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Sitaram Khadka,1 Dhan Bahadur Shrestha,2 Pravash Budhathoki,3 Era Rawal4 1Department of Pharmacy, Shree Birendra Hospital; Nepalese Army Institute of Health Sciences, Kathmandu 44600, Nepal; 2Department of Emergency Medicine and General Practice, Mangalbare Hospital, Morang 56600, Nepal; 3Department of Emergency Medicine and General Practice, Dr Iwamura Memorial Hospital, Bhaktapur 44800, Nepal; 4Department of Emergency Medicine and General Practice, Kathmandu Medical College, Kathmandu 44600, NepalCorrespondence: Sitaram KhadkaDepartment of Pharmacy, Shree Birendra Hospital; Nepalese Army Institute of Health Sciences, Kathmandu 44600, NepalTel +00977-9851077589Email sitaram.khadka@naihs.edu.npAbstract: Coronavirus disease (COVID-19) pandemic has been a global disease burden. It has affected more than sixteen million people in the world within seven months of its first outbreak in Wuhan. Different treatment modalities, therapeutic and prophylactic agents for its therapy are underway. Until the proven therapy gets available, repurposing of drugs is a better way out. Hydroxychloroquine (HCQ) has been a potential recourse of treatment in this regard for COVID-19 management. As different episodes of cardiac adverse events of HCQ are reported, safety concerns are now a prime objective. The risk-benefit analysis is mandatory to address rational drug therapy even in such a global health crisis. In this article, we want to evaluate the safety and efficacy of HCQ in COVID-19 management.Keywords: cardiac arrhythmia, COVID-19, drug repositioning, hydroxychloroquine, severe acute respiratory syndrome coronavirus-2

Background: Bilothorax is defined as the presence of bile in the pleural space. It is a rare condition, and diagnosis is confirmed with a pleural fluid-to-serum bilirubin ratio of >1., Methods: The PubMed, Embase, Google Scholar, and CINAHL databases were searched using predetermined Boolean parameters. The systematic literature review was done per PRISMA guidelines. Retrospective studies, case series, case reports, and conference abstracts were included. The patients with reported pleural fluid analyses were pooled for fluid parameter data analysis., Results: Of 838 articles identified through the inclusion criteria and removing 105 duplicates, 732 articles were screened with abstracts, and 285 were screened for full article review. After this, 123 studies qualified for further detailed review, and of these, 115 were pooled for data analysis. The mean pleural fluid and serum bilirubin levels were 72 mg/dL and 61 mg/dL, respectively, with a mean pleural fluid-to-serum bilirubin ratio of 3.47. In most cases, the bilothorax was reported as a subacute or remote complication of hepatobiliary surgery or procedure, and traumatic injury to the chest or abdomen was the second most common cause. Tube thoracostomy was the main treatment modality (73.83%), followed by serial thoracentesis. Fifty-two patients (51.30%) had associated bronchopleural fistulas. The mortality was considerable, with 18/115 (15.65%) reported death. Most of the patients with mortality had advanced hepatobiliary cancer and were noted to die of complications not related to bilothorax., Conclusion: Bilothorax should be suspected in patients presenting with pleural effusion following surgical manipulation of hepatobiliary structures or a traumatic injury to the chest. This review is registered with CRD42023438426., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2024 Roshan Acharya et al.)

