Pneumothorax, pneumomediastinum and subcutaneous emphysema as respiratory complications of COVID-19.

BACKGROUND: Pneumothorax, pneumomediastinum and subcutaneous emphysema are respiratory complications of Coronavirus disease 2019 occurring with noteworthy frequency in patients especially with severe disease. They can be life-threatening and often complicate patient managment. METHODS: This was a retrospective, observational study of patients admitted in Nepal Armed Police Force hospital from 13/05/2020 to 28/12/2021 diagnosed with pneumothorax, pneumomediastinum or subcutaneous emphysema singly or in combination. Data were collected from clinical charts, imaging records and electronic medical records of Severe Acute Respiratory Syndrome Coronavirus-type 2 positive patients 18 years and older. The frequency and type of the defined complications, the inflammatory markers and ventilatory parameters just prior to their diagnosis, the duration of hospitalization and ICU admission and in-hospital mortality rate were studied. RESULTS: Out of 4013 COVID-19 patients admitted in the hospital during the period, a total of 28 patients were observed to develop the complications, the overall incidence being 0.7% among hospitalized patients and 5.6% among ICU patients. The proportion of subcutaneous emphysema (64.3%) was highest followed by pneumomediastinum (46.4%) and then pneumothorax (39.3%) existing singly or in combination among the 28 patients, where four patients developed the complications spontaneously. Mean Positive End Expiratory Pressure of 12.1±2.6 cmH2O and Peak Inspiratory Pressure or Pressure Support of 30.9±10.3 cmH2O were observed for patients under positive pressure ventilation. Most of the patients who developed the complications (78.6%) died during treatment. CONCLUSIONS: Pulmonary air leak complications occur frequently in COVID-19 patients treated with or without positive pressure ventilation signifying increased disease severity, risk of ICU admission and high mortality rate. Hence, clinicians should be vigilant of these complications in all patients affected with COVID-19 and institute timely management.

Awake Prone Positioning In COVID Positive Patients: A Retrospective Study.

BACKGROUND: While the advanced health care settings are struggling hard to handle the sudden surge of COVID-19 cases, resource poor settings in developing countries like Nepal can barely stand to fight the increasing number of severe cases. Easily available cost effective interventions would be great blessing for such settings. This study aimed to study if awake prone positioning can be used as such intervention in COVID 19. METHODS: The retrospective study involved 150 patients admitted between November 2020 and January 2021 at Nepal Armed Police Force Hospital and met specific inclusion criteria. Data was obtained at four different time points in relation to prone position and was analysed using International Business Machines Statistical Package for the Social Sciences (SPSS) version 23. RESULTS: It was found that among 150 patients, majority (109; 72.7%) were males and 60(40%) had some comorbidities. The mean oxygen saturation was found to increase significantly from 87.18 %(SD 3.531) to 91.08(SD 2.206) after fifteen minutes of prone positioning. One way ANOVA test showed that there was significant difference in oxygen saturation between at least two time points. (F (3,596) = [180.005], p=0.000). Games Howell Post Hoc test for multiple comparisons showed that the mean value of SPO-2 was significantly different across all four time points, at significance level 0.05. CONCLUSIONS: This study found Awake Prone positioning as a promising cost effective and feasible intervention for improving oxygenation in COVID 19 and thus could be a blessing to the resource poor health care settings.

Sepsis among Adults Admitted to Intensive Care Unit of a Tertiary Care Centre.

Introduction: Sepsis is a syndrome that starts with an infection, causes organ dysfunction, and leads to death is a global health issue in critically ill patients. While its epidemiology is well-known in high-income countries, it is poorly understood in low- and middle-income countries, including Nepal. This study aimed to find out the prevalence of sepsis among adults admitted to the intensive care unit of a tertiary care centre. Methods: This descriptive cross-sectional study was conducted among adults admitted to the intensive care unit after obtaining ethical approval from the Ethical Review Board. Data was collected from 11 January 2022 and 29 December 2022 from hospital records. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Results: Among 195 patients, the prevalence of sepsis was seen in 74 (37.95%) (31.14-44.76, 95% Confidence Interval). Septic patients had a median age of 44 (interquartile range: 33.75±60.25) years. A total of 40 (54.05%) were male. A total of 28 (37.84%) septic patients were identified with ≥2 diagnoses, while 9 (12.16%) had ≥2 comorbidities. Conclusions: The prevalence of sepsis among adult patients admitted to the intensive care unit was higher as compared to other studies done in other international studies. Keywords: intensive care units; prevalence; sepsis.

