Generalized tetanus in an elderly patient: A case report.

Introduction and importance: Tetanus is a rare disease caused by Clostridium tetani causing painful muscle spasms and respiratory failure. Case Presentation: A patient from a rural part of the country presented with a nonhealing and increasingly painful penetrating wound. The patient had a purulent wound and later developed risus sardonicus and muscle spasms of tetanus and his blood culture grew the bacteria. His condition was later complicated by respiratory failure, sepsis, and multiorgan failure. He was managed in the ICU with Intravenous antibiotics, respiratory support with endotracheal Intubation and mechanical ventilation, Intravenous Immunoglobin, and multiple organ support. The patient was taken off the ICU by the family for financial reasons and ultimately succumbed to the illness. Clinical Discussion: Tetanus, is a rare vaccine-preventable illness that is underreported. Spasms control and organ support is still the mainstay of treatment. Conclusion: Strict clinical vigilance is important for the early diagnosis and management of tetanus.

Alcoholic Liver Disease among Patients Admitted to the Department of Internal Medicine of a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Alcoholic liver diseases comprise a spectrum of liver diseases including fatty liver, alcoholic hepatitis, and cirrhosis. Diagnosis at advanced stages is frequent for this condition and data regarding the prevalence of such patients at early stages are limited. The aim of this study is to find out the prevalence of alcoholic liver disease among patients admitted to the Department of Internal Medicine of a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among 538 patients admitted to the Department of Internal Medicine of a tertiary care centre in Nepal between 3rd November, 2021 and 22nd February, 2022 after receiving ethical approval from the Institutional Review Committee of the hospital (Reference number: 006-078/079). Convenience sampling was done. Data were collected and entered in Microsoft Excel and analysed using Statistical Package for the Social Sciences version 24.0. Point estimate at 95% Confidence Interval was calculated along with frequency and percentage for binary data along with mean and standard deviation for continuous data. Results: Among 538 patients, alcoholic liver disease was seen in 42 (7.80%) (5.53-10.07 at 95% Confidence Interval). The mean age of the patients was 53.85±10.88 years. Among these patients 25 (59.52%) were males and 17 (40.47%) of them were females. Conclusions: Our study showed that the prevalence of alcoholic liver disease was lower as compared to similarly reported literature. Keywords: alcoholic liver diseases; jaundice; liver function test; Nepal.

Experiences of Young Doctors Working in Rural Nepal.

Medical graduates studying on full and partial scholarships are subjected to a mandatory two years of bonding service program to overcome regional inequalities in the distribution of health workers between rural and urban areas. It might be a challenging journey, but it is crucial for the personal and professional growth of young doctors. Working in places distant from home and medical school can also be difficult, especially when the doctors are not adequately trained. During the bond, young graduates are exposed to a variety of clinical and non-clinical circumstances, which can aid in their maturation. Keywords: health; health policies; rural health.

Emergency Caesarean Section in a COVID-19 Infected Mother in a Primary Health Care Centre.

People from rural areas of Nepal struggle to have access to adequate medical care on time. Most of the tertiary centres are overburdened by patients, while the peripheral health facilities have been unable to function efficiently due to a lack of infrastructures and skilled manpower needed to run hospitals smoothly. We present a case of a 21-year-old primigravida at 41 weeks and 3 days of gestation with mild COVID-19 symptoms who underwent a Caesarean section for non-progression of labour and foetal distress at a primary health care centre in Nepal; however, both maternal and foetal outcomes were favourable. Therefore, upgrading the quality of care in peripheral health facilities can help in the achievement of accessibility, equity, and quality in health care service in Nepal. Keywords: caesarean section; COVID-19; health equity; Nepal; primary health care.