Background and Aim: Obesity affects nearly 650 million adults worldwide, and the prevalence is steadily rising. This condition has significant adverse effects on cardiovascular health, increasing the risk of hypertension, coronary artery disease, heart failure, and atrial fibrillation (AF). While anticoagulation for obese patients with AF is a well-established therapy for the prevention of thromboembolism, the safety and efficacy of different anticoagulants in this specific population are not well explored. This meta-analysis aimed to compare direct oral anticoagulants (DOAC) to vitamin K antagonists in obese populations with AF., Methods: The PRISMA guidelines were followed for this meta-analysis, registered in PROSPERO (CRD42023392711). PubMed, PubMed Central, Embase, Cochrane Library, and Scopus databases were searched for relevant articles from inception through January 2023. Two independent authors screened titles and abstracts, followed by a full-text review in Covidence. Data were extracted in Microsoft Excel and analyzed using RevMan v5.4 using odds ratio as an effect measure., Results: Two thousand two hundred fifty-nine studies were identified from the database search, and 18 were included in the analysis. There were statistically significant reductions in the odds of ischemic and hemorrhagic stroke in the DOAC group compared with the VKA group (OR 0.70, CI 0.66-0.75) and (OR 0.47, CI 0.35-0.62), respectively. In addition, the DOAC group exhibited lower odds of systemic embolism (OR 0.67, CI 0.54-0.83), major bleeding (OR 0.62, CI 0.54-0.72), and composite outcome (OR 0.72, CI 0.63-0.81)., Conclusion: Based on the findings from this meta-analysis, DOACs demonstrate superior safety and efficacy in obese patients with AF compared with VKAs. These results may have significant implications for guiding anticoagulation strategies in this patient population., (© 2024 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Background and Aims: Despite the decriminalization of abortion in Nepal in 2002, unsafe abortion is still a significant contributor to maternal morbidity and mortality. Nepal has witnessed a significant drop in abortion-related severe complications and maternal deaths owing to the legalization of abortion laws, lowered financial costs, and wider accessibility of safe abortion services (SAS). However, various factors such as sociocultural beliefs, financial constraints, geographical difficulties, and stigma act as barriers to the liberal accessibility of SAS. This review aimed to determine key barriers obstructing women's access to lawful, safe abortion care and identify facilitators that have improved access to and quality of abortion services., Methods: A systematic search strategy utilizing the databases PubMed, CINAHL, Scopus, and Embase was used to include studies on the accessibility and safety of abortion services in Nepal. Data were extracted from included studies through close reading. Barriers and facilitators were then categorized into various themes and analyzed., Results: Of 223 studies, 112 were duplicates, 73 did not meet the inclusion criteria, and 18 did not align with the research question; thus, 20 studies were included in the review. Various barriers to SAS in Nepal were categorized as economic, geographic, societal, legal/policy, socio-cultural, health systems, and other factors. Facilitators improving access were categorized as economic/geographic/societal, legal/policy, socio-cultural, and health systems factors. The patterns and trends of barriers and facilitators were analyzed, grouping them under legal/policy, socio-cultural, geographic/accessibility, and health systems factors., Conclusion: The review identifies financial constraints, unfavorable geography, lack of infrastructure, and social stigmatization as major barriers to SAS. Economics and geography, legalization, improved access, reduced cost and active involvement of auxiliary nurse-midwives and community health volunteers are key facilitators., Competing Interests: The authors declare no conflict of interest., (© 2024 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Background and Aims: Current clinical guidelines for treating left ventricular thrombus (LVT) are limited by inadequate evidence to inform the comparative efficacy of oral anticoagulants. In this meta-analysis, we aimed to compare the efficacy and safety of direct oral anticoagulants (DOAC) to vitamin K antagonists (VKA) in patients with LVT., Methods: Four standard databases were searched for relevant literature comparing the efficacy and safety between DOAC and VKA for LVT treatment, published before August 19, 2023. Both the randomized controlled trials and observational studies were included in the analysis. The outcomes of interest were the resolution of LVT, all-cause mortality, stroke, systemic embolism, and bleeding. Data from the selected studies were extracted and analyzed using RevMan 5.4 using odds ratio., Results: Among 3959 studies from the database search and bibliography review, 33 were included in the analysis. LVT resolution was observed in 72.59% in the DOAC group versus 67.49% in the VKA group (odds ratio [OR]: 1.28, confidence interval [CI]: 1.07-1.53). Mortality was lower in the DOAC group (11.71% vs. 18.56%) (OR: 0.60, CI: 0.36-1.00; borderline statistical significance). Likewise, bleeding events (9.60% vs. 13.19%) (OR: 0.65, CI: 0.52-0.81) and stroke (7.54% vs. 11.04%) (OR: 0.71, CI: 0.53-0.96) were also significantly lower in the DOAC group., Conclusion: DOAC use for LVT showed better thrombus resolution and reduced risk of bleeding and stroke compared to VKA. Likewise, DOAC use was associated with lower mortality with borderline statistical significance., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Background and Aims: Hepatitis B is a leading cause of chronic liver disease and subsequent liver transplantation. This is a vaccine-preventable illness. Health workers continue to be at risk for blood-borne pathogens due to occupational exposures. The overall goals of our study were to determine the prevalence of exposure to needle sticks and sharp-related injuries (NSSI) and hepatitis B vaccination status among healthcare workers (HCWs) of Nepalgunj Medical College Teaching Hospital (NGMCTH), Kohalpur, Banke, Nepal., Methods: A descriptive cross-sectional study was conducted among HCWs at the NGMCTH following ethics approval by the NGMCTH Ethics Review Committee. A pretested structured questionnaire was used to compile the data. Data was collected from September 15, 2021 to September 14, 2022. Collected data entered in Microsoft Excel and analyzed using statistical package for social sciences version 22. Analyzed data were presented using simple descriptive statistics with appropriate figures and tables., Results: A total of 304 among 506 HCWs (60.1%) participated in the survey were exposed to Needle sticks. Nine of whom (3.7%) were injured substantially (more than 10 times). Among nursing students, 21.3% had experience with NSSI. 71.7% of HCWs had received at least one dose of the hepatitis B vaccine, of whom 61.9% (44.5% of total HCWs) had received three doses., Conclusions: This study demonstrated that more than two-quarters of HCWs were exposed to NSSI. Despite being at risk, vaccination status was still low, and less than half only received three complete doses. Precaution should be taken when working with instrumentation and procedures. Hepatitis B immunization programs for HCWs should be delivered at no cost with 100% coverage and protection. Raising awareness about hepatitis B infection and immunization remains crucial to primary prevention., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Background and Aims: Cerebral embolic protection (CEP) devices are employed to capture embolic debris and reduce the risk of stroke during transcatheter aortic valve replacement (TAVR). Evidence is mixed regarding the safety and efficacy of CEP. We aimed to summarize the safety and effectiveness of CEP use during TAVR., Methods: Electronic databases, including PubMed, PubMed Central, Scopus, Cochrane Library, and Embase, were searched using relevant search terms for articles relating to CEP. All relevant data from 20 studies were extracted into a standardized form. Statistical analyses were performed using Revman 5.4. Odds ratio (OR) or mean differences (MDs) were used to estimate the desired outcome with a 95% confidence interval (CI)., Results: Twenty studies (eight randomized controlled trials [RCTs]) involving 210,871 patients (19,261 in the CEP group and 191,610 in TAVR without the CEP group) were included. The use of CEP was associated with a lower odds of 30-day mortality by 39% (OR: 0.61, 95% CI: 0.53-0.70) and stroke by 31% (OR: 0.69, 95% CI: 0.52-0.92). Comparing devices, benefit in terms of mortality and stroke was observed with the use of the Sentinel device (Boston Scientific), but not among other devices. No differences were observed in the outcomes of acute kidney injury, major or life-threatening bleeding events, or major vascular complications between groups. When only RCTs were included, there were no observed differences in the primary or secondary outcomes for CEP versus no CEP use during TAVR., Conclusions: The totality of evidence suggests a net benefit for the use of CEP, weighted by studies in which the Sentinal device was used. However, given the RCT subanalysis, additional evidence is needed to identify patients at the highest risk of stroke for optimal decision-making., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