Accounting for albedo change to identify climate-positive tree cover restoration.

Restoring tree cover changes albedo, which is the fraction of sunlight reflected from the Earth's surface. In most locations, these changes in albedo offset or even negate the carbon removal benefits with the latter leading to global warming. Previous efforts to quantify the global climate mitigation benefit of restoring tree cover have not accounted robustly for albedo given a lack of spatially explicit data. Here we produce maps that show that carbon-only estimates may be up to 81% too high. While dryland and boreal settings have especially severe albedo offsets, it is possible to find places that provide net-positive climate mitigation benefits in all biomes. We further find that on-the-ground projects are concentrated in these more climate-positive locations, but that the majority still face at least a 20% albedo offset. Thus, strategically deploying restoration of tree cover for maximum climate benefit requires accounting for albedo change and we provide the tools to do so.

Adipocyte dysfunction promotes lung inflammation and aberrant repair: a potential target of COPD.

Background: Obesity and chronic obstructive pulmonary disease (COPD) are prevailing worldwide, bringing a heavy medical burden. Clinical and pathophysiological relationship between obesity and COPD is paradoxical and elusive. We aim to explore their inherent associations from clinical, genetic, and animal levels. Methods: We performed literature review and cohort analysis of patients with COPD to compare lung function, symptom, and prognosis among different weight groups. After retrieving datasets of obesity and COPD in Gene Expression Omnibus (GEO) database, we carried out differentially expressed gene analysis, functional enrichment, protein-protein interactions network, and weighted gene co-expression network analysis. Then, we acquired paraffin-embedded lung tissues of fatty acid-binding protein 4-Cre-BMPR2fl/fl conditional knockout (CKO) mice that were characterized by adipocyte-specific knockout of bone morphogenetic protein receptor 2 (BMPR2) for staining and analysis. Results: Our cohort study reports the effect of obesity on COPD is inconsistent with previous clinical studies. Lung function of overweight group was statistically superior to that of other groups. We also found that the inflammatory factors were significantly increased hub genes, and cytokine-associated pathways were enriched in white adipose tissue of patients with obesity. Similarly, injury repair-associated genes and pathways were further enhanced in the small airways of patients with COPD. CKO mice spontaneously developed lung injury, emphysema, and pulmonary vascular remodeling, along with increased infiltration of macrophages. BMPR2-defiecient adipocytes had dysregulated expression of adipocytokines. Conclusion: Inflammation and abnormal repair might be potential mechanisms of the pathological association between obesity and COPD. BMPR2-associated adipocyte dysfunction promoted lung inflammation and aberrant repair, in which adipocytokines might play a role and thus could be a promising therapeutic target.

Extra-pulmonary Tuberculosis among Tuberculosis Patients Visiting a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Tuberculosis outside of the lung is extrapulmonary tuberculosis. The diagnosis of extrapulmonary tuberculosis is not easy in a community setting even in district hospitals. Clinical symptoms and radiological diagnosis are effective for the diagnosis of pulmonary and extra-pulmonary cases. The aim of the study is to find out the prevalence of extra-pulmonary tuberculosis among tuberculosis patients visiting a tertiary care centre. Methods: This was a descriptive cross-sectional study conducted among the patient visiting a tertiary care centre from August 2019 to January 2020 after taking ethical approval from Institutional Review Committe (Reference number: 86) which observed different clinicoradiological and laboratory features in patients with extrapulmonary tuberculosis to address their respective accuracy and usability in measuring the burden of tuberculosis. The interview was taken for the symptoms, and then radiological and laboratory data were collected. Convenience sampling was used. Point estimate and 95% confidence interval were calculated. Results: Out of 60 patients with tuberculosis, 39 (65%) (62.83-67.17, 95% Confidence Interval) were diagnosed with extrapulmonary tuberculosis. Among them, 30 (76.9%) were with pleural effusions followed by lymphadenopathy in 9 (23.07%). Conclusions: The prevalence of extra-pulmonary tuberculosis was found to be higher as compared to the study done in similar settings. Keywords: extrapulmonary; pulmonary; tuberculosis.

