Tertiary Care Center Research Articles

The Role of Medical Thoracoscopy with Talc Poudrage in Spontaneous, Iatrogenic, and Traumatic Pneumothorax: A Prolonged Experience of a Tertiary Care Center.

Medical thoracoscopy is a minimally invasive and safe procedure mostly performed for unexplained exudative pleural effusions but may be considered for pneumothorax (PNX). This retrospective study included participants affected by PNX who underwent medical thoracoscopy with talc poudrage at a single academic hospital from 2008 to 2021. The primary endpoint was the observation of complete radiographical lung re-expansion and absence of air supply from the chest drain within 7days of medical thoracoscopy. The secondary endpoint was achieving no recurrence of ipsilateral PNX at 24months post-discharge. A total of 95 patients affected by primary spontaneous PNX (PSP), secondary spontaneous PNX (SSP), iatrogenic, and traumatic PNX were enrolled. An additional procedure was required by 17.89% of patients, and only one patient with SSP required subsequent surgery. Recurrence of PNX occurred on the same side within 24months after discharge in 9.47% of patients, with a median time to recurrence of 13.5months. The PSP group was significantly more likely to achieve the primary endpoint. Pleural morphology was significantly associated with reaching the primary endpoint, while receiving a cumulative dose of talc greater than or equal to 4g during hospitalization was associated with a lower risk of meeting it. Receiving a cumulative dose of talc greater than or equal to 4g led in all cases to the achievement of the secondary endpoint. Patients with iatrogenic and traumatic PNX had an excellent prognosis in both the short- and long-term evaluation. Medical thoracoscopy is an effective procedure for treating PNX in the acute setting in selected cases while preventing long-term relapses. Large prospective clinical studies are needed to support and better define the role of medical thoracoscopy in current clinical practice.

Avoidable admissions after minimally invasive hysterectomy

ObjectiveTo determine the rate of avoidable admissions following anticipated same-day discharge for patients undergoing minimally invasive hysterectomy and to identify risk factors associated with such admissions.MethodsA retrospective review was performed...

Clinical spectrum of tuberculosis in adolescents (10–19 years) in a tertiary care center of North India

Background\\objectivesThere is limited literature available to characterize tuberculosis (TB) in adolescents despite them sharing a high burden of the disease. Ours is the first prospective study in India and worldwide to study the clinical profile of tuberculosis in adolescents aged 10–19 years.Methods: We enrolled 82 children and adolescents between March 2021 to March 2022. The diagnosis of TB was made on the basis of National Tuberculosis Elimination Program (NTEP) guidelines 2020. Adolescents were divided into 3 age groups: early (10–13 years), middle (14–17 years), and late adolescents (18–19 years)and the results were compared among the three groups. A two-sided p value of <0.05 was considered statistically significant.Results: The middle age adolescents comprised majority of our study population and females were more than males. The common presenting features were fever, chest pain, breathing difficulty with majority belonging to lower socioeconomic status. The pulmonary TB accounted for 56% and extrapulmonary constituted 44% of the cases. The notable extrapulmonary cases were disseminated TB with secondary lymphangiectasia, compressive myelopathy, sacroiliac joint arthropathy among others. Infiltrates/consolidation were the most frequent radiological findings in patients with pulmonary TB. The microbiological confirmation was available in 44% of the cases. The microbiological positivity was higher in histopathological specimens and in late adolescents. Two patients were rifampicin resistant. Conclusion: There was a varied clinical presentation of TB in this population. The extrapulmonary cases as well as the microbiological yield increased with increasing age of the cases.

Predictors of Sepsis and Sepsis-related Mortality in Critically Ill Burn Patients: A Single Tertiary Care Center Experience.