There are limited data available on outcomes and pathophysiology behind ST-segment elevation myocardial infarction (STEMI) in populations without standard modifiable risk factors (SMuRFs). The authors carried out this meta-analysis to understand the differences in treatment and outcomes of STEMI patients with and without SMuRFs., Methods: A systematic database search was performed for relevant studies. Studies reporting desired outcomes among STEMI patients with and without SMuRFs were selected based on predefined criteria in the study protocol (PROSPERO: CRD42022341389). Two reviewers independently screened titles and abstracts using Covidence. Full texts of the selected studies were independently reviewed to confirm eligibility. Data were extracted from all eligible studies via a full-text review of the primary article for qualitative and quantitative analysis. In-hospital mortality following the first episode of STEMI was the primary outcome, with major adverse cardiovascular events (MACE), repeat myocardial infarction (MI), cardiogenic shock, heart failure, and stroke as secondary outcomes of interest. Odds ratio (OR) with a 95% CI was used to estimate the effect., Results: A total of 2135 studies were identified from database search, six studies with 521 150 patients with the first STEMI episode were included in the analysis. The authors found higher in-hospital mortality (OR: 1.43; CI: 1.40-1.47) and cardiogenic shock (OR: 1.59; 95% CI: 1.55-1.63) in the SMuRF-less group with no differences in MACE, recurrent MI, major bleeding, heart failure, and stroke. There were lower prescriptions of statin (OR: 0.62; CI: 0.42-0.91) and Angiotensin converting enzyme inhibitor /Angiotensin II receptor blocker (OR: 0.49; CI: 0.28-0.87) at discharge in SMuRF-less patients. There was no difference in procedures like coronary artery bypass graft, percutaneous coronary intervention, and thrombolysis., Conclusion: In the SMuRF-less STEMI patients, higher in-hospital mortality and treatment discrepancies were noted at discharge., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Outcomes following in-hospital cardiac arrest (IHCA) in patients with COVID-19 have been reported by several small single-institutional studies; however, there are no large studies contrasting COVID-19 IHCA with non-COVID-19 IHCA. The objective of this study was to compare the outcomes following IHCA between COVID-19 and non-COVID-19 patients., Methods: We searched databases using predefined search terms and appropriate Boolean operators. All the relevant articles published till August 2022 were included in the analyses. The systematic review and meta-analysis were conducted as per Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. An odds ratio with a 95% confidence interval (CI) was used to measure effects., Results: Among 855 studies screened, 6 studies with 27,453 IHCA patients (63.84% male) with COVID-19 and 20,766 (59.7% male) without COVID-19 were included in the analysis. IHCA among patients with COVID-19 has lower odds of achieving return of spontaneous circulation (ROSC) (OR: 0.66, 95% CI: 0.62-0.70). Similarly, patients with COVID-19 have higher odds of 30-day mortality following IHCA (OR: 2.26, 95% CI: 2.08-2.45) and have 45% lower odds of cardiac arrest because of a shockable rhythm (OR: 0.55, 95% CI: 0.50-0.60) (9.59% vs. 16.39%). COVID-19 patients less commonly underwent targeted temperature management (TTM) or coronary angiography; however, they were more commonly intubated and on vasopressor therapy as compared to patients who did not have a COVID-19 infection., Conclusions: This meta-analysis showed that IHCA with COVID-19 has a higher mortality and lower rates of ROSC compared with non-COVID-19 IHCA. COVID-19 is an independent risk factor for poor outcomes in IHCA patients.

Background: There is no clear consensus on the preference for pharmacological cardioversion (PC) in comparison to electric cardioversion (EC) for hemodynamically stable new-onset atrial fibrillation (NOAF) patients presenting to the emergency department (ED)., Methods: A systematic review and meta-analysis was conducted to assess PC (whether being followed by EC or not) vs. EC in achieving cardioversion for hemodynamically stable NOAF patients. PubMed, PubMed Central, Embase, Scopus, and Cochrane databases were searched to include relevant studies until 7 March 2022. The primary outcome was the successful restoration of sinus rhythm, and secondary outcomes included emergency department (ED) revisits with atrial fibrillation (AF), hospital readmission rate, length of hospital stay, and cardioversion-associated adverse events., Results: A total of three randomized controlled trials (RCTs) and one observational study were included. There was no difference in the rates of successful restoration to sinus rhythm (88.66% vs. 85.25%; OR 1.14, 95% CI 0.35-3.71; n = 868). There was no statistical difference across the two groups for ED revisits with AF, readmission rates, length of hospital stay, and cardioversion-associated adverse effects, with the exception of hypotension, whose incidence was lower in the EC group (OR 0.11, 95% CI 0.04-0.27: n = 727)., Conclusion: This meta-analysis suggests that there is no difference in successful restoration of sinus rhythm with either modality among patients with hemodynamically stable NOAF.

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia associated with high morbidity and mortality. AF treatment is guided by a patient-provider risk-benefit discussion regarding drug versus ablation or combination. Thermal ablation has a high rate of adverse events compared to pulsed field ablation (PFA). In this systematic review, we aimed to determine the safety and efficacy of PFA., Methods: The electronic search for relevant articles in English was completed in PubMed, PubMed Central, Cochrane library, Scopus, and Embase databases till July 2022. The screening was completed via the use of Covidence software. The risk of bias assessment and data extraction from the included studies was performed, and the narrative synthesis was performed accordingly., Results: A total of six studies were selected for review and 1897 patients receiving PFA were involved in these studies. Our review was focused on pulmonary vein isolation success, major adverse events, and arrhythmia recurrence. Successful pulmonary vein isolation (PVI) was completed in 100% of cases except in two studies. In one of them, six out of seven patients (86%) in the epicardial cohort had successful PVI. In the MANIFEST-PF survey, the acute PVI success rate was 99.9%. The major complications were rare and included pericardial tamponade, vascular complications requiring surgery, and stroke. The atrial arrhythmia recurrence was higher in the thermal group than in the PFA group (39% vs. 11%)., Conclusions: The success rate of PVI by PFA is high, and major adverse events are low. PFA is found to decrease the recurrence of atrial arrhythmia compared to thermal ablation. Substantial randomized controlled trials (RCTs) are needed to validate the efficacy and safety of PFA over conventional methods.