Dried rhododendron flower ingestion presenting with bradycardia and hypotension: a case report.

BACKGROUND: Rhododendron toxicity can be a life-threatening situation when manifested; it results in bradycardia and hypotension. Treatment remains challenging when it is complicated with refractory hypotension involving the multiorgan system if not treated early. CASE PRESENTATION: A 33-year-old Magar male presented with history of ingestion of two handfuls of white rhododendron flower. He had ingested the flowers believing that it would help relieve the pain and remove the materials stuck in his food pipe. Symptoms presented included muscular discomfort, dizziness, nausea, palpitation, tingling sensation around the face and lips, difficulty breathing, chest tightness, and difficulty swallowing within 4-5 hours after the ingestion of the dried flower. High-flow oxygen, intravenous fluids, atropine, and other supportive measures were used during the emergency, followed later by transfer to the intensive care unit for further observation. CONCLUSION: The patient was discharged with complete recovery after 2 days of hospital stay. Intentional or accidental ingestion of toxic plants can be severe or even life-threatening. Thus, clinicians should be familiar with local toxic plants with grayanotoxin action.

Humanitarian engineering at the sustainability-development nexus: mapping vulnerability and capability factors for communities at risk of water-based disasters.

Access to resources that is equitable and sustainable provides a critical foundation for community harmony and development. Both natural and human-induced disasters present major risks to sustainable development trajectories and require strategic management within regional and local plans. Climate change and its impacts, including intensified storms, flash floods, and other water-based disasters (WD), also pose a serious and increasing threat. Small, remote communities prone to weather extremes are particularly vulnerable as they often lack effective early warning systems and experience energy insufficiency. Humanitarian engineering provides a transdisciplinary approach to these issues, supporting practical development resources such as renewable energy, which can also be adapted for disaster response. This study details an exploratory investigation of community vulnerability and capability mapping (VCM) that identifies communities with high WD risk and limited response capability which may benefit from risk reduction engagement and program co-development. By presenting criteria appropriate for VCM, we highlight the anthropocentric characteristics that could potentially be incorporated within community-led action as part of a comprehensive scheme that promotes sustainable development.

Prevalence of Psychological Effect of COVID-19 on Medical Professionals in a Tertiary Care Center.

INTRODUCTION: COVID-19 is a pandemic disease first detected in Wuhan, China on last December 2019. Many doctors and nurses, were infected and lost their life by COVID-19 around the world. Therefore COVID-19 brought unbearable psychological pressure on doctors, and nurses. The objective of this study is to find the prevalence of anxiety among medical doctors and nurses. METHODS: This is a descriptive cross-sectional study of 101 doctors and nurses carried out in a tertiary care center. Convenience sampling was done with the study period from April to May 2020. Ethical approval was taken from the institutional review board of NAMS (IRB reference no. 1076). The collected data stored and analyzed with statistical software (SPSS version 26.0). Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: Out of 101 participants prevalence of anxiety was found to be 74 (73.3%) (64.68-81.33 at 95% Confidence Interval). Among them, 9 (8.9%) of participants experienced sever types of generalized anxiety disorder, 23 (22.8%) moderate, and 42 (41.6%) mild type. Similarly, 18 (17.8%) and 10 (9.9%) of participants felt very difficult and extreme difficulty at the workplace and home respectively. CONCLUSIONS: The mental health of medical doctors and nurses is significantly affected during the COVID-19 pandemic. Hospital administration should conduct psychological preparedness training to the medical profession before posting on duty to provide quality health services to the patients.

The Evaluation of Thyromental Height Test as a Single, Accurate Predictor of Difficult Laryngoscopy.