Clinical diagnosis of sepsis is challenging, emphasizing the importance of regular bacterial surveillance, and tailored antimicrobial therapy. This study aims to elucidate the predictors of sepsis in critically ill burn patients. A retrospective analysis was conducted on patients admitted to the burn intensive care unit between 2016 and 2022. Demographics, type of burn, total body surface area (TBSA), presence of inhalation injury, mortality, sepsis, deep vein thrombosis, pulmonary embolism, pneumonia, cultures, and laboratory findings were collected. Descriptive statistics and survival analysis were used to analyze trends during the 7-year period. The study encompassed 196 participants. Among patient factors, men constituted 73.4% (n = 102) of those without sepsis and 86.0% (n = 49) with sepsis, with an association between sepsis and lower age (34 versus 41 years) as well as larger TBSA (41.1% versus 17.3%). Inhalation injury was a significant predictor of sepsis [35.1% (n = 20) versus 11.6% (n = 16)]. Mortality was higher in sepsis cases [17.5% (n = 10) versus 2.9% (n = 4)], as well as positive blood cultures [47.4% (n = 27) versus 2.2% (n = 3)], positive wound cultures [71.9% (n = 41) versus 12.2% (n = 17)], and positive fungal cultures [12.3% (n = 7) versus 0% (n = 0)]. Multivariable analysis identified age and TBSA as significant predictors of sepsis (P = 0.025, P < 0.001). Age, TBSA affected emerge as a strong risk factor for sepsis among critically ill burn patients. It underscores the need for vigilant monitoring to improve outcomes and reduce sepsis-related mortality.

Janus kinase 2 mutation-negative polycythemia-associated retinal changes in otherwise asymptomatic patients

Purpose: The purpose of this study was to document secondary polycythemia (SP)-associated retinal changes and the favorable role of phlebotomy in the treatment of SP-induced retinal complications. Design: This was a retrospective, observational, noncomparative case series. Participants: A total of 8 eyes of 4 male patients with an age range of 28–78 years were studied. Materials and Methods: A total of 04 consecutive patients were received over a year on an outpatient basis at a single tertiary care center, with only vision-related complaints. After documentation of ocular findings, all the patients were subjected to meticulous clinical and laboratory evaluation to determine the cause of ocular conditions. Patients were subjected to the treatment for underlying pathological conditions based on the outcomes of their clinical and laboratory evaluation. Main Outcome Measures: Determination of Janus kinase 2 (JAK2) mutation-negative SP as a cause of associated retinal complications and favorable role of phlebotomy as a treatment measure. Results: All the patients were adult, nonsmoker, and nonalcoholic males. A total of 05 eyes were diagnosed with proliferative vitreoretinopathy while 2 eyes had retinal venous occlusion. One eye was normal. Except SP, no other cause for retinal lesions could be ascertained in all patients. Three patients underwent phlebotomy as decided by the hematologists. Each patient was followed monthly for 6 months. All the patients showed resolution of retinal lesions at the end of follow-up. Conclusion: Nonpolycythemia vera (PV) erythrocytosis or unmutated JAK2 SP is still a very poorly studied entity. Almost no information is available regarding ocular involvement and its treatment in SP. Our observations suggest that SP may run a chronic course causing serious retinal damage such as other myeloproliferative disorders or PV and that phlebotomy has an important role in the management of such cases.

Glaucoma burden and its profile in a tertiary care centre of North-East India: A retrospective hospital-based study

ABSTRACT Purpose: To estimate the proportion and pattern distribution of glaucoma disease in a teaching hospital of North-East India. Materials and Methods: Retrospective hospital-based study of glaucoma cases from January 2014 to December 2022. Results: Out of a total of 89725 new patients, 449 patients had glaucoma with a prevalence of 0.50% (95% CI: 0.46%-0.55%) of which 361 (80.4%) were ≥40 years and 88 (19.6%) were &lt;40 years. The commonest type was POAG (32.1%) followed by PACG (17.6%) while JOAG was 7.8%. Males (67.2%) were predominant with a male: female ratio of 2.0:1. The mean age of patients was 53.4 (17.1) years. PACG was found to be significantly higher among females (p=0.001) whereas POAG was higher among males (p=0.003). There was no association of either age or systemic conditions with the prevalence of POAG and PACG. Hypertension and diabetes were present among 139 (31.0%) and 103 (23.0%) respectively while 13 (2.9%) had chronic obstructive pulmonary disease (COPD), 5 had coronary artery disease (CAD) and 5 hypothyroidism. Conclusion: The prevalence of glaucoma though lower compared to other parts of the country, the number was significant, warranting screening activities owing to its silent nature. PACG was significantly higher among females while POAG was higher among males. Systemic factors like COPD, CAD and hypothyroidism require further studies for better understanding of the temporal association with glaucoma.