Importance: The usefulness of computed tomography of the head (CTH) in patients with acute-onset atraumatic altered mental status (AMS) is poorly understood, but use in these patients remains high., Objective: To evaluate the use of CTH (event rate) in patients with AMS and the positive outcome event rate of the performed CTH studies., Data Sources: The PubMed/MEDLINE, PubMed Central, Embase, and CINAHL databases were searched using predefined Boolean parameters. All studies that met inclusion criteria until January 31, 2022, were included., Study Selection: Randomized clinical trials and observational, cohort, and case-control studies were included. Conference abstracts, reviews, letters, case reports, case series, systematic literature, and meta-analyses were excluded., Data Extraction and Synthesis: The systematic literature review was performed per Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data were independently extracted by 2 authors. Data were pooled using a random-effects method., Main Outcomes and Measures: Event rate of CTH use in patients with acute atraumatic AMS. The CTH event rates and positive CTH event rates were calculated with 95% CIs., Results: Of 9338 studies identified, 26 qualified for the systematic review and 25 for the meta-analysis. The 25 studies in the meta-analysis included a total of 79 201 patients. The CTH event rate was 94% (proportion, 0.94; 95% CI, 0.76-1.00), and the positive CTH event rate was 11% (proportion, 0.11; 95% CI, 0.07-0.15). There was significant heterogeneity among the studies included (I2 > 50%, P < .001), for which a random-effects model was used. There was significant publication bias, as evident by an asymmetric funnel plot. There was no fluctuation of the results during the sensitivity analysis, which reassured the reliability of the data., Conclusions and Relevance: In this meta-analysis, CTH use among patients with acute-onset atraumatic AMS was very high with a low yield. Large-scale studies are needed to guide clinical decision-making in such a situation.

The study aimed to determine the level of self-reported adherence to antihypertensive drug(s) and its associated factors among patient with hypertension at a tertiary care center. The authors performed hospital based observational cross-sectional study using semi-structured questionnaires, WHO STEP tool and Hill and Bone high blood pressure compliance scale from December 1, 2021 to February 28, 2022. Descriptive statistics, Chi-square/Fisher's exact test and non-parametric tests were used for statistical analysis. Among 150 cases included in the study, majority (94, 62.67%) had good adherence based on Hill and Bone high blood pressure compliance scale with adherence level labelled as "good adherence" (score 3) and "not good adherence" (score < 3). The adherence to drug therapy was significantly better in females compared to males (50 [71.43%] vs. 44 [55.00%], p = .038). Among the factors related to hypertension and anti-hypertensive therapy, people with higher body mass index (ρ = -.324, n = 56, p = .015) and taking three or more pills (6, 1.71%, p = .017) had lower adherence to therapy. Likewise, forgetfulness (30, 53.57%), ineffective counseling (7, 12.50%), and missed follow-up (13, 23.21%) were the factors associated with lower adherence to anti-hypertensive therapy. This study finds good adherence among the patients taking anti-hypertensive medications. However, with the improved education, lesser number of pills and physical fitness help to adhere with the anti-hypertensive therapy., (© 2022 The Authors. The Journal of Clinical Hypertension published by Wiley Periodicals LLC.)

Background: Dengue is one of the common arboviral infections and is a public health problem in South East Asia. The aim of this systematic review and meta-analysis was to evaluate the prevalence and distribution of dengue in SAARC (South Asian Association for Regional Cooperation) countries., Methods: The PubMed, PubMed Central, Embase and Scopus databases were searched for relevant studies. Statistical analysis on data extracted from the selected studied was conducted using the Comprehensive Meta-Analysis Software (CMA) version 3 software package. Proportions were used to estimate the outcome with a 95% confidence interval (CI)., Results: Across all studies, among cases of suspected dengue, 30.7% were confirmed dengue cases (proportion: 0.307, 95% CI: 0.277-0.339). The seroprevalence of dengue immunoglobulin (Ig)G, IgM or both (IgM and IgG) antibodies and dengue NS1 antigen was 34.6, 34.2, 29.0 and 24.1%, respectively. Among the different strains of dengue, dengue virus (DENV) strains DENV-1, DENV-2, DENV-3 and DENV-4 accounted for 21.8, 41.2, 14.7 and 6.3% of cases, respectively. The prevalence of dengue fever, dengue hemorrhagic fever and dengue shock syndrome was 80.5, 18.2 and 1.5%, respectively. Fever was a commonly reported symptom, and thrombocytopenia was present in 44.7% of cases. Mortality was reported in 1.9% of dengue cases., Conclusions: Dengue is a common health problem in South East Asia with high seroprevalence. DENV-2 was found to be the most common strain causing infection, and most dengue cases were dengue fever. In addition, thrombocytopenia was reported in almost half of the dengue cases., (© 2022. The Author(s).)

