Factors Affecting Discharges against Medical Advice in an Emergency Department of a Tertiary Care Center

Introduction: Patients leaving against the advice of the treating team before being certified as fit is a major concern and challenge for the treating professionals as it possesses adverse medical outcomes. This study hence aimed at identifying the prevalence and major factors affecting such discharges so that advocacy can be done to help prevent it. Methods: A descriptive cross-sectional study was conducted at emergency department of a tertiary center in Lalitpur from 15th May 2019 to 15th August 2019. All the patients visiting the emergency department were included in the study and a non-probability purposive sampling method was used excluding the patients who denied giving reasons for them leaving against medical advice. Data was collected using pre-structured questionnaire and analyzed using SPSS-v21 software. Results: A hundred and fifteen patients (4.08%) left against medical advice out of 2812 patients who presented to emergency department. There were 63 male patients (54.8%), 75 patients of the total patients in the age group of 15-44 years (65.2%) and those living within a distance of 1km from the hospital (53%). The most common reason for the patients leaving against medical advice was found to be due to financial constraint (38.3%) followed by preference to other hospitals (16.5%). Conclusion: Patients leaving against medical advice possesses a small percentage of actual hospital admissions but is still a major health concern as it drastically increases the morbidity, re-admission rates and total health-care costs. Hence, understanding the general characteristics and predictors of such discharges is of utmost importance to help improve the patient outcome and reduce the health-care costs.

SARS-CoV-2: A virus that is shaking the world

The coronavirus disease -19 and the causative virus, SARS-CoV-2 has had a profound impact globally during the year 2020. The virus has spread to over 213 countries and has created a climate of fear and uncertainty. In this article the author reflects on the pandemic, its effects and also the impact of measures to contain the virus.

Urine Incontinence Before and After Delivery in Primipara

Introduction: Urinary incontinence is a common condition in pregnancy and postpartum period. It causes discomfort, embarrassment, loss of confidence and self esteem. This study aimed to determine the occurrence of urinary incontinence in pregnant attending antenatal clinic in a tertiary hospital. Methods: A descriptive observational study was conducted to find out occurrence of urinary incontinence in primiparous attending department of obstetrics and gynecology from August 2014 to August 2015 at B.P. Koirala Institute of Health Sciences. Results: The total of 100 primigravida were enrolled in the study. Out of which six had urinary incontinence with mean age of 23 years. Most of them were in the period of gestation group 38–40 weeks. 22% of total were obese with mean BMI of 26.69 kg/m2. Seventy nine patients had vaginal delivery, four had vacuum assisted vaginal delivery and 17 had cesarean section. Age and Body Mass Index (BMI) was not found to be associated with urinary incontinence. Oxford grading for assessment of perineal muscle after delivery showed decline in pelvic muscle tone which was significantly associated with urinary incontinence. However, the mode of delivery, and birth weight of baby was not found to be significant. Conclusion: The study finding suggested that pregnancy acts a risk factor for development of UI although no preference could be drawn regarding the mode of delivery. Our study also concluded antepartum UI as a risk factor for postpartum UI.

Outcome of Titanium Elastic Nailing in the Surgical Management of Femoral-Shaft Fracture in Children

Introduction: Femoral shaft fracture is one of the most common orthopedic injuries of the children. These fractures treated non-operatively by traction followed by hip spica require prolonged hospitalization causing undue physical and psychological stress for patient and patient family. Loss of reduction is also commonly seen with hip spica that leads to unacceptable complications like angular deformities and limb length discrepancies. Titanium Elastic Nailing (TEN) is becoming widely accepted treatment for femoral shaft fractures in children due to its simplicity and physeal protective stable load sharing construct that allows early mobilization. The purpose of this study was to see the outcome of operative treatment of femoral shaft fracture in children by TEN. Methods: A retrospective observational study was carried out in the Department of Orthopedics in National Academy of Medical Sciences, National Trauma Center from February 2017 to January 2019. Study was undertaken in 22 children between the age group of 5-14 years with femoral shaft fractures. Fixation with TEN was done for all fractures within nine days of injury. Patients were assessed radiologically as well as clinically until fractures healed. The results were evaluated using Flynn scoring criteria. Results: Radiological union was seen in all cases between 6–12 weeks after surgery. The mean operating time was 58 (48-115) minute and mean hospital stay after surgery was 9 (6-15) days. Results were excellent in 14 patients (63.63%), satisfactory in 6 patients (27.37%) & poor in 2 patients (9%). Six patients had skin irritation at nail insertion site which resolved after removal of nails. Functional range of motion in both hip and knee joints of affected limb was preserved in all cases after the removal of nails. Conclusion: TEN is an effective and safe treatment of femoral shaft fractures in children of 5-14 years of age group.