Admission Rate of Patients Visiting Emergency Department in a Tertiary Care Center in Kathmandu

Introduction: Emergency departments serve as the initial point of contact for patients with a wide range of conditions. Not all patients visiting get admitted to the hospital. The admission rate varies from 20% in the United States to 40.83% in Nepal. Given the variability in these results across different regions, there is a need to better understand the admission rates from the Emergency Department.Methods: A descriptive cross-sectional study was conducted after obtaining ethical approval( Reference Number: 58 (6-11)E2 081/082) in the Emergency Department of a tertiary health care center. Retrospective data was collected from the data register. The data from April 2023 to April 2024 was collected. A sample size of 222 was calculated and convenience sampling was done. Demographic details like age, sex, and data regarding admission status were collected. Data was collected in MS Excel and was analyzed using JASP software. Results: Out of 222 patients that presented to the emergency department, 53 (23.87%)(18.26-29.47,95 % Confidence Interval) were admitted to the ward or intensive care unit of the hospital, whereas 167 (75.23) got discharged, 1 (0.45%) was brought dead and 1 (0.45%) expired. The median age of patients was 43 (IQR: 26-62). The admission rate of females was 20 (17.24%), whereas for males it was 33 (31.13%).Conclusions: The prevalence of admission of patients visiting the emergency department was higher than similar US based studies. There was a higher percentage of female patients presenting to theemergency department, while those being admitted were mostly males.

Cesarean Section under General Anesthesia over 10 Years at Tertiary Care Center: A Descriptive Cross-sectional Study

Introduction: The global surge in cesarean deliveries necessitates safe anesthetic practices to optimize outcomes. While the neuraxial block is the preferred method, specific conditions warrant general anesthesia. This study is aimed to determine the prevalence of cesarean sections under general anesthesia at a tertiary care center. Methods: A descriptive cross-sectional study was conducted on cesarean sections performed between April 14, 2013, and April 13, 2023, at a tertiary care center. Ethical approval was obtained from the Institutional Review Committee (Reference number: 20092023/01). Total sampling was done. Data for the past ten years were manually collected from hospital records using a self-structured proforma and analyzed using Microsoft Excel 2018 and IBM SPSS version 26. The point estimate and 95% confidence interval were calculated for the study. Results: In this study, there were 216 (2.98%) (95% CI: 2.59-3.38%) cesarean sections under general anesthesia in 10 years. Notably, among them, there were 103 (47.69%) primigravida, nullipara 130 (60.19%), 135 (62.50%) with no living children, and 161 (74.54%) without any past abortions. In most cases, 182 (84.26%) were emergency procedures and 34 (15.74%) were elective. Fetal bradycardia with distress was the primary indication observed in 121 (56.02%) cases, followed by 32 (14.81%) maternal requests. Additionally, twenty-one cases were found initially planned as cesarean sections under subarachnoid block but were converted to general anesthesia. The prevalence in this study was found within the recommended limits.Conclusions: The findings highlight that the majority of these procedures were emergency cases, predominantly due to fetal distress, with a notable proportion involving primigravida and nulliparous women.

Normative values of oxygen saturation by pulse oximetry (SpO2) in apparently healthy children from Eastern India - A cross-sectional study.

The primary objective was to determine normative values of oxygen saturation (SpO2) by pulse oximetry in apparently healthy children, aged 1 month to 14 years. The secondary objective was to explore any variation in oxygen saturation levels by age and gender. It was a cross-sectional study conducted at a tertiary care centre and schools in Bhubaneswar, Odisha, India, from January 2021 to December 2022. Apparently healthy children were enrolled. Using a standardized pulse oximeter and appropriately sized probes, SpO2 was recorded after stabilization of plethysmograph waves. Three consecutive readings were taken, and an average was noted. The 2.5th centile SpO2 value was taken as the lower limit of normal. The median (IQR) saturation of the sample population was 99.7% (99-100). The 2.5th, 5th, 25th, and 75th percentiles were 97.7%, 98%, 99%, and 100%, respectively. Median SpO2 and its percentiles were estimated for each age group. The 2.5th centile SpO2 for infantile age group was 96.4%. No significant age and gender-wise variations of SpO2 were noted. The present study established normal reference range oxygen SpO2 levels in apparently healthy children from an eastern India region that is situated at 62 m (204 ft) above the sea level.