Background: Headache is the most prevalent neurological symptom which can be of a serious condition, as in brain tumor, but mostly it is a benign condition that includes primary headache such as migraine or tension-type headache (TTH). Migraine reoccurs frequently and is more severe but owing to the high prevalence of TTH, however, impaired quality of life due to TTH is greater than that of migraine at the population level. Medical students are constantly subjected to stress and in such a condition, it was necessary to find out the burden of headache among medical students. This cross-sectional study done among medical students aims to generate some data and literature which will change the outlook of stakeholders towards headache disorders among medical students., Methods: This cross-sectional study is based upon Headache Screening Questionnaire-English Version questionnaire based upon the ICHD-3 beta criteria. Medical students of Kathmandu valley were sampled by using convenient sampling and data were collected. Data were refined in Microsoft Excel and imported to SPSS 20 for analysis., Results: A total of 352 individuals were part of this study, out of which 229 (65.1%) were males and 123 (34.9%) were females with a mean age of 21.72 ±  1.601 years (mean ± SD). Prevalence of migraine and TTH was found to be 15.3% (95% confidence interval [CI]: 11.7%-19.3%) and 40.3% (95% CI: 34.9-45.2), respectively. Through multivariate binomial regression, it was observed that the odds of being diagnosed with migraine increased with age (adjusted odds ratio [AOR] = 1.266 [1.013-1.583], p  = 0.038), females had twice the odds of experiencing migraine headaches compared to males (AOR = 2.119 [1.074-4.180], p  = 0.03), and medical students who stayed at the hostel were at lesser odds of experiencing migraine headache (AOR = 2.772 [1.501-5.118], p  = 0.01)., Conclusion: Prevalence of migraine and TTH among undergraduate medical students was found to be 15.3% and 40.3%, respectively., Competing Interests: The authors declare no conflict of interest., (© 2022 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Ascites is the most common complication of liver cirrhosis. Midodrine is a vasoconstrictor that improves splanchnic and systemic hemodynamics, reduces ascites, and improves clinical outcomes. Here, we aimed to examine the role of midodrine in cirrhosis-related ascites. Scopus, Embase, PubMed, and PubMed Central databases were searched for relevant randomized controlled trials comparing midodrine with other interventions in patients with cirrhotic ascites on November 25, 2020, using appropriate keywords like "midodrine", "ascitic cirrhosis", "peritoneal paracentesis" and suitable Boolean operators. Odds ratio (OR) and mean difference (MD) were used to analyze pool data as appropriate with a 95% confident interval (CI). A total of 14 studies were included in our analysis including 1199 patients. The addition of midodrine resulted in statistically significant improvement in mean arterial pressure (MAP) (MD, 3.95 mmHg; 95% CI, 1.53-6.36) and MELD (Model for End-Stage Liver Disease) score (MD, -1.27; 95% CI, -2.49 to -0.04) compared to standard medical treatment (SMT). There was also a significant improvement in plasma renin activity and plasma aldosterone concentration. However, there was no significant improvement in mortality or serum creatinine compared to SMT. In addition, there was no statistically significant improvement in MAP, plasma renin activity, plasma aldosterone concentration, MELD score, overall mortality, and paracentesis-induced circulatory dysfunction comparing midodrine with albumin. Midodrine alone leads to significant improvement in various clinical parameters in patients with cirrhotic ascites compared to standard medical care. At the same time, it was found to be non-inferior to albumin. Therefore, further well-designed studies need to be carried out on midodrine in addition to albumin for optimal clinical benefits among patients with ascites due to cirrhosis., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Shrestha et al.)

Background:  Extracorporeal membrane oxygenation (ECMO) has emerged as a newer method for managing severe acute respiratory distress syndrome (ARDS) and ARDS refractory to conventional management. However, its current role in the management of ARDS is not clear. Therefore, we conducted this meta-analysis to compare the mortality rates of ECMO over conventional management in ARDS., Methods:  PubMed, PubMed Central, Embase, and Scopus were searched using appropriate keywords. We selected studies in adults with ARDS that compared the outcomes of patients treated with ECMO vs. conventional management. Cochrane Risk of Bias (RoB) 2.0 and the JBI (Joanna Briggs Institute) quality assessment tools were used for assessing the risk of bias in RCTs and observational studies, respectively. The I 2 statistic was used to evaluate heterogeneity, and quantitative synthesis was performed using fixed or random effects to pool studies based on heterogeneities. Meta-analysis was conducted using Revman 5.4., Result: Twelve studies were included in this meta-analysis. As compared to the conventional management (mechanical ventilation: MV), patients treated with ECMO had lower odds of 30-days mortality (OR, 0.56; 95% CI, 0.37 to 0.84) and 90 days mortality (OR, 0.59; 95% CI, 0.41 to 0.85). However, there was no significant difference between in-hospital mortality (OR, 0.75; 95% CI, 0.40 to 1.41) and intensive care unit (ICU) mortality (OR, 1.00; 95% CI, 0.36 to 2.79). Similarly, length of hospital stays (LOS) (MD, 3.92; 95% CI, -6.26 to 14.11) did not show statistically significant differences across the two groups. However, the average ICU stay (ICU LOS) was 7.28 days longer in the ECMO group compared with the MV group (MD, 7.28; 95% CI, 2.55 to 12.02)., Conclusion:  Twenty-eight days and 90-days mortality were decreased in patients managed with ECMO compared with the MV group. Also, ICU LOS was found to be longer in the ECMO group. Furthermore, no statistical difference was found between the two groups for in-hospital mortality and hospital LOS., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Shrestha et al.)

