Journal of Kathmandu Medical College

Patient safety and health care regulatory system in Nepal

Satish Kumar Deo — 2024-03-21

The healthcare regulations aims to address social problems, protect patient safety as well as deliver quality care impartially. However, the fragmented regulatory system in Nepal poses significant barriers to building a strong patient safety culture. Globally, countries such as Canada, Australia, Sweden, Thailand and the Philippines have established comprehensive systems defined by centralized leadership, adverse event reporting mechanisms as well as inclusive policy-making processes directed towards promoting patient safety. Overburdened practitiners, scarce resources, poor communication, and the lack of standard operating procedures are some of the challenges Nepal faces. Regulatory bodies such as the Professional Councils and Ministry of Health and Population function without appropriate coordination or incident reporting system; hence, as a result, progress is delayed. The lessons learned from international experience highlights the need for an integrated patient safety framework and a central statutory authority . This would need infrastructure investments, professional development, and transparency in reporting systems at the national level. With these reforms, Nepal can create a strong and unified healthcare system focussed on patient safety and public well-being.

A holistic approach to traumatised anterior teeth

Swati Rani Gupta — 2024-03-21

As oral cavity stands the sixth most afflicted area of human body, it frequently encounters instances of traumatic dental injuries. While severe injuries like avulsions are prompt at seeking dental attention, less severe injuries like enamel dentin fractures are often reported after substantial delay. Over time, these cases may present with myriad signs and symptoms including sudden pain, swelling, discolouration and immature root development, requiring comprehensive management. This case report discusses one such instance of a traumatic dental injury that presented years after the initial trauma with multiple findings. Each problem was addressed sequentially which transformed the situation holistically.

Effect of daily versus twice per day tamsulosin in management of ureteral stent symptoms among patients visiting a tertiary level hospital

Prajwal Paudyal — 2024-03-21

Introduction: Currently, tamsulosin 0.4 mg daily is the dosage indicated for lower urinary tract symptoms for patients with an indwelling stent. In treating benign prostatic hyperplasia, a total maximum dose of 0.8 mg tamsulosin is used (either 0.4 mg twice daily or 0.8 mg daily), which has shown increased efficacy compared to the 0.4mg daily dose without an increase in adverse effects

Objective: Our goal was to compare two different dosing regimens (0.4 mg daily vs. 0.4 mg twice per day) of tamsulosin for ureteral stent-related discomfort.

Methodology: A prospective comparative study was conducted in Kathmandu Medical College and Teaching Hospital, Kathmandu among 60 patients who had unilateral ureteral stent placed. Patient who have undergone DJ stenting on the odd days of the calendar were advised to take once a day 0.4 mg tamsulosin, and the patients undergoing stenting on the even days of the calendar were advised to take twice a day 0.4 mg tamsulosin who had developed lower urinary tract symptoms (LUTS), with USSQ Score >10 on seventh post-operative day. Both the groups were asked to fill Ureteral Stent Symptom Questionnaire (USSQ) after informed consent at four weeks before stent removal to assess mean change in USSQ score.

Result: It was observed that mean USSQ score was 38.36±16.07 (Range: 12-77) in once a day tamsulosin group whereas mean USSQ score was 14.87 ± 8.62 (Range: 3-32) in twice a day tamsulosin group. The USSQ score significantly reduced in patients taking 0.8 mg tamsulosin. (p=0.001). The incidence of adverse events like headache, abnormal ejaculation, and orthostatic hypotension was more frequent with tamsulosin 0.8 mg but not significant. Only dizziness was significantly more frequent in twice a day tamsulosin group. (p <0.001).

Conclusion: The administration of twice a day tamsulosin improves stent-related urinary symptoms as compared to once daily dosage without much increment in side effects.

Effect of basic life support training among health care providers at a tertiary level hospital in Nepal

Samjhana Basnet — 2024-03-21

Introduction: Basic Life Support (BLS) is a fundamental skill used to restore cardiac, pulmonary, and cerebral circulation through cardiopulmonary resuscitation (CPR) in patients with cardiac arrest, ideally within seconds of the incident or trauma. The survival of cardiac arrest victims depends on early recognition and high-quality CPR, which requires the knowledge, practice, and confidence of the BLS provider.

