Underdiagnosis of acute pulmonary embolism in physically active middle age man with syncope

Acute pulmonary embolism is a component of venous thromboembolism which may prove fatal if not suspected and subsequently treated. So, it is a disease that needs high clinical suspicion to prevent mortality and morbidity. Suspicion is very low in young healthy individuals in comparison to old age individuals with multiple co-morbid conditions. A physically active individual without genetic predisposition is considered to be at low risk for deep vein thrombosis and pulmonary embolism. Here, we present one overweight case who had 3 episodes of syncope in 4 days interval as well as breathlessness who came to our hospital and was diagnosed and treated with acute pulmonary thromboembolism

Bioequivalence study of two brands of phenytoin sodium 100mg formulations in healthy adult male rabbits

The objective of the study was to compare the bioavailability of a single oral 100 mg dose of two brands of phenytoin sodium formulations available in the Nepalese market. Formulation B was taken as test drug and compared with the innovator brand which was taken as reference standard. A randomized, two-way crossover study was done in six healthy adult male rabbits. All six rabbits received a single oral 100 mg dose of both the formulations with a two-week washout period between the formulations. Blood samples for plasma phenytoin levels were collected at 0.25, 1, 2, 4, 6, 8, 10, 12, 16, 24 hours. The pharmacokinetic parameters of the two brands of phenytoin sodium calculated were area under the concentration versus time curve from time zero to 24 hours (AUC 0-24), Area under the Curve from time zero to infinity (AUC(0-infinity)), peak plasma concentration (C-max) and time of peak concentration (t(max)). Formulation B failed to comply in terms of Area under the Curve (AUC), an important pharmacokinetic parameter to test bioequivalency, which was tested at significance level 0.05. This showed that the test formulation is not bioequivalent with the innovator. Taken together, our preliminary findings suggest that further studies in a large population is needed before switching phenytoin brands once a patient is carefully titrated to a given phenytoin brand

The COVID‐19 Pandemic Not Only Poses Challenges, but Also Opens Opportunities for Sustainable Transformation

The COVID-19 pandemic has impacted social, economic, and environmental systems worldwide, slowing down and reversing the progress made in achieving the Sustainable Development Goals (SDGs). SDGs belong to the 2030 Agenda to transform our world by tackling humankind's challenges to ensure well-being, economic prosperity, and environmental protection. We explore the potential impacts of the pandemic on SDGs for Nepal. We followed a knowledge co-creation process with experts from various professional backgrounds, involving five steps: online survey, online workshop, assessment of expert's opinions, review and validation, and revision and synthesis. The pandemic has negatively impacted most SDGs in the short term. Particularly, the targets of SDG 1, 4, 5, 8, 9, 10, 11, and 13 have and will continue to have weakly to moderately restricting impacts. However, a few targets of SDG 2, 3, 6, and 11 could also have weakly promoting impacts. The negative impacts have resulted from impeding factors linked to the pandemic. Many of the negative impacts may subside in the medium and long terms. The key five impeding factors are lockdowns, underemployment and unemployment, closure of institutions and facilities, diluted focus and funds for non-COVID-19-related issues, and anticipated reduction in support from development partners. The pandemic has also opened a window of opportunity for sustainable transformation, which is short-lived and narrow. These opportunities are lessons learned for planning and action, socio-economic recovery plan, use of information and communication technologies and the digital economy, reverse migration and “brain gain,” and local governments' exercising authorities

Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial

Background Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage. Methods In this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries. We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack number. Participants, care givers, and those assessing outcomes were masked to allocation. We originally planned to enrol 15 000 women with a composite primary endpoint of death from all-causes or hysterectomy within 42 days of giving birth. However, during the trial it became apparent that the decision to conduct a hysterectomy was often made at the same time as randomisation. Although tranexamic acid could influence the risk of death in these cases, it could not affect the risk of hysterectomy. We therefore increased the sample size from 15 000 to 20 000 women in order to estimate the effect of tranexamic acid on the risk of death from post-partum haemorrhage. All analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN76912190 (Dec 8, 2008); ClinicalTrials.gov, number NCT00872469; and PACTR201007000192283. Findings Between March, 2010, and April, 2016, 20 060 women were enrolled and randomly assigned to receive tranexamic acid (n=10 051) or placebo (n=10 009), of whom 10 036 and 9985, respectively, were included in the analysis. Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00; p=0·045), especially in women given treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the placebo group, RR 0·69, 95% CI 0·52–0·91; p=0·008). All other causes of death did not differ significantly by group. Hysterectomy was not reduced with tranexamic acid (358 [3·6%] patients in the tranexamic acid group vs 351 [3·5%] in the placebo group, RR 1·02, 95% CI 0·88–1·07; p=0·84). The composite primary endpoint of death from all causes or hysterectomy was not reduced with tranexamic acid (534 [5·3%] deaths or hysterectomies in the tranexamic acid group vs 546 [5·5%] in the placebo group, RR 0·97, 95% CI 0·87-1·09; p=0·65). Adverse events (including thromboembolic events) did not differ significantly in the tranexamic acid versus placebo group. Interpretation Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset. Funding London School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and Bill & Melinda Gates Foundation

Non-high density lipoprotein cholesterol versus low density lipoprotein cholesterol as a discriminating factor for myocardial infarction

Abstract Background Serum total cholesterol (TC) and LDL cholesterol (LDL-C) have been used as major laboratory measures in clinical practice to assess cardiovascular risk in the general population and disease management as well as prognosis in patients. However, some studies have also reported the use of non-HDL cholesterol (non-HDL-C). As non-HDL-C can be calculated by subtracting HDL-C from TC, both of which do not require fasting blood sample in contrast to LDL-C which requires fasting blood sample, we aimed to compare non-HDL-C with LDL-C as a predictor of myocardial infarction (MI). Methods This hospital based cross sectional study was undertaken among 51 cases of MI and equal number of controls. MI was diagnosed based on the clinical history, ECG changes and biochemical parameters. 5 mL of fasting blood sample was collected from each research participant for the analysis of lipid profile. Non-HDL-C was calculated by using the equation; Non-HDL-C = TC – HDL-C. Statistical analysis was performed using SPSS 14.0. Results 42 MI cases were dyslipidemic in contrast to 20 dyslipidemic subjects under control group. The differences in the median values of each lipid parameter were statistically significant between MI cases and controls. The lipid risk factors most strongly associated with MI were HDL-C (OR 5.85, 95% CI 2.41-14.23, P value = 0.000) followed by non-HDL-C (OR 3.77, 95% CI 1.64-8.66, P value = 0.002), LDL-C/HDL-C (OR 3.38, 95% CI 1.44-7.89, P value = 0.005), TC/HDL-C (OR 2.93, 95% CI 1.36-7.56, P value = 0.026), LDL-C (OR 2.70, 95% CI 1.20-6.10, P value = 0.017), TC (OR 2.68, 95% CI 1.04-6.97, P value = 0.042) and Tg (OR 2.54, 95% CI 1.01-6.39, P value = 0.047). Area under the receiver operating curve was greater for non-HDL-C than for LDL-C. Non-HDL-C was also found to be more sensitive and specific than LDL-C for MI. Conclusions HDL-C and non-HDL-C are better discriminating parameters than LDL-C for MI. Thus, we can simply perform test for HDL-C and non-HDL-C both of which do not require fasting blood sample rather than waiting for fasting blood sample to measure LDL-C.</p