Background and Aim: Norepinephrine is currently the first-line vasopressor for septic shock. We conducted this meta-analysis to examine the outcomes of adult patients with septic shock who received vasopressin instead of norepinephrine., Methods: We selected studies in adults with septic shock that compared the outcomes of patients treated with vasopressin versus norepinephrine. Cochrane ROB 2.0 and the Joanna Briggs Institute quality assessment tools were used to assess the risk of bias in RCTs and observational studies. Meta-analysis was conducted using RevMan 5.4., Results: Eight studies were included in this meta-analysis. There were no significant differences in 28-day mortality rates (OR, 1.07; CI, 0.80-1.44) and intensive care unit (ICU) mortality (OR, 0.74; CI, 0.21-2.67) between the two groups. Similarly, length of ICU stay, length of hospital stay, mean arterial pressure at 24 h, urine output at 24 h, and serious adverse events also did not differ significantly. However, the odds of renal replacement therapy (RRT) requirement in the vasopressin group were substantially lower than in the norepinephrine group (OR, 0.68; CI, 0.47-0.98)., Conclusion: There were no differences in mortality, duration of hospitalization, and adverse effects in adults with septic shock across the two groups. However, the patients treated with vasopressin had lower chances of requiring RRT., Relevance for Patients: Vasopressin use as the first-line vasopressor in septic shock showed a significant reduction in RRT, though there were no significant differences in terms of mortality and other adverse events. Therefore, vasopressin can be considered as a first-line vasopressor in septic shock patients with other risk factors which may contribute to renal failure requiring RRT., Competing Interests: The authors declare that they have no competing interests., (Copyright: © 2022 Whioce Publishing Pte. Ltd.)

Introduction: Chronic kidney disease is defined as structural or functional damage of the kidney persisting for three or more months. Studies have shown hypertension and diabetes as the leading causes of chronic kidney disease. The aim of this study is to find out the prevalence of end-stage renal disease patients undergoing haemodialysis in a tertiary care hospital., Methods: This was a descriptive cross-sectional study conducted among 96 patients undergoing haemodialysis from February 13, 2021 to April 4, 2021 in the hemodialysis unit of a tertiary care centre after receiving ethical clearance from the Institutional Review Committee (Reference number: 354). Convenience sampling was done and all patients older than 18 years who were on maintenance haemodialysis on an outpatient basis were included in the study. Data were collected using a self-administered questionnaire. Data were analysed using the Statistical Package for the Social Science version 22.0. Point estimate at 95% Confidence Interval was calculated along with frequency and percentages for binary data and mean with standard deviation for continuous data., Results: Among 96 patients undergoing haemodialysis, the prevalence of end-stage renal disease was 83 (86.45%) (79.60-93.30 at 95% Confidence Interval). The most common underlying condition was hypertensive nephropathy in 34 (40.96%) patients, followed by both hypertensive and diabetic nephropathy in 26 (31.33%) patients., Conclusions: The prevalence of end-stage renal disease in our study was higher when compared to similar studies conducted in similar settings. Early diagnosis and adequate treatment of hypertension and diabetes could be crucial to reducing the prevalence of the end-stage renal disease., Keywords: chronic kidney failure; chronic renal insufficiency; end stage renal disease; hemodialysis; Nepal.

Background Teenage pregnancy is considered a high-risk pregnancy in terms of reproductive outcome and the subsequent financial constraint. Objective To assess the prevalence of teenage pregnancy, associated risk factors, and outcomes in the context of Nepal. Method We searched electronic databases to search relevant articles published from January 2000 till October 2020 using the keywords with appropriate Boolean operators. All the data were extracted into a standardized form designed in Excel. We conducted a statistical analysis using Comprehensive Meta-Analysis Software (CMA) version 3. Data pooled for proportion with 95% confidence interval (CI). A Forest plot was used to visualize the degree of variation between studies. Result Fourteen studies were included in the analysis after the rigorous screening of 4425 studies. Prevalence of teenage pregnancy was 13.2% (Proportion, 0.132; CI, 0.077- 0.215). Among teenage pregnancies, 11.8% were already multigravida (Proportion, 0.118; CI, 0.029-0.374). Among teen pregnancies, 18.6% were illiterate; among the literate, only 25.9% were of education above grade 10,31.9% were unaware of contraceptive methods, and only 3.2% reported using any contraception methods. 75.4% of teenage pregnancies had a vaginal delivery with or without episiotomy, 6.5% by instrumental deliveries, and 21.5% by cesarean section. Preterm delivery was 12.0%, and post-term delivery was 8.2%. Abortion was reported in 11.1% of teenage pregnancies. Major tears were reported in 52.9%, obstructed labor was in 4%, and pre-labor rupture of the membrane was in 7.0% of teenage pregnancies. The low birth weight of newborns was 19.4%. Stillbirth and neonatal deaths were 1.7% and 1.4%, respectively. Conclusion The prevalence of teenage pregnancy in Nepal was 13.2%. The majority of them did not use any form of contraceptives; and had low education. Several maternal and neonatal complications were reported among teenage pregnancies.

Background: The current guidelines recommend targeted temperature management (TTM) as part of the post-resuscitation care for comatose patients following out-of-hospital cardiac arrest. These recommendations are based on the weak evidence of benefit seen in the early clinical trials. Recent large multicentered trials have failed to show a meaningful clinical benefit of hypothermia, unlike the earlier studies. Thus, to fully appraise the available data, we sought to perform this systematic review and meta-analysis of randomized controlled trials., Methods: We searched four databases for randomized controlled trials comparing therapeutic hypothermia (32-34 °C) with normothermia (≥36 °C with control of fever) in adult patients resuscitated after out-of-hospital cardiac arrest. Independent reviewers did the title and abstract screening, full-text screening, and extraction. The primary outcome was mortality six months after cardiac arrest, and secondary outcomes were neurological outcomes and adverse effects., Relevance for Patients: Six randomized controlled trials were included in this review. There was no significant difference between the hypothermia and normothermia groups in mortality till 6 months follow up after out-of-hospital cardiac arrest (OR 0.88, 95% CI 0.67-1.16; n = 3243; I 2  = 51%), or favorable neurological outcome (OR 1.31, 95% CI 0.93-1.84; n = 3091; I 2  = 68%). Rates of arrhythmias were notably higher in the hypothermia group than the normothermia group (OR 1.43, 95% CI 1.20-1.71; n = 3029; I 2  = 4%). However, odds for development of pneumonia showed no significant differences across two groups (OR 1.13, 95% CI 0.98-1.31; n = 3056; I 2  = 22%). Therefore, targeted hypothermia with a target temperature of 32-34 °C does not provide mortality benefit or better neurological outcome in patients resuscitated after the out-of-hospital cardiac arrest when compared with normothermia., Competing Interests: The authors declare that they have no competing interests., (© 2022 The Authors.)

