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Background: Most of the scoring systems to predict difficult laparoscopic cholecystectomy are based on pre-operative clinical and radiological findings. Recently the Parkland Grading Scale system was introduced as a simple intra-operative grading scale. This study aims to utilize the Parkland Grading Scale system to assess the intraoperative challenges during laparoscopic cholecystectomy. Method: This was a prospective, cross-sectional study done at Chitwan Medical College and Teaching Hospital, Chitwan, Nepal. All the patients underwent laparoscopic cholecystectomy from April 2020 to March 2021. Based on the initial intra-operative finding, Parkland Grading Scale was noted and at the end of the surgery, the level of difficulty was given by the operating surgeon. All the pre-operative, intra-operative, and post-operative findings were compared with the scale. Results: Out of 206 patients, there were 176 (85.4%) females, and 30 (14.6%) males. The median age was 41 years (Range 19–75). The median body mass index was 23.67 kg/m2. There were 35(17%) patients with a history of previous surgery. The rate of conversion to open surgery was 5.8%. According to Parkland Grading Scale, 67(32.5%), 75(36.4%), 42(20.4%), 15(7.3%), and 7(3.4%) were graded as grade 1, 2, 3, 4, and 5 respectively. There was a difference in the Parkland grading scale in patients with a history of acute cholecystitis, gallbladder wall thickness, pericholecystic collection, stone size, and body mass index (p < 0.05). The total operative time, level of difficulty in surgery, rate of help needed from colleagues or replacement as the main surgeon, bile spillage, drain placement, gallbladder decompression, and conversion rate all increased with an increase in scale (p < 0.05). There was a significant increase in the development of post-operative fever, and post-operative hospital stay as the scale increased (p < 0.05). The Tukey-Kramer test for all pair-wise comparisons revealed that each grade was significantly different from each other (p < 0.05) on the difficulty of surgery except for grade 4 from 5. Conclusion: Parkland Grading Scale system is a reliable intra-operative grading system to assess the difficulty in laparoscopic cholecystectomy and helps the surgeon to change the strategy of surgery. An increase in scale is associated with an increased difficulty level of the surgery. [ABSTRACT FROM AUTHOR]

Introduction: COVID-19 is an emerging infectious disease with a high transmission rate and substantial deaths. Various vaccines have been developed to combat it. This study is aimed to assess COVID-19 vaccine acceptance and hesitancy among the Nepalese population through a web-based survey. Materials and methods: This is a web-based cross-sectional descriptive study of Nepalese people 18 years and above from different regions of Nepal who use social media (Facebook, Twitter, Reddit) as well as instant messaging applications (Messenger, Viber, WhatsApp). The duration of the study was 3 months from 1st June 2021 to 31st August 2021. The sampling technique used was self-selected non-probability sampling. A validated questionnaire had been taken to record the data. Results: A total of 307 participants were included in the study. About three-fourths of participants 231 (75.2%) had not been vaccinated while 76 (24.8%) had been vaccinated with COVID -19 vaccine. Out of 231 non-vaccinated participants, most of participants 213 (92.2%) had shown acceptance of the COVID-19 vaccine. More than two-thirds of participants believed that the vaccine would protect them, their family members, and the community from having COVID-19 in the future. Very few participants 18 (7.2%) were hesitant to receive the vaccine against COVID-19. About two-thirds of participants were being afraid of adverse effects of the COVID-19 vaccine while more than half of participants hesitated due to lack of enough information regarding COVID-19 vaccine. Conclusion: This study can aid in the planning of vaccination campaigns and the direction of future public health efforts aimed at increasing COVID-19 vaccine uptake. [ABSTRACT FROM AUTHOR]