Study of Anatomical Variations of Nose and Para-nasal Sinuses in Computed Tomography Scan

Introduction: Computed tomography (CT) has nowadays become the investigation of choice for diagnosis and evaluation of anatomical variations of the nose and paranasal sinuses. Methods: A cross sectional study was conducted in the Department of Radiology of Lumbini Medical College Hospital from June 2019 to May 2020. Total of 130 patients were enrolled for the study. All patients were subjected to Siemens Somatom scope 16 slice CT scan. Each scan was studied for the presence of agger nasi cell, concha bullosa, deviated nasal septum, haller cell, onodi cell, uncinate process variation and type of olfactory fossa. Results: The mean age of patients was 36. 86 ±12.06 years. There were 76 males (58.5%) and 54 females (41.5%) with male: female ratio of 1.4:1 with highest range in age group of 31 to 45 years (46.9%). Anatomical variation between male and female was statistically not significant (p>0.05). The most common anatomical variation noted was nasal septal deviation (73.1%), then agger nasi cell (59.3%), concha bullosa (24.6%), paradoxical medial turbinate (7.7%), onodi cell (6.9%), uncinate process variation (5.4%) and least was haller cell (4.6%). Most of the scans had more than one anatomical variation, which was statistically significant (p<0.05). The most common type of olfactory fossa depth was Keros type II (61.5%). Conclusion: Computed tomography of the paranasal sinus has improved the visualization of anatomical variation hence radiologist must pay close attention to variants.

Knowledge, Attitude and Practices towards COVID-19 among Medical Students

Introduction: In late December 2019, COVID-19 was first seen in Wuhan, China which has been spreading to the whole world in subsequent months. Till the time this manuscript is written, COVID-19 has infected more than 2million people and killed more than 129843 people all around the world. First step in fighting against COVID-19 is to have appropriate knowledge and correct attitude and practices. Methods: This study was done to know the knowledge, attitude and practices on COVID-19 amongst medical students of Kathmandu University School of Medical Sciences (KUSMS) using internet based structured questionnaires. The survey was conducted from April 2, 2020 to April 09, 2020 (one-week after lock down following COVID-19 spread in Nepal). Structured questionnaire was used by the Medical students of Kathmandu University Hospital. There were 19 questionnaires regarding Knowledge, three regarding Attitude and five regarding Practices. Results: Out of 631 responders, the mean correct Knowledge score was 83.4%. Of the 19 Knowledge questionnaires, the mean score was 15.8 (Range 0-19). Regarding the Attitude questionnaire, 81.7% responders had a positive attitude toward COVID-19 being controlled globally in near future. Majority of the responders wore masks when going out in recent days (96%) and 97.6% of responders didn’t go to crowded places during this period. Conclusion: Medical Students have good knowledge, optimistic attitude and appropriate preventive practices towards COVID-19. Better knowledge is associated with online or onsite training obtained about COVID-19 outbreaks. Optimistic Attitude and appropriate preventive practices was associated with better knowledge of the responders.

COVID-19 Transmission Dynamics: A Little Bit of Confusion

No abstract available.

COVID-19 and Herd Immunity: A Dilemma to Understand

No abstract available.

Efficacy of The Subcostal Transversus Abdominis Plane Block In Laparoscopic Cholecystectomy: A Comparison With Conventional Port- Site Infiltration

Introduction: Pain experienced following laparoscopic cholecystectomy derives significantly from incision made in anterior abdominal wall. Many patients experience moderate to severe pain following laparoscopic cholecystectomy. This study aimed to compare the efficacy of ultrasound guided bilateral subcostal transversus abdominal plane (TAP) block with port-site infiltration for post-operative analgesia after laparoscopic cholecystectomy. Methods: Sixty patients undergoing laparoscopic cholecystectomy were randomly allocated to two groups to receive port-site infiltration of local anaesthesia or ultrasound guided subcostal TAP block at the end of surgery before extubation. All patients received 1 gm paracetamol intravenously 8 hourly. Post-operative pain was assessed using visual analogue score at 0,1,2,4,8,16 and 24 hours. Time to first analgesic requirement and total opioid consumption over 24 hours were recorded. Results: Ultrasound guided bilateral subcostal transversus abdominis plane block significantly reduced post-operative pain score compared to port site infiltration. We observed statistically significant differences in visual analogue score between two groups at all other time frame. The 24 hours opioid consumption was less in Subcostal TAP (136±66.31μg VS 202±80.58μg, p=0.001). Time for rescue analgesia was prolonged in patient receiving subcostal TAP (3.63±2.09 hrs VS 1.73±1.60 hrs, p=0.0002). Conclusion: Ultrasound guided bilateral subcostal transversus abdominal block provides superior post-operative analgesia and reduced opioid consumption after laparoscopic cholecystectomy compared to port-site infiltration.

Iatrogenic Displaced Maxillary Third Molar Tooth

Minor to major complications may occur during the third molar extraction but should be optimized. Surgeons should know how to diagnose the case and manage the complications. We hereby report one of the rare complications of upper third molar extraction; iatrogenic displacement in infratemporal space. We emphasized hence on management of such technically sensitive case using 3D virtual surgical planning. The use of computer-assisted three-dimensional surgical planning to reconstruct the tooth in its localized position and orientation makes the operation more accurate, more convenient, and avoids damage to vital structures.