Gallstone disease is the common cause of acute pancreatitis. The role of early endoscopic retrograde cholangiopancreatography (ERCP) in biliary pancreatitis without cholangitis is not well-established. Thus, this study aims to compare the outcome of early ERCP with conservative management in patients with acute biliary pancreatitis without acute cholangitis. An online search of PubMed, PubMed Central, Embase, Scopus, and Clinicaltrials.gov databases was performed for relevant studies published till December 15, 2020. Statistical analysis was performed using RevMan v 5.4 (The Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen). Odds Ratio (OR) with a 95% confidence interval was used for outcome estimation. Among 2700 studies from the database search, we included four studies in the final analysis. Pooling of data showed no significant reduction in mortality (OR 0.59, 95% CI 0.32 to 1.09; p=0.09); overall complications (OR 0.56, 95% CI 0.30 to 1.01; p=0.05); new-onset organ failure (OR 1.06, 95% CI 0.65 to 1.75; p=0.81); pancreatic necrosis (OR 0.80, 95% CI 0.49 to 1.32; p=0.38); pancreatic pseudo-cyst (OR 0.44, 95% CI 0.16 to 1.24; p=0.12); ICU admission (OR 1.64, 95% CI 0.97 to 2.77; p=0.06); and pneumonia development (OR 0.81, 95% CI 0.40 to 1.65; p=0.56) by urgent ERCP comparing with conventional approach for acute biliary pancreatitis without cholangitis. Henceforth, early ERCP in acute biliary pancreatitis without cholangitis did not reduce mortality, complications, and other adverse outcomes compared to the conservative treatment., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Shrestha et al.)

Introduction: Cesarean Section is the most common obstetrics surgery done for both maternal and fetal indications. There is a rising trend of cesarean section rates which is associated with increased maternal morbidities. This study aims to find out the prevalence of repeat Cesarean Section among women with previous cesarean sections done in a tertiary centre., Methods: This was a descriptive cross-sectional study conducted in a tertiary care hospital of Nepal from August 2020 to January 2021. Pregnant women with previous Cesarean Section status without other pelvic surgery and medical comorbidities were included and data were collected regarding intraoperative findings. Ethical approval was taken from the Institutional Review Committee (Reference Number: 14). A convenience sampling technique was used. Data were analysed using Statistical Package for the Social Sciences version 22. Point estimate at 95% Confidence Interval was calculated, with frequency and percentage., Results: Out of 1315 patients undergoing Cesarean Section, the prevalence of Repeat Cesarean Section was found to be 184 (13.99%) (12.11-15.86 at 95% Confidence Interval)., Conclusions: The prevalence of Repeat Cesarean Cection from our study was similar to other studies done in similar settings. Repeat Cesarean Cection confers peri-operative morbidities which adversely affect postoperative recovery. Repeat Cesarean Cection continues to contribute to morbidity over subsequent pregnancies and serious maternal morbidity.

Introduced in the 1970s to meet the academic needs of a growing number of students with relatively stagnant faculty, team-based learning (TBL) has revolutionized the modern classroom structure. Contrary to the traditional didactic model where the teacher assumes the central role and students are passive listeners, TBL participants are actively involved in the learning process. Teachers act as facilitators while the TBL participants work in groups to solve problems through engagement with their peers. The objective of the article is to conduct a systematic review on team-based learning using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The studies were searched in databases like PubMed®, Scopus®, Embase®, and PubMed Central® using appropriate keywords. Two authors screened the papers, and a third author resolved the conflicts. This was followed by a bibliographic review based on the references of the selected study and bias assessment using the Joanna Briggs Institute (JBI) critical appraisal tool. The team-based learning model is increasingly being used by different institutions globally. TBL and traditional lecture-based teaching outcomes revealed that TBL participants performed better in academic, clinical, and communication domains. In addition, TBL enhanced learners' engagement, collaborative spirit, and satisfaction. Our study results are similar to the prior meta-analysis and systematic review. Nevertheless, this systematic review remains more comprehensive, up-to-date, and inclusive thus far. Team-based learning is a pragmatic and superior approach to learning among health care professionals. It has resulted in better academic, clinical, and communication outcomes. This finding spans all the medical and allied professions studied in this systematic review., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Joshi et al.)

Background: An ever-increasing number of studies have reported an increased incidence of spontaneous pulmonary barotrauma such as pneumothorax, pneumomediastinum, and subcutaneous emphysema in patients with COVID-19. We conducted this systematic review and meta-analysis to assess the value and significance of the available data., Methods: A thorough systematic search was conducted to identify studies of barotrauma in hospitalized patients with COVID-19. Data analysis of case reports was done using a statistical package for the social sciences (SPSS) version 22, and meta-analysis was performed using CMA-3., Results: We identified a total of 4488 studies after thorough database searching.118 case reports and series, and 15 observational studies were included in the qualitative analysis. Fifteen studies were included in the quantitative analysis. The observational studies reported barotrauma in 4.2% (2.4-7.3%) among hospitalized patients; 15.6% (11-21.8%) among critically ill patients; and 18.4% (13-25.3%) in patients receiving invasive mechanical ventilation, showing a linear relationship of barotrauma with the severity of the disease. In addition, barotrauma was associated with a longer length of hospital stay, more extended ICU stay, and higher in-hospital mortality. Also, a slightly higher odds of barotrauma was seen in COVID-19 ARDS compared with non-COVID-19 ARDS., Conclusion: COVID-19 pneumonia is associated with a higher incidence of barotrauma. It presents unique challenges for invasive and non-invasive ventilation management. Further studies are required to unravel the underlying pathophysiology and develop safer management strategies., Competing Interests: The authors declare that they have no competing interests., (© 2022 The Authors.)