Objective: This study aimed to assess the effect of a BLS training program among healthcare providers at a tertiary hospital.

Methodology: This study was conducted at Dhulikhel Hospital, Kathmandu University Hospital from November 2021 to December 2022 on 294 healthcare professionals who underwent an 8-hour-long video-based BLS training program using census sampling . Knowledge related to BLS was assessed before and after the training using a quasi-experimental study design. Furthermore, the attitude and perceived confidence of the participants were also evaluated.

Result: There was a significant increase in the participant’s mean knowledge score following the BLS training program (mean pre-training score (SD): 9.97 (2.29), mean post-training score:15.04 (0.88), p <0.0001). Post-training feedback showed that the participants had a positive attitude toward BLS and were confident in their ability to perform CPR.

Conclusion: After the training, the participants demonstrated improved knowledge, attitude, and perceived confidence scores. Regular BLS training for health care providers will contribute to preventing mortality and morbidity related to cardiac arrest.

Knowledge and practice on chronic kidney disease prevention and associated factors among hypertensive patients attending in a hospital in eastern Nepal

Anju Kumari Mahato — 2024-03-21

Introduction: The steady decrease of kidney function is referred to as chronic kidney disease (CKD) that increases the socio-economic burden. Among various factors that cause CKD, hypertension is one of the second leading causes.

Objective: To assess knowledge and practice on chronic kidney disease prevention and associated factors among hypertensive patients.

Methodology: An analytical cross-sectional study was conducted among 405 hypertensive patients, who attended medical outpatient department at Koshi Hospital, Biratnagar from 2022 April to 2022 June. Non-probability purposive sampling technique was used. The study instrument was adopted and modified into local contest from the CKD Screening Index developed by Khalil et al. Descriptive statistics (frequency, percentage, mean, median and standard deviation) was used to explain variables. Binary logistic regression was used to determine the factors connected to knowledge and practice towards CKD prevention with p-value of <0.05 and confidence interval of 95% was considered.

Result: Based on findings mean age of the participants was 61.71 ± 11.272 years with 54.6% females. Half of the hypertensive patients had good (50.9%) level of knowledge whereas majority of them had good practice (87.4%) to prevent CKD. Furthermore, level of knowledge is associated with sex, ethnicity and educational status whereas level of practice is associated with sex, place of residence, and family history.

Conclusion: Half of the hypertensive patients had good level of knowledge whereas majority had good practice on prevention of CKD. Appropriate health promotion and health education programs are required to increase level of knowledge and practice among hypertensive patients.

Antimicrobial prescribing patterns and cost analysis study in intensive care units of tertiary level hospital

Binaya Shrestha — 2024-03-21

Introduction: Examining antibiotic prescribing trends serves as a crucial gauge for assessing the quality and adherence to clinical practices.

Objective: To study the patterns of antimicrobial prescription and utilisation in different intensive care units (ICUs); the average expenditures on prescribed antimicrobials; and the association between antimicrobial usage and incurred costs.

Methodology: An observational cross-sectional study was conducted in different ICUs of Kathmandu Medical College from 2022 June to October. A total of 140 prescriptions of patients admitted in intensive care units were obtained by convenient sampling technique after ethical clearance. The total number of drugs and antibiotics, the class, dose, route, and cost of antimicrobials were noted. Data were analysed by SPSS v. 21.

Result: Among the 140 prescriptions studied, a total of 261 antimicrobials were prescribed with an average of 1.86 antimicrobial per prescriptions. Most of the prescriptions belonged to patients admitted in medical intensive care units. The average cost of antimicrobial in patient up to age 45 years was Nepali rupees 2,475.73/- and 8,987.25/- in patients aged more than 45 years.

Conclusion: Antimicrobials are prevalent in ICU prescriptions and substantially contribute to overall drug expenses. This study showed that ceftriaxone was the most frequently used antimicrobials in intensive care units. Moreover high utilisation rates and cost of antimicrobials prescribed in ICUs are significant concern that requires urgent attention through implementation of guidelines and antimicrobial restriction policies.