Profile of Ectopic Pregnancy at Western Regional Hospital

Background &amp; Objective: Ectopic pregnancy (EP) is one of the common life threatening obstetric emergencies which if not recognized and managed on time can be ruptured which could be a cause of death.  Unfortunately, the world wide incidence of EP is in an increasing trend. The main objective of this study is to assess the frequency, trends, blood loss and management aspects of EP at Western Regional Hospital (WRH), Pokhara.Materials &amp; Methods: The study was carried out in the department of Obstetrics and Gynecolgy, WRH. Data were collected and analyzed from patient’s records and discharge summary during the period of 2072-1-1 to 2072-9-30 B.S, retrospectively. Total number of hospital deliveries (7250) during this period was obtained from record section. Diagnosis of EP was made by urine beta- hcg (human chorionic gonado-tropin hormone) test and pelvic ultrasonography.Results:  The incidence of ectopic pregnancy was one in every 168 deliveries. Forty three such ectopic pregnancies were diagnosed and managed during the period, the mean age was 26.34 years, the median being the age of 25-29 years (16 patients). Twenty seven patients had ruptured ectopic pregnancy. Of all the cases, the number of patients with heterotopic pregnancy and intra uterine contraceptive device (IUCD) in situ were one for each (2.3%). All cases were satisfactorily managed with no mortality, and a mean of 6.1 days of hospital stay.Conclusion: Ectopic pregnancies are common cause of hospital admission, irrespective of patient's age all of which were managed at WRH with no mortality.</p

Primary Percutaneous Coronary Intervention (PPCI) in acute myocardial infarction complicated with cardiogenic shock in a newly emerging cardiac center in Nepal

&lt;ul&gt;&lt;li&gt;&lt;strong&gt;BACKGROUND&lt;/strong&gt;: Acute myocardial infarction (AMI) is complicated by cardiogenic shock in 7~10% of patients. Mortality rate is exceedingly high and reaches 70-80% in those treated conservatively. Large thrombolytic trials demonstrate 60% mortality with most effective thrombolytic agent.&lt;/li&gt;&lt;li&gt;&lt;strong&gt;METHODS&lt;/strong&gt;: In between September 2005 to August 2008 total PCI in Shahid Gangalal National Heart Center (SGNHC) in Nepal was 452. Among them primary PCI (PPCI) in AMI with cardiogenic shock was done in only 16 patients (3.5%).&lt;/li&gt;&lt;li&gt;&lt;strong&gt;RESULTS&lt;/strong&gt;: This study showed in-hospital mortality of 50% (n = 8). Of 50% (n = 8) alive patients with cardiogenic shock who underwent PPCI, 6&amp;nbsp; atients are in routine follow-up over 12 months and 2 were doing well in subsequent 6 months but not in follow up after that.&lt;/li&gt;&lt;li&gt;&lt;strong&gt;CONCLUSION&lt;/strong&gt;: Primary PCI in AMI complicated by cardiogenic shock has lower mortality and improved outcome. High cost, high in-hospital ortality and lack of trained personnel are major limitations.&lt;/li&gt;&lt;li&gt;&lt;strong&gt;KEY WORDS:&lt;/strong&gt; Primary percutaneous coronary intervention, acute myocardial infarction, cardiogenic shock, SGNHC (Shahid Gangalal National Heart Center).&lt;/li&gt;&lt;/ul&gt

How Policy and Development Agencies Led to the Degradation of Indigenous Resources, Institutions, and Social-Ecological Systems in Nepal: Some Insights and Opinions