Direct oral anticoagulants (DOAC) including factor Xa inhibitors are associated with bleeding events which can lead to severe morbidity and mortality. Reversal agents like andexanet alfa (AA) and 4F-PCC (Four-factor prothrombin concentrate complex) are available for treating bleeding that occurs with DOAC therapy but a comparison on their efficacy is lacking. In this study, we analyzed the efficacy and safety of patients treated with andexanet alfa for bleeding events from DOAC. Databases were searched for relevant studies where AA was used to determine efficacy and safety in bleeding patients who were on factor Xa inhibitors. Published papers were screened independently by two authors. RevMan 5.4 (The Cochrane Collaboration, 2020) was used for data synthesis. Odds ratio (OR) and mean difference (MD) was used to estimate the outcome with a 95% confidence interval (CI). Among 1245 studies were identified after a thorough database search and three studies were included for analysis. AA resulted in lower odds of mortality compared to 4F- PCC (OR, 0.37; 95% CI, 0.20-0.71) among patients with intracerebral hemorrhage. There was no difference in thrombotic events between patients receiving AA and 4F-PCC (OR, 2.40; 95% CI, 0.36-15.84). No differences in length of hospital stay and intensive care unit (ICU) stay were seen between patients receiving AA and 4F-PCC. In conclusion, andexanet alfa reduced in-hospital mortality in patients who had bleeding due to factor Xa inhibitors compared to 4F-PCC. However, there were no differences in thrombotic events, length of ICU, and hospital stay between patients treated with AA and 4F-PCC., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Shrestha et al.)

Functional dyspepsia is a common gastrointestinal disorder characterized by postprandial fullness or early satiety and epigastric burning or pain in the absence of organic disease. Acotiamide is a novel prokinetic motility drug being used in functional dyspepsia. Databases like PubMed, PubMed Central, Embase, and Scopus were searched for studies comparing the use of acotiamide and placebo for people with functional dyspepsia. Quantitative synthesis was performed using RevMan 5.4 (Cochrane, London, United Kingdom). The improvement in symptoms of functional dyspepsia after treatment was higher in people treated with acotiamide than placebo, although not statistically significant (OR, 1.48; 95% CI, 0.93 to 2.35; n = 1697; I 2 = 59%). Among the commonly reported adverse effects, namely, raised in serum prolactin (OR 1.02, 95% CI 0.64 to 1.61; n = 1709; I 2 = 44%), raised in alanine transaminase (OR 1.27, 95% CI 0.70 to 2.33; n = 1709; I 2 = 0%), and raised in serum bilirubin (OR, 0.98; 95% CI, 0.52 to 1.87; I 2 = 0%) did not differ between two groups. Acotiamide seems to be a promising agent in functional dyspepsia. However, further larger studies are needed to evaluate the role of acotiamide in functional dyspepsia., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Shrestha et al.)

Belimumab is a recombinant human IgG-1λ monoclonal antibody. It inhibits the B-cell activating factor (BAFF) and is approved for patients with systemic lupus erythematosus (SLE) older than five years with positive autoantibody. We aimed to evaluate the role of belimumab in the maintenance phase of treatment for lupus nephritis (LN). PubMed, PubMed Central (PMC), Cochrane Library, and Embase were searched using appropriate keywords. The screening of title and abstract was done in Covidence, followed by data extraction of the relevant studies based on inclusion criteria. Review manager (RevMan 5.4) was used for data analysis with random or fixed effects model based on heterogeneities. Two randomized controlled trials were included in the quantitative analysis. There were 1.71 times higher odds of complete renal response in the belimumab group than in the control group (odds ratio (OR), 1.71; 95% confidence interval (CI), 1.12-2.60; I-square (I 2 ) ​​​​= 0%). Similarly, there was 34% lower odds for having no response among the belimumab group (OR, 0.66; 95% CI, 0.45-0.96; I 2 = 0%). No significant differences between the two groups were observed for the occurrence of treatment-related adverse events (TRAEs) (OR, 1.07; 95% CI, 0.74-1.56; I 2 = 0%), treatment-related serious adverse events (OR, 0.54; 95% CI, 0.15-1.96; I 2 = 68%), and treatment-related infections (OR, 0.65; 95% CI, 0.27-1.55; I 2 = 21%).Therefore, belimumab and standard treatment were instrumental for beneficial renal response in patients with lupus nephritis and were not associated with increased odds of adverse effect compared with the standard treatment alone., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Shrestha et al.)

After almost a year of declaring COVID-19 a global pandemic, unusual presentations of the disease continue to be reported. Very little is known about its association with pleural disease. Here, we present a case of empyema thoracis in a 39-year-old male admitted with COVID-19. The pleural fluid later turned serosanguinous and eventually bleeding from other sites also occurred. During his treatment, antibiotics were given, thoracocentesis was performed and later thoracotomy was done. He died on the 19th day of admission following a hemorrhagic stroke. Pleural disease, although considered atypical and unusual presentation of COVID-19, needs careful and prompt diagnosis and earliest intervention. COVID-19, being a disease that involves multiple systems, and presentation of the disease may eventually lead to circulatory dysfunction and hence should be kept under consideration.