Organophosphorus Poisoning among Patients Admitted to the Intensive Care Unit of the Department of Internal Medicine in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

INTRODUCTION: Organophosphates are potent cholinesterase inhibitors that when ingested in excessive amounts can be fatal. Organophosphorus poisoning has become an important clinical problem with increased mortality in the country from accidental or intentional ingestion of, or exposure to the pesticide. This study aimed to find out the prevalence of organophosphorus poisoning among patients admitted to the Intensive Care Unit of the Department of Internal Medicine in a tertiary care centre. METHODS: A descriptive cross-sectional study was conducted among patients admitted to the Intensive Care Unit of the Department of Internal Medicine of a tertiary care centre after receiving ethical approval from the Institutional Review Committee (Reference number: 2003202205). The study was conducted between 1 February 2021 and 1 February 2022 using hospital records. Convenience sampling was done among the patients who met the eligibility criteria. The diagnosis of organophosphorus poisoning was made based on the patient's history, clinical examination and the measurement of serum acetylcholinesterase levels. Point estimate and 95% Confidence Interval were calculated. RESULTS: Among 1108 patients admitted, organophosphorus poisoning was seen in 50 (4.15%) (3.29-5.73, 95% Confidence Interval). CONCLUSIONS: Our study found that the prevalence of organophosphorus poisoning was lower when compared to similar studies done in similar settings.

Status Dystonicus with Atypical Presentation in Developmentally Delay Child: A Case Report.

Status dystonicus is characterised by involuntary sustained or intermittent muscle contractions of muscles causing repetitive twisting movements, abnormal postures of the body, or both is a rare but life-threatening movement disorder. Early diagnosis and management of status dystonicus prevent serious complications. We report a 2 years old previously developmental delay diagnosed girl who presented with generalised contractions of the whole body. Tightening of limbs is aggravated by touching her backside which is a very unique feature. Dystonia is associated with severe sweating and was confused with a seizure event. The patient was treated with midazolam, clonidine, phenytoin, gabapentin, pyridoxine, baclofen, and trihexyphenidyl. She was admitted to the intensive care unit for monitoring. The patient partially recovered after 10 days of treatment. Keywords: aspiration; children; dystonia; epilepsy; pneumonia.

Emergency Stay Duration of Patients in Emergency Department of A Tertiary Care Hospital in Nepal: A Descriptive Cross-sectional Study.

INTRODUCTION: Emergency department of a hospital is responsible for providing medical and surgical care to patients arriving at the hospital in need of immediate care. Emergency department is not staffed or equipped to provide prolonged care. Duration of stay in the Emergency department directly affects the quality of patient care. Longer length of stay is associated with Emergency department overcrowding, decline in patient care, increased mortality and decreased patients satisfaction. The main aim of this study is to find the mean stay duration of patients in the emergency department of a tertiary care hospital in Nepal. METHODS: This is a descriptive cross-sectional study which was conducted in a tertiary care teaching hospital from Jan 15,2019 to Jan 30, 2019. Ethical clearance was obtained from Kathmandu Medical College- Instutional Review Committee. The calculated sample size was 587. Consecutive sampling technique was used. The data thus obtained was entered in SPSS version 20 and necessary calculations were done. RESULTS: The mean emergency stay duration was obtained to be 3.18 hours at 95% confidence interval (C.I and standard deviation was 2.51 hours. Female had longer mean duration of stay (3.25 hours) compared to male (3.11 hours). The maximum length of stay was 15.3 hours. Most of the patients attending the emergency department were discharged right through the emergency department 398 ( 67.8%). Mean duration of stay was longest (5.06 hours) for the referral group. CONCLUSIONS: The mean stay duration in Emergency Department of tertiary care hospital in Nepal is getting shorter compared to similar study done previously.

Severe Birth Asphyxia without Sequelae: A Case Report.

Perinatal asphyxia is one of the major causes of neonatal morbidity and mortality. It mainly causes neurodevelopmental delay leading to hypoxic-ischemic encephalopathy. We present here the case of a preterm male baby of 1670 grams born at 31+3 weeks of gestation delivered by 25-year-old primi mother through vaginal delivery with history of umbilical cord prolapse. At birth, the baby had no heart rate and cyanosed following which he was resuscitated according to the Neonatal Advanced Life Support 2015 guidelines protocol. After 5 minutes of neonatal resuscitation, the baby's heart rate reappeared, but was only upto 20 beats/min and resuscitation thus continued. But heart rate did not improve despite of using all form of resuscitation procedure including intubation and drugs. After 2 hours, baby cried spontaneously and later baby was managed in Neonatal Intensive Care Unit according to the neonatal unit protocol of the hospital. Keywords: birth asphyxia; cord prolapse; hypoxic ischemic encephalopathy.

Acute Stroke in Tubercular Meningitis: A Case Report.