Background: The liver is the second most injured organ following blunt abdominal trauma (BAT) after the spleen. Although the computed tomography (CT) scan is considered as the gold standard for diagnosing liver injury in BAT, it may not readily available in all the hospitals. This study was performed to evaluate the role of aspartate transaminase (AST) and alanine transaminase (ALT) in patients with BAT and its significance in predicting the diagnosis and severity of the liver injury. Method: The study was conducted in Chitwan Medical College Teaching Hospital (CMCTH) from February 2019 to May 2020. It was a prospective observational study. All the patients with BAT were received by on-duty surgical residents in the emergency department. Based on the imaging and operative finding, patients with liver injury and without liver injury were noted with the associated injury. For comparisons of clinical and grading characteristics between the two groups (liver injury and no liver injury), the chi-squared test was used for categorical variables as appropriate, and the Mann-Whitney U test used for quantitative variables (AST and ALT). The comparisons between more than two groups (grade of injury) were performed using the Kruskal-Wallis test. The receiver operating characteristic (ROC) was used to calculate the optimal cut-off value of AST and ALT. Results: Among the 96 patients admitted with BAT, 38 patients had liver injury and 58 patients had no liver injury. The median length of the intensive care unit (ICU) stay of patients with liver injury was higher than without liver injury. There was a significant difference in the median level of AST and ALT (< 0.001) between patients with liver injury and no liver injury. The area under the ROC curve of AST was 0.89 (95% confidence interval 0.86–0.98) and of ALT was 0.92 (95% confidence interval 0.83–0.97). The area under the curve demonstrated that the test was a good predictor for the identification of liver injury and also the severity of liver enzymes. The cut-off values for the liver injury were 106 U/l and 80 U/l for AST and ALT, respectively. Based on these values, AST ≥ 106 U/l had a sensitivity of 71.7%, a specificity of 90%, a positive predictive value of 86.8%, and a negative predictive value of 77.6%. The corresponding values for ALT ≥ 80 U/l were 77.8%, 94.1%, 92.1%, and 82.8%, respectively. Conclusion: In conclusion, we report the optimal cut-off value of AST and ALT for liver injury in BAT as ≥ 106 U/l and 80 U/l, respectively. The elevated level of AST and ALT might assist the emergency physicians and surgeons to timely refer the suspected patients with the liver injury to a tertiary center. [ABSTRACT FROM AUTHOR]

Background: Adherence to ART is the primary determinant of viral suppression and the risk of transmission, disease progression and death. Adherence of at least 95% is needed for optimal suppression. This study aimed at determining the adherence to Anti-Retroviral Therapy (ART) and its associated factors among People Living with HIV and AIDS in ART Center of Chitwan, Nepal.Methods: A descriptive cross-sectional study was conducted among 231 clients aged 18 years to 49 years taking ART from Bharatpur Hospital of Chitwan and those who have been enrolled in ART for at least 6 months, were interviewed. Systematic Sampling technique was used. Semi-structured questionnaire was prepared by taking reference from the AIDS Clinical Trial group questionnaire (ACTG). Adherence was measured by patient self report. Data was entered Epi Data 3.1 and analyzed using Statistical Package for Social Sciences (SPSS) software where the P value of < 0.05 was accepted as being statistically significant. The independent variables which were found significant at p-value 0.10 in bivariate analysis were fitted in multivariable logistic regression model. Multivariable logistic regression model was performed to know the net effect of the independent variables on Adherence to ART medication.Results: The overall adherence in the last month was found to be 87.4%. Wrist watch and mobiles were seen as a facilitating factor for taking ART on time as clients taking ART used to set alarm to get informed of the medication time. Adherence was associated with female sex (AOR = 10.550 CI: 1.854-60.046), family consisting only parents and their children (AOR = 4.877, CI: 1.246-19.079), having no habit of taking alcohol (AOR = 5.842 CI: 1.294-26.383), HIV duration of more than 3 years (AOR = 10.055 CI: 2.383-42.430), picking up ART medications on their own (AOR = 7.861, CI: 1.670-36.998) and not having side effects of ART (AOR = 8.832, CI: 2.059-37.890).Conclusion: Identifying and evaluating the problems faced by ARV drug users can foster the achievement of ART related goals and addressing ART related problems in a rational way. Effective and appropriate monitoring of non adherence behaviors can help patients increase adherence level fostering improvement in treatment outcome. [ABSTRACT FROM AUTHOR]

Introduction: Pancreaticoduodenectomy (Whipple procedure), even after significant evolution, continues to be associated with a high morbidity. The study aimed to find out the prevalence of complications following pancreaticoduodenectomies performed by a single surgeon over a span of 20 years in tertiary care hospitals of Nepal., Methods: This was a descriptive cross-sectional study conducted from hospital records of patients who underwent pancreaticoduodenectomy between 1999 and 2019 at different institutions in Chitwan, where the principal author was involved. Ethical clearance was taken from the Institutional Review Committee. Convenience sampling was done. Patients' clinical characteristics and diagnoses were noted. Data entry was done using Statistical Package for the Social Sciences version 20. Point estimate at 95% Confidence Interval was calculated, with frequency and percentage., Results: Out of 327 patients who underwent pancreaticoduodenectomy, complications were found in 125 (38.2%) (32.9-43.7 at 95% Confidence Interval). Respiratory complications were the commonest 32 (9.8%), followed by septicemia 25 (7.6%) and cardiac complications 24 (7.3%). Delayed gastric emptying and postoperative pancreatic fistula were seen in 11 (6.8%) and 4 (2.5%) in the first decade respectively. In the second decade, delayed gastric emptying was noted in 2 (1.2%) and postoperative pancreatic fistula in 1 (0.6%) patient., Conclusions: The prevalence of complications in our study was comparable to other national and international studies. Surgery-specific complications such as delayed gastric emptying and postoperative pancreatic fistula showed a decline over the decade.