Characterization of Etiology and Pattern of Dental Extraction among Patients Presenting to Dental Department of a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction: Dental extraction is a common curative treatment against pain provided to the patients. A limited number of scientific literature are available that characterizes the reasons for teeth extractions in Nepalese population. The aim of this study is to find out the causes for dental extraction in patients and explore the relationships between demographic variables and loss of teeth in the Nepalese population.Methods: This is a descriptive cross-sectional study performed to assess the predictors and reasons for permanent tooth extraction among the Nepalese patients who visited dental department in a tertiary health care center from 18th June 2022 to 17th June 2023. Ethical approval was obtained from the Institutional Review Committee (Approval No: 52/22). Demographic details were recorded, diagnosis established and the teeth in question were extracted. Descriptive statistical analysis was performed.Results: A total of 465 (42.66%) permanent teeth were extracted from the 1090 patients, out of which 198 (18.16%) were male and 267 (24.49%) were female patients between the age of 10 years to 70 years. Among all the participants, 726 (66.60%) patients were educated while 364 (33.40%) were uneducated, 165 (15.13%) extraction were done due to peridontal disease and 213 (19.54%) of extraction was done due to endodontic disease.Conclusions: Endodontic and periodontal diseases were the most common causes of dental extraction. Permanent molars and incisors were extracted the most.

Evaluation of Etiological Factors Associated With Abnormal Uterine Bleeding Among Teenage Girls in a Tertiary Care Center: A Cross-Sectional Study

Evaluation of Etiological Factors Associated With Abnormal Uterine Bleeding Among Teenage Girls in a Tertiary Care Center: A Cross-Sectional Study

Serum Potassium Level in Acute Organophosphorus Poisoning and its Correlation with Severity in Patients Presenting to Emergency Room in a Tertiary Hospital

Background: Organophosphorus compounds (OPCs) are common causes of accidental and suicidal poisoning in agricultural countries like Nepal. Serum cholinesterase, used to diagnose organophosphorus poisoning (OP), is not reliable for predicting its severity. This study aimed to assess serum potassium as an alternative prognostic indicator for OP poisoning severity. Methodology: This single-centric cross-sectional study included patients presenting with OP poisoning at a tertiary care center over six months. Total 86 cases met the inclusion criteria. The Peradeniya organophosphorus poisoning (POP) scale categorized patients by severity. The association between OP poisoning severity and serum potassium level at presentation was studied. Results: Of the 86 cases, 47 (55%) were females. The mean age was 26.96 years (SD: 8.73), ranging from 18 to 65 years. Most cases, 53% (n=46), were aged 20-29 years. Chlorpyriphos (50%) + cypermethrin (5%) was the most common OP compound, used in 29% cases. Malathion (50%) was the least used, in 7% (n=6) of cases. At presentation, 36% (n=31) had hypokalemia, among which 6 had mild poisoning (POP score: 0-3), while 25 had moderate to severe case of poisoning (POP score: 4-11). The association between OP poisoning severity and hypokalemia was statistically significant (p-value &lt;0.001, OR: 23.958, 95% CI). Conclusion: Serum potassium levels in patients presenting within 12 hours of OP poisoning significantly correlate with severity, as determined by the POP scale. Hypokalemia is prevalent in moderate to severe OP poisoning cases, with higher POP scores linked to lower serum potassium levels.

Diagnostic yield of combined ACR TI-RADS and Sonoelastography in solid thyroid nodules in tertiary care center: A prospective cross-sectional Study