BACKGROUND: Thyromental Height Test is a relatively new, easy method considered as a more accurate predictor of difficult laryngoscopy than existing methods. The aim of this study was to evaluate its accuracy in predicting difficult laryngoscopy as compared to commonly used methods. METHODS: This hospital based, cross-sectional, observational study was conducted on 246 patients scheduled for surgery under general anesthesia with endotracheal intubation. Airway assessment was done during pre-anesthetic assessment by Thyromental Height Test, Modified Mallampati Test, Thyromental Distance and Sternomental Distance measurements and predicted as 'difficult' or 'easy' laryngoscopy based on accepted cut-off values. Direct laryngoscopic view was assessed after administration of general anesthesia by a laryngoscopist unaware of the pre-anesthetic assessments and recorded as 'actual' difficult or easy laryngoscopy based on Cormack-Lehane grades. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of each clinical test were determined. RESULTS: Thyromental Height Test had the highest sensitivity (71.42%) and negative predictive value (98.9% respectively) but lowest accuracy (77.2%). Maximum specificity was observed with Thyromental Distance and Sternomental Distance (97.49% each). Thyromental Distance had the highest positive predictive value (25%) and accuracy (95.52%). CONCLUSIONS: Thyromental Height Test, with its high sensitivity, is a useful predictor of difficult laryngoscopy. However, due a high number of false positives and relatively low accuracy, it cannot be considered as a sole, reliable and accurate predictor of difficult laryngoscopy.

Tuberculosis in Staff and Students of Patan Hospital.

BACKGROUND: There is a high risk of occupational exposure to tuberculosis among healthcare workers in endemic countries. Regular screening for tuberculosis among healthcare workers is not carried out in Nepal. Infection control measures are also not routinely implemented. The aim of this study was to determine the prevalence of active tuberculosis among staff/students at Patan Hospital. METHODS: Participants were given a self-administered questionnaire and invited to undergo chest radiography. Cases were scored and reviewed based on predetermined criteria, and presumptive tuberculosis cases were invited to undergo sputum smear and culture. Participants were categorized according to the extent of patient contact and asked about history of tuberculosis medication. RESULTS: Among 560 participants, 76.8% had direct contact with patients. Fifty-eight (10.4%) gave history of cough >2 weeks. Based on symptom history and chest radiography, 20.0% (n=112) cases were reviewed, and 12.5% (n=14) of those reviewed had sputum tested for acid-fast bacilli. One participant had culture-positive tuberculosis. Fifty participants (8.9%) reported tuberculosis in the past, among which 42.0% (n=21) occurred after employment at Patan Hospital and 42.0% before joining Patan Hospital. Security staff, radiology technicians and ward cleaning staff had the highest proportion of cases with a history of tuberculosis.History of tuberculosis medication had no relation with age, sex, education, body mass index and smoking.The incidence rate of tuberculosis at Patan Hospital was 3.6 per 1000 person-years. CONCLUSIONS: Overall incidence of tuberculosis among healthcare workers is noteworthy. However, this study suggests when symptomatic tuberculosis occurs in healthcare worker at Patan Hospital, it is diagnosed and there is not a large pool of undiagnosed tuberculosis.

Human papilloma virus vaccination in Nepal: an initial experience in Nepal.

Cervical cancer is the most common cancer among women in Nepal. Human papilloma virus (HPV) infection, a recognized cause of cervical cancer, is very common in sexually active women and HPV vaccination has been recommended as a prophylactic therapy. If HPV infection is prevented by the HPV vaccination to the adolescent girls, cervical cancer is also prevented. We received 3,300 vials of quadrivalent human papilloma virus (types 6, 11, 16, 18) recombinant vaccine (Gardasil; Merck and Co.) as a gift from the Australian Cervical Cancer Foundation (ACCF) which has a mission to provide life-saving HPV cervical cancer vaccines for women in developing countries, who cannot otherwise afford vaccination. HPV vaccine was offered to 1,096 of 10 to 26 year aged girls attending 17 secondary schools. In total, 1,091 (99.5%) received the second dose and 1,089 (99.3%) received the third dose of the vaccine. The remaining 5 girls at second dose and 2 girls at third dose remained unvaccinated. No serious vaccine related adverse events were reported except mild pain at the injection site in 7.8% of the vaccine recipients. High cost and low public awareness are the key barriers for successful implementation of the vaccination program in resource limited developing countries. In conclusion, HPV vaccine is safe with high acceptability in Nepalese school girls. However a large population study for longer follow up is warranted to validate the findings of this vaccination program.