Most of the strokes in tubercular meningitis are multiple, bilateral, and located in the basal ganglia, especially the 'tubercular zone', which comprises of the caudate, anterior thalamus, anterior limb, and genu of the internal capsule. These are attributed to the involvement of medial striate, thalamotuberal, and thalamostriate arteries, which are embedded in exudates and likely to be stretched by coexistent hydrocephalus. Corticosteroids with antitubercular therapy were thought to reduce mortality and morbidity but their role in lowering strokes has not been proven. The mechanism of stroke in our case was vasculitis. Here, we are reporting a case of 22-years female patient with tubercular meningitis. She had complications of ischemic infarct and severe communicating hydrocephalus with a seizure disorder. Keywords: meningeal tuberculosis; stroke; tuberculoma; vasculitis.

Prevalence of Depression among Medical Students of a Tertiary Care Teaching Hospital.

INTRODUCTION: Depression is one of the major problems encountered by medical students. This may cause a negative effect on cognitive functioning and learning of students resulting in poor health care and service delivery in future. The presence of this major problem is necessary to be evaluated. Enough recent data regarding its prevalence is not available in our country. Thus, the main aim of this study is to find the prevalence of depression among medical students of a tertiary care teaching hospital. METHODS: This is a descriptive cross-sectional study which was conducted among undergraduate medical students of a tertiary teaching hospital over a four-month period (July to October 2019). Ethical clearance was received from the Institutional Review Committee of the same tertiary teaching hospital. Random sampling technique was used to collect data to meet the calculated sample size. Data analysis was done in the Statistical Package for Social Sciences. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: The prevalence of depression among selected medical students of Kathmandu Medical College and Teaching Hospital is 59 (27.2%) at 95% Confidence Interval (21.28-33.12%). Thirty (14%) of the participants were mildly depressed, 21 (10%) moderately depressed while 8 (4%) were severely depressed according to Beck's Depression Index II. CONCLUSIONS: Prevalence of depression among medical students is relatively significant as found in similar studies done in other centres. Thus appropriate programs and strategies should be implemented to avoid depression from causing a negative effect on cognitive functioning and learning of students. Favourable environment where students are able to talk about their mental health issues is a must.

Behavioral Characterization of κ Opioid Receptor Agonist Spiradoline and Cannabinoid Receptor Agonist CP55940 Mixtures in Rats.

Pain is a significant clinical problem, and there is a need for more effective treatments with reduced adverse effects that currently limit the use of µ opioid receptor agonists. Synthetic κ opioid receptor agonists have no abuse liability and well-documented antinociceptive effects; however, adverse effects (diuresis, dysphoria) preclude their use in the clinic. Combining κ opioids with nonopioid drugs (cannabinoid receptor agonists) allows for smaller doses of each drug to produce antinociception. This study tested whether a potentially useful effect of the κ opioid receptor agonist 2-(3,4-dichlorophenyl)-N-methyl-N-[(5R,7S,8S)-7-pyrrolidin-1-yl-1-oxaspiro[4.5]decan-8-yl] (spiradoline; antinociception) is selectively enhanced by the cannabinoid receptor agonist 2-[(1R,2R,5R)-5-hydroxy-2-(3-hydroxypropyl) cyclohexyl]-5-(2-methyloctan-2-yl)phenol (CP55940). Cumulative dose-response functions were determined in eight male Sprague-Dawley rats for spiradoline (0.032-32.0 mg/kg, i.p.) and CP55940 (0.0032-1.0 mg/kg, i.p.) for antinociception, hypothermia, food-maintained responding, and diuresis. Alone, each drug dose dependently increased tail withdrawal latencies from 50°C water, decreased body temperature by ∼4°C, and eliminated food-maintained responding. Spiradoline, but not CP55940, significantly increased urine output at doses that eliminated responding. Smaller doses of spiradoline and CP55940 in mixtures (3:1, 1:1, and 1:3 spiradoline:CP55940) had effects comparable to those observed with larger doses of either drug administered alone: the interaction was additive for antinociception and additive or greater than additive for hypothermia and food-maintained responding. Collectively, these data fail to provide support for the use of these mixtures for treating acute pain; however, κ opioid/cannabinoid mixtures might be useful for treating pain under other conditions (e.g., chronic pain), but only if the adverse effects of both drugs are not enhanced in mixtures.