Background: Thyroid nodules are prevalent, and accurate differentiation between benign and malignant nodules is crucial for management. We aim to evaluate the effectiveness of combining Thyroid Imaging Reporting and Data System (TIRADS) scoring with strain elastography, specifically the Elasticity Contrast Index (ECI), to differentiate between benign and malignant thyroid nodules. Methods: This analytical cross-sectional study involved 77 patients with solid thyroid nodules identified through B-mode ultrasonography. ACR TI-RADS scores, ECI values, and combined scores were compared with Fine needle aspiration Cytology (FNAC) results. Statistical analysis was performed using SPSS, and Pearson correlation tests were conducted to assess the correlation with FNAC findings. Result: The TI-RADS scoring system has a sensitivity of 83.3%, a specificity of 66.1%, and a positive predictive value of 42.9% for distinguishing benign and malignant nodules. Strain elastography with ECI values has a sensitivity of 94.4%, specificity of 98.3%, PPV of 94.4%, and NPV of 98.3%. Combining ACR TI-RADS and strain elastography achieves a sensitivity of 100%, specificity of 66.1%, NPV of 100%, and PPV of 47.4%. Conclusion: The study emphasizes the benefits of integrating noninvasive methods like ultrasound elastography and ACR TI-RADS for improved diagnostic precision, minimizing invasion and patient discomfort. This strategy is particularly advantageous for TI-RADS 3 nodules and reduces unnecessary procedures. However, FNAC should be reasonable and validated for higher classifications.

Hypertensive Retinopathy among Hypertensive Patients in a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction: Hypertension manifests in the eyes as retinopathy, choroidopathy, and optic neuropathy of which retinopathy can be used as a predictor for systemic morbidities and mortalities. The study aims to determine the prevalence of hypertensive retinopathy among hypertensive patients visiting the outpatient Department of Ophthalmology in a tertiary care center.Methods: A descriptive cross-sectional study was conducted among hypertensive patients from 4th April to 19th November 2023 after obtaining ethical approval from the Institutional Review Committee (Reference number: 2079/80/96). A Convenience sampling method was used. The Point estimate was calculated at a 95% Confidence Interval. Results: Among 161 hypertensive patients, hypertensive retinopathy was present in 70 (43.48%) (35.82-51.14, 95% Confidence Interval). Grade I hypertensive retinopathy accounted for 35 (50%) followed by Grade II HR in 17 (24.29%), Grade III HR in 14 (20%) and Grade IV HR in 4 (5.71%) in the study participants.Conclusions: The prevalence of hypertensive retinopathy was found to be higher than other studies done in similar settings.

Evaluation of the Sofa Score in Predicating Outcome of Sepsis Patients Admitted to a Tertiary Care Center in Nepal

Background Sepsis is a major health burden with life- threatening conditions, which leads to a high rate of mortality in patients. The Sequential Organ Failure Assessment (SOFA) score, which assesses organ dysfunction across multiple systems, has been considered a reliable indicator of the severity of critical illness. We have carried out this study to evaluate the predictive value of the SOFA score in assessing the mortality of patients with sepsis on admission.  Methods Our study was a cross-sectional, descriptive study carried out in patients with sepsis who were admitted to the medical ICU of Chitwan Medical College from December 15, 2021, to December 14, 2022. Patient sampling was done based on a non-probability convenience sampling technique.  Results In a study of 130 patients, 54.6% were male and 45.4% were female. The mean SOFA score was 7.1, with a median of 7. 38.5% (50 patients) died due to sepsis. The mean SOFA score was higher among deceased patients (9.3) than survivors (5.8). Higher SOFA scores were associated with increased mortality. 46% of patients required inotropes/Vasopressor support for shock. Patients requiring vasopressor support had a significantly higher mortality rate (53.3%) compared to those who did not need support (25.7%). 13.1% of patients required mechanical ventilatory support, and the majority of these patients (70.6%) had mortality.  Conclusion SOFA score is a valuable tool to assess organ dysfunctions and it can predict the outcome of patients admitted with sepsis.

Multidrug Resistance Gram-negative Bacteria in Intensive Care Unit of Tertiary Care Hospital: A Descriptive Cross-sectional Study

Introduction: Antimicrobial resistance is global health problem, amongst major causes for mortality. It is one of the hinderance for achievement of Sustainable Goal 3 (Good health and well-being) of WHO. Multidrug resistant gram negative bacteria are major threat to humanity especially patients admitted in intensive care unit. This is associated with to treatment failure and mortality of the patients in intensive care unit. Therefore, this study was conducted to find out the prevalence of Multidrug resistant gram negative bacteria in intensive care unit of tertiary care center. Methods: A descriptive cross-sectional study was conducted in the Department of Microbiology of a tertiary care hospital from February, 2020 till August, 2021 for 18 months after obtaining ethical approval from the Institutional Review Committee (Reference Number: 246). All the samples from Intensive Care Unit were processed following standard methodology. Only Gram-negative bacteria isolated from samples were included in the study. Convenience sampling method was used. The point estimated was calculated at 95% Confidence Interval. Data was entered in Microsoft Excel 2016 and analysis was done using IBM SPSS Statistics version 16.0.Results: Out of 500 samples only 380 showed growth of gram negative bacteria. The prevalence Multi Drug Resistance was 83.15%. The prevalence of multidrug resistant was notably higher among Acinetobacter spp (100%) followed by Non fermenter (95%) and Escherichia coli (87.1%). Multidrug resistant isolates were least resistant towards carbapenem group of antibiotics.Conclusions: The prevalence of Multidrug resistant gram negative bacteria was found to be lower than in the study conducted in similar setting.