Comparative study between septoplasty with or without nasal packing

Abishesh Shakya — 2024-03-21

Introduction: Deviated nasal septum is a common condition in otorhinolaryngology, often requiring septoplasty. The side effects of nasal packing have led to an increasing preference for septoplasty without packing.

Objective: To compare the advantages and disadvantages of septoplasty with or without nasal packing.

Methodology: A prospective, comparative study was conducted in the Ear, Nose, and Throat Department at Universal College of Medical Sciences Teaching Hospital, Siddharthanagar, Rupandehi, Nepal, over 18 months (2016 November to 2018 April) after getting institutional ethical clearance. Total 40 patients (aged 15–70 years) with symptomatic deviated nasal septum undergoing septoplasty were included in this study using non-probability convenient sampling. Lottery method was used to divide patients into two groups: Group A, who underwent septoplasty with nasal packing and Group B, who underwent septoplasty without nasal packing. Post-operative pain and bleeding were assessed on the first, second, fifth, seventh, and 30^th post-operative days, while synechiae formation was evaluated on the seventh and 30^th post-operative days. Data analysis was performed using SPSS v.17, applying the Chi-square test, with statistical significance level set at p ?0.05.

Result: The mean age of patients was 33.4 ± 15.3 years. Pain was significantly higher in the nasal packing group on the first post-operative day (p = 0.013). Synechiae formation was more frequent in the packing group on the seventh (p = 0.035) and 30^th post-operative days (p = 0.042).

Conclusion: Septoplasty with packing increases morbidity (pain and synechiae). Therefore, septoplasty without packing may be a preferable alternative.

Anxiety among reproductive age women with polycystic ovarian syndrome

Narayani Paudel — 2024-03-21

Introduction: Polycystic ovarian syndrome is a most common endocrine disorder commonly seen in young reproductive age women and is commonly manifested by presence of multiple signs and symptoms like oligomenorrhoea, hirsutism, obesity, and emotional disturbances. These symptoms are frequently linked with decline in women’s self-esteem and self-image and may have psychological problems like anxiety and depression.

Objective: To assess the level of anxiety among reproductive age women with polycystic ovarian syndrome.

Methodology: A descriptive cross-sectional study was conducted among 169 reproductive age women having polycystic ovarian syndrome. Women were selected purposively from polycystic ovarian syndrome WARRIOR Nepali women group. They were approached through Facebook social media. Data were collected through self-administered questionnaire from 2022 October to 2022 November by using Google Forms. SPSS v.21 was used to analyse the data. Both descriptive and inferential statistics were used.

Result: Out of 169, more than two third (115, 68%) women had moderate to severe level of anxiety, and 54 (32%) had minimal to mild level of anxiety. Level of anxiety was significantly associated with education, duration of diagnosis of polycystic ovarian syndrome, presence of acne, and thickened dark patches on the skin of women.

Conclusion: Overall, anxiety was highly prevalent among reproductive age women with polycystic ovarian syndrome. Early detection and prompt treatment of polycystic ovarian syndrome is required to reduce the level of anxiety among women.

Scoring system in predicting perforated duodenal ulcer morbidity in a tertiary level hospital of eastern Nepal

Nirmal Prasad Sah — 2024-03-21

Introduction: Perforated peptic ulcer (PPU) disease is a common indication of emergency surgery, accounting for 2–10% of all peptic ulcer cases. The American Society of Anaesthesiologists (ASA), Boey, and the peptic ulcer perforation (PULP) score are the most regularly utilised scoring systems to risk stratify patients who are likely to develop complications and to focus resources on high-risk patients.

Objective: To assess the accuracy of PULP score, Boey, and ASA in predicting 30-day perforated peptic ulcer morbidity.