Rapid growth of environmental problems, economic volatilities, and social changes have increased the scopes of adopting environmentally friendly and resilient production systems. Regenerative farming and forestry practices are such systems appropriate for mountain communities in Nepal. They had performed better with indigenous resources, institutions, and social-ecological systems. Unfortunately, the assets have been degraded to extinction, mainly commencing works of national and international development agencies. Consequently, regenerative practices are disappearing. Despite appeals and commitments, the degradations of the assets are not halted and reversed. This study used secondary sources of data and work experiences and explained the working faults of the external agencies involved in the agriculture, forestry, and wildlife sectors. It elucidated that most regenerative practices had sustained well in forest and farm resource-integrated production systems and a modest degree of natural and human inputs and production environments. The production environments degraded when the government agencies provided foreign agencies opportunities to be involved actively in policy formulation and implementation of agriculture and forestry-related sectors. The foreign agencies meddled in the national policies and community practices and modified the production environments for their interests and benefits. They intervened in policies and local communities to practice a farming system based on extremely human-made and imported inputs and institutions and to manage forest-related resources in extremely intact natural systems. In the policy discourses and decisions, the farming inputs, practices, and institutions popularly practiced in developed countries are considered superior whereas the indigenous ones are considered inferior. Agricultural plans and policies have overvalued flash yield or other direct returned and undervalued environmental friendliness, indirect economic benefits, and social advantages to prioritize support of the government and other agencies. The introduced farming inputs and institutions displaced or hampered the indigenous ones. The foreign agencies also meddled in forest policies and practices of the country to address environmental and economic problems of developed countries which resulted in adverse impacts on the indigenous assets. They intervened in the resource management policies with financial and technical inputs to destroy some of the assets and make the forest-related resource management that results in better benefits (offsetting GHG emission, enhancing tranquility and serenity of recreational sites, and potentially expanding agricultural markets) to the people of developed countries. This study has explained how the officials and experts of both government and foreign agencies abused and misused some strategic tactics and overused, poorly used and disused, others in their work process to address their self-centered interests and problems. In essence, intentional destructive interventions of the policy and development agencies have resulted in degradation to the extinction of the indigenous assets in the communities

How Policy and Development Agencies Led to the Degradation of Indigenous Resources, Institutions, and Social-Ecological Systems in Nepal: Some Insights and Opinions

Rapid growth of environmental problems, economic volatilities, and social changes have increased the scopes of adopting environmentally friendly and resilient production systems. Regenerative farming and forestry practices are such systems appropriate for mountain communities in Nepal. They had performed better with indigenous resources, institutions, and social-ecological systems. Unfortunately, the assets have been degraded to extinction, mainly commencing works of national and international development agencies. Consequently, regenerative practices are disappearing. Despite appeals and commitments, the degradations of the assets are not halted and reversed. This study used secondary sources of data and work experiences and explained the working faults of the external agencies involved in the agriculture, forestry, and wildlife sectors. It elucidated that most regenerative practices had sustained well in forest and farm resource-integrated production systems and a modest degree of natural and human inputs and production environments. The production environments degraded when the government agencies provided foreign agencies opportunities to be involved actively in policy formulation and implementation of agriculture and forestry-related sectors. The foreign agencies meddled in the national policies and community practices and modified the production environments for their interests and benefits. They intervened in policies and local communities to practice a farming system based on extremely human-made and imported inputs and institutions and to manage forest-related resources in extremely intact natural systems. In the policy discourses and decisions, the farming inputs, practices, and institutions popularly practiced in developed countries are considered superior whereas the indigenous ones are considered inferior. Agricultural plans and policies have overvalued flash yield or other direct returned and undervalued environmental friendliness, indirect economic benefits, and social advantages to prioritize support of the government and other agencies. The introduced farming inputs and institutions displaced or hampered the indigenous ones. The foreign agencies also meddled in forest policies and practices of the country to address environmental and economic problems of developed countries which resulted in adverse impacts on the indigenous assets. They intervened in the resource management policies with financial and technical inputs to destroy some of the assets and make the forest-related resource management that results in better benefits (offsetting GHG emission, enhancing tranquility and serenity of recreational sites, and potentially expanding agricultural markets) to the people of developed countries. This study has explained how the officials and experts of both government and foreign agencies abused and misused some strategic tactics and overused, poorly used and disused, others in their work process to address their self-centered interests and problems. In essence, intentional destructive interventions of the policy and development agencies have resulted in degradation to the extinction of the indigenous assets in the communities