Exploring factors affecting Anganwadi workers’ performance motivation: a mixed-methods study in a tertiary care center of central India

Background: The integrated child development services (ICDS) scheme in India employs Anganwadi workers (AWWs) to improve child well-being, reduce health risks, and support maternal education. Despite their crucial role, factors influencing AWWs’ motivation and performance are not well understood. This study examined how individual, program, community, and organizational factors impact AWWs’ motivation in a tertiary care center in central India. Methods: A mixed-methods study was conducted in a tertiary care center in central India, involving 105 AWWs surveyed with a validated questionnaire and 40 AWWs participating in focus group discussions. The study explored individual, community, and health system factors influencing AWWs’ motivation. Results: Results showed that motivation levels were high among 42.85% of AWWs, moderate among 40%, and low among 17.14%. Key motivators included social responsibility, job satisfaction, supportive supervision, and adequate training. However, demotivating factors included inadequate incentives, high workload, insufficient family support, and lack of essential tools and supplies. Conclusions: AWWs’ performance motivation is influenced by a combination of individual, community, and health system factors. Enhancing their motivation requires addressing these factors through targeted interventions such as improved incentives, workload management, better family support, and ensuring the availability of essential tools and supplies. Understanding and addressing these factors can significantly enhance the effectiveness of the ICDS scheme.

Clinicopathological Profile of Pyoderma Gangrenosum: A 10-Year Retrospective Study from a Tertiary Care Center in South India

Clinicopathological Profile of Pyoderma Gangrenosum: A 10-Year Retrospective Study from a Tertiary Care Center in South India

Clinical evaluation of skin lesions among patients with systemic lupus erythematosus: Experience from a tertiary care centre

Clinical evaluation of skin lesions among patients with systemic lupus erythematosus: Experience from a tertiary care centre

Gram-negative bacterial colonization in the gut: Isolation, characterization, and identification of resistance mechanisms

BackgroundThe gut microbiome is made up of a diverse range of bacteria, especially gram-negative bacteria, and is crucial for human health and illness. There is a great deal of interest in the dynamic interactions between gram-negative bacteria and their host environment, especially considering antibiotic resistance. This work aims to isolate gram-negative bacteria that exist in the gut, identify their species, and use resistance-associated gene analysis to define their resistance mechanisms. MethodsSamples were collected from all patients who had a stool culture at a tertiary care center in Lebanon. Each type of bacteria that was identified from the stool samples was subjected to critical evaluations, and all discovered strains underwent antimicrobial susceptibility testing. Polymerase chain reaction was used to profile the genes for Carbapenem-resistant Enterobacteriaceae (CRE), Extended-spectrum beta-lactamase (ESBL), and that of Pseudomonas aeruginosa strains. ResultsEscherichia coli, Klebsiella species, and Pseudomonas aeruginosa turned out to be the predominant microbiota members. Escherichia coli strains had a high frequency of extended-spectrum beta-lactamase genes, with the most discovered gene being bla CTX-M. Additionally, a considerable percentage of isolates had carbapenemase-resistant Enterobacteriaceae genes, suggesting the rise of multidrug-resistant strains. Multidrug resistance genes, such as bla mexR, bla mexB, and bla mexA, were found in strains of Pseudomonas aeruginosa, highlighting the possible difficulties in treating infections brought on by these bacteria. ConclusionThe findings highlight the critical importance of effective surveillance and response measures to maintain the effectiveness of antibiotics considering the introduction of multidrug resistance genes in Pseudomonas aeruginosa and ESBL and CRE genes in Escherichia coli.