagnostic catheters, its manipulation, use of dye and radiation exposure and safety. We would like to share our experience in training and disseminating the knowledge of digital subtraction angiography to the residents.

Lipid metabolic differences in cows producing small or large milk fat globules: Fatty acid origin and degree of saturation.

This study compared cows that consistently produce milk with small (volume-weighted mean diameter of 2.92-3.83 µm, with an average diameter of 3.29 µm) or large (volume-weighted mean diameter of 4.58-5.67 µm, with an average diameter of 4.92 µm) milk fat globule (MFG) size distributions in terms of the fatty acid (FA) composition of the MFG core. Selected cows fell into the respective size group over at least 3 independent measurements, including an observation period before the experiment. Further selection criteria were similar milk production traits between cows (milk yield, fat yield, fat/protein ratio) and established lactation (>50 d in milk). However, the selected groups differed in parity (parity 1-3 and 3-5 in the small and large MFG groups, respectively), and the small MFG group was an average of 25 d in milk later in their lactation period. All cows were under the same nutritional management and environmental conditions. Here, we show that cows with the small or large MFG phenotype differed in their lipid metabolism in terms of the FA composition of the MFG core. Our results indicate that cows with the small MFG phenotype produced milk with higher concentrations of unsaturated FA despite being fed the same diet. We suggest that this characteristic of the small MFG phenotype is the result of increased uptake of long-chain FA from the blood circulation. A relationship between the degree of unsaturation and MFG size was also identified in preliminary studies across other species-namely, camels, sheep, and goats. These findings show the potential for on-farm selection of cows (and potentially other dairy species) based on MFG size to produce milk with improved nutrient composition. This could lead to purpose-specific separation of milk based on MFG size and FA profile, both known to alter the technological properties of milk.

Endoscopic Management of Foreign Body Impaction in the Upper Gastrointestinal Tract in a Tertiary Care Centre of Nepal.

Background Ingested foreign body impaction on upper gastrointestinal tract is common incidence among children, older age group, mentally challenged individuals, and people the influence of alcohol. In most cases, the foreign bodies pass spontaneously and uneventfully but when this does not occur; endoscopic management to ensure removal under direct visualization is required. Relief upon removal of foreign body and prevention of complications is essential. Objective To assess the endoscopic management and outcome of foreign body impacted in the upper gastrointestinal tract. Method This is a hospital based observational retrospective cross sectional study involving 165 patients at Endoscopy Department of Dhulikhel Hospital in Nepal between November 2015 and October 2019. The data regarding the demographic profile, clinical characteristics and endoscopic findings were retrieved and analyzed to determine endoscopic interventions performed, complications and outcomes. Result One hundred and sixty five patients presenting with history of ingestion of foreign body were included in the study. The mean age of the patients was 46.8 ± 19.1 years with male predominance (60%). The most common site of foreign body impaction was oesophagus (70%). The most common foreign body encountered was bone (62.2%) among which chicken bones (91.1%) were most frequent. For the retrieval of sharp-pointed foreign bodies, rat forceps and graspers (45.7%) were most commonly used. Total 14 cases required rigid oesophagoscopy as the foreign body could not be retrieved by flexible endoscopy. Conclusion Foreign body ingestion and its impaction in the upper gastrointestinal tract has been found to be common in endoscopic practise. Early detection and timely removal of foreign bodies is of utmost importance to avoid discomfort to the patient as well as to ensure successful removal without complications.

Recovery Pattern in Different Surgical Approaches on Thoracic Enhanced Recovery based Fourteen-Step Protocol in Patients Undergoing Cardio-thoracic Surgery at University Hospital of Nepal.