Methodology: A retrospective cross-sectional study was done in a tertiary care hospital in Nepal with review of two-year (2018 April 14 to 2020 May 12) data of all (census) perforated duodenal ulcer (PDU) patients (74 cases). Data were collected after taking ethical clearance, which included demographic, clinical history, laboratory investigation, operative finding, and post-operative morbidity and mortality. For inferential statistics, Chi-square, and Independent t-test were applied to find significant association between various cut off values and numerical values of score and other selected variable. A receiver operating characteristic (ROC) curve analysis was used to determine the scale's predictive accuracy for each outcome.

Result: Male predominance (5.7:1) was present (Mean age 46.49 years). Post PDU repair morbidity and mortality were 37.83% and 4.05% respectively. Higher ASA (>3), Boey (>1), PULP (>6), raised creatinine level, and preoperative comorbidity (n = 15) were significantly associated with morbidity. Boey displayed largest (84%) area under the curve (AUC) in predicting morbidity.

Conclusion: Boey and PULP score can be utilised as precise predictor of morbidity.

Posterior chordal preservation with anterior artificial neochord reconstruction in rheumatic mitral valve replacement

Nikesh Bhandari — 2024-03-21

Introduction: Following mitral valve replacement, adaptation of left ventricle depends upon the annulo-ventricular continuity. Artificial chordal reconstruction has been mentioned as means to maintain annulo-ventricular continuity in patients in whom total chord preservation is not feasible.

Objective: This study aimed to compare the difference in left ventricle internal diameter in diastole and systole, ejection fraction and pulmonary artery systolic pressure after six months of surgery, in patients undergoing posterior chords preserving mitral valve replacement with mitral valve replacement with posterior chord preservation and neochord reconstruction at the anterior mitral annulus.

Methodology: A comparative observational study was conducted from 2019 December to 2020 December) at Manmohan Cardiothoracic and Vascular and Transplant Centre after ethical approval using convenience sampling. A total of 30 patients were divided into two groups: Posterior preservation and artificial neochord reconstruction (Group I) versus Posterior Chord preservation (Group II). Echocardiographic measurement of left ventricle internal diameter in diastole and systole, ejection fraction, pulmonary artery systolic pressure was done preoperatively, after seventh post-operative day and sixth post-operative month.

Result: Left ventricle internal diameter in diastole in Group I and Group II were 43±2.96 mm and 48.93±4.94 mm (p=0.01) and in systole in Group 1 and Group 2 were 29.26±2.96 mm and 35.93±5.23 mm (p=0.01) at six months. There were no significant differences in left ventricle ejection fraction and pulmonary artery systolic pressure after six months of surgery.

Conclusion: Mitral valve replacement with artificial neochord reconstruction resulted in decrease in left ventricle internal diameter in diastole and systole after six months of surgery.

A prospective observational study comparing the effects of two doses of post-delivery oxytocin on uterine contractility in parturients undergoing elective caesarean section in a tertiary level hospital

Ujma Shrestha — 2024-03-21

Introduction: Oxytocin is commonly used in caesarean sections following delivery of baby to prevent haemorrhage, but the optimal dose is not clear. This study compared intravenous one international unit (IU) versus (vs) five IU oxytocin on uterine contractility during elective caesarean sections.

Objective: To compare the efficacy and safety of intravenous one IU and five IU oxytocin in terms of uterine contractility and side effects.

Methodology: A prospective observational study among 114 pregnant women undergoing elective caesarean sections under spinal anaesthesia was done at the Department of Anaesthesiology and Perioperative Critical Care at Kathmandu Medical College Teaching Hospital from 2021 September to 2023 January. Ethical approval was taken before data collection. One group received intravenous one IU oxytocin and the other five IU, followed by infusion. Uterine contraction adequacy was assessed at three minutes (primary outcome) and at two, five, six, and nine minutes (secondary outcomes), along with uterine tone, need for rescue uterotonics, and side effects.

Result: No significant difference in uterine tone was observed at three minutes (93.1% vs. 98.2%, p-value 0.183) or at two, five, and six minutes. However, tone was significantly lower at nine minutes with one IU (82.76% vs 96.43%, p-value 0.017). Palmar erythema and facial flushing were more frequent with five IU.

Conclusion: Intravenous one IU oxytocin is comparable to five IU for maintaining uterine contraction in the short term during elective caesarean sections, with fewer side effects.