Background Cardio-thoracic surgery involves open and minimally invasive techniques. Enhanced recovery after surgery is used for early recovery from surgery. Enhanced recovery after surgery decreases hospital stay duration. Patients undergoing Enhanced recovery after surgery after video assisted thoracic surgery use less pain killers and have less hospital cost. There has not been any study on outcomes on patient who follow physiotherapy protocol designed in our setting. Objective To find the physiotherapy outcomes in patients undergoing thoracic enhanced recovery after surgery (T-ERAS) based 14 step protocol locally designed at Dhulikhel Hospital, Kathmandu University Hospital (DH, KUH). Method This is a retrospective cross sectional observational study. All the cases who underwent cardiothoracic surgery were classified based on the approach of chest surgery performed into groups Sternotomy, Thoracotomy and Video Assisted Thoracic Surgery (VATS) groups. Patients were advised for Thoracic Enhanced recovery after surgery based on the protocol that has been devised at Dhulikhel Hospital. The recovery of patients based on activities they could perform was noted and analyzed. Result Both ICU stay and hospital stay in number of days were highest in thoracotomy (6.04 days) group while that was lowest in video assisted thoracic surgery group (1.67 days). There is a similar recovery until step 5, i.e. 2 days and rapid progression in further steps in video assisted thoracic surgery group while it is much slower in both sternotomy and thoracotomy groups. Conclusion Postoperative mobilization and physiotherapy enhance early healing and decrease hospital stay. Mean hospital stay and ICU stay were shorter for video assisted thoracic surgery cases compared to Thoracotomy and Sternotomy groups and the mean days to achieve different steps varied within the protocol between groups compared.

First Reported Death of a Postpartum Woman Due to Coronavirus Disease 2019 in Nepal: A Lesson Learnt.

The first case of coronavirus disease 2019 was reported on December 31, 2019 in Wuhan, China where the average case fatality rate was 6.1 ± 2.9%. There are 453 deaths as of September 24, 2020 in Nepal. We report the first death of a 29-years-old postpartum woman due to COVID-19 in Nepal who was referred from a rural health center to Dhulikhel Hospital. On arrival, she was taken to the acute respiratory zone of the emergency department to provide immediate lifesaving procedures. Despite the repeated resuscitative measures, return of spontaneous circulation could not be achieved. The real time polymerase chain reaction test was positive. Our case report highlights the importance of early clinical suspicion, importance of "safety first" in healthcare settings, and the chain of management in such patients. We consider the fact that a postpartum woman registered as the first case of COVID-19 related death in Nepal to be an area of further study.

Indications of Fetal Echocardiography and Detection of Congenital Heart Disease Prenatally in Tertiary Care Hospital.

Background Congenital Heart Diseases are common childhood congenital anomalies encountered in developed and developing countries. Due to the improved prenatal diagnostic modalities, the diagnosis of cardiac disease is increasing in newborns. Fetal echocardiography is considered a good and accurate diagnostic method for congenital heart disease. Objective To study the common indications of fetal echocardiography and the detection of congenital heart disease in Dhulikhel Hospital, Kathmandu University Hospital. Method In this hospital-based, retrospective study, we reviewed medical records of 324 fetuses who were indicated for fetal echocardiography at Dhulikhel Hospital over 24 months period of time (September 1, 2017 to August 31, 2019). Result The mean age of pregnant women at presentation for fetal echocardiography was 30.7 ± 4.7 years. The mean gestational age at diagnosis was 28.9 ± 4.9 weeks. Among all the pregnant women, 208 (65%) presented during the second trimester and 112 (35%) presented during the third trimester. Maternal indications for fetal echocardiography were seen in48.12% cases, whereas fetal indications were seen in 42.81% cases. The most common indication was for maternal gestational diabetes (30.31%). Among the 324fetal echocardiography results, 65.43% cases had normal findings, echogenic intra-cardiac foci were seen in 18.82% and significant abnormal findings were seen in 15.74% of cases. Among all women having maternal indication for echocardiography, 34 (22.07%) fetus had some form of abnormal findings, whereas only 17 (12.40%) fetus with fetal indication showed abnormal findings (p < 0.05). Conclusion Indication of fetal echocardiography is increasing and can be a good diagnostic tool to improve prognosis and outcome of a newborn. It has become widely used in pediatric cardiology. Raising awareness is necessary regarding the importance of fetal echocardiography in the management and outcome of a newborn with cardiac anomalies.