Online learning has been in a rising trend across the world due to increasing technology in education. Corona Virus Disease 2019 (COVID-19) pandemic enforced all the academic institutions to start online classes for the students. But the students' readiness for the adoption of online learning remains unknown. Hence, this study aimed to assess the readiness of online classes among students. Descriptive cross-sectional web based survey was carried out among 704 students who have enrolled in various streams of Bachelor level programs in Chitwan Medical College. The finding of this study revealed that 87.1% of students from various faculties were ready for online classes during COVID pandemic and 88.8% had internet facility in their home setting. Furthermore, this study found that readiness for online classes was significantly higher among female than male students (89.7% vs.83.5%, p=0.016) and students who had internet accessibility in their residence than those who did not have it (83.8% vs.34.2%, p=<0.001) but there was no significant association between readiness for online classes with academic programs (p=0.062) and years (p=0.905). Therefore, online learning can be considered as a viable alternative method in the academic institutions for the students. Keywords: COVID-19 Pandemic; online classes; readiness; students.

Introduction: The lack of knowledge among health care professionals leads to diagnostic delays, further spread of disease, and poor infection control practices. Health care professionals must be updated knowledge regarding COVID-19. This study aims to assess the knowledge of health care professionals regarding COVID -19 in a medical college in Chitwan., Methods: A Knowledge, Attitude and Practice Study was carried out in a tertiary care hospital in Chitwan, Nepal from April 22, 2020, to April 28, 2020. The institutional review committee of Chitwan Medical College provided ethical approval for the research. Data were collected with an online questionnaire using Google forms. The questionnaire was sent out to 724 potential responders who included health care professionals from medical, dental, nursing, and allied health sciences in Chitwan Medical College. A convenient sampling method was used for data collection. Data were analyzed using Statistical Package of Social Sciences., Results: A total of 181 respondents completed the web survey. Overall, a total of 35 (19.3%) respondents were found to have "Good" knowledge; 105 (58%) respondents had "Fair" knowledge and 41 (22.7%) respondents had "Poor" knowledge regarding various aspects of COVID-19. There was no significant difference among the various health professional groups in their knowledge scores under the four knowledge domains., Conclusions: The study of knowledge of health care professionals could act as a reference for the prevention and better management of COVID-19. This study shows that there is a need to implement periodic educational interventions and training programs on infection control practices for COVID-19 across all healthcare professions.

Critical Care Medicine is a specialty dealing with the comprehensive management of patients having, or at risk of developing, acute, life threatening organ dysfunction. The glaring need of critical care services and human resources for critical care have become more evident in the face of the current COVID-19 Pandemic. At this juncture, when the world is facing threat to humanity with an increasing number of deaths due to COVID 19 pandemic, the discussion about the need for ICU beds and human resources for critical care management has re-surfaced and is being increasingly realized. In Nepal, as of 15th April, 2020, there are 194 hospitals with ICU facilities. The total ICU bed strength is 1595 in 194 hospitals (which is approximately 6% of all hospital beds) and only around 50% of them are equipped with ventilators (840). These figures indicate that Nepal has approximately 2.8 ICU beds per 100,000 population. As Nepal braces to contain a major COVID-19 outbreak, the hospital capacities of the country have already come under huge pressure. If the number of confirmed cases of COVID-19 continue to rise at the current pace, the shortage of critical care facilities will become more glaring than ever before. The current pandemic is a tremendous opportunity for health planners to accelerate action and ensure that the country is well-equipped to contain the COVID-19 pandemic. We need to be working towards infrastructure and human resource strengthening and expansion in critical care, in order to efficiently contain the pandemic.

The COVID-19 pandemic is unfolding at an unprecedented pace. The unprecedented threat provides an opportunity to emerge with robust health systems. Nepal has implemented several containment measures such as Rapid Response Team formulation; testing; isolation; quarantine; contact tracing;surveillance, establishment of COVID-19 Crisis Management Centre and designation of dedicated hospitals to gear up for the pandemic. The national public health emergency management mechanisms need further strengthening with the proactive engagement of relevant ministries; we need a strong, real-time national surveillance system and capacity building of a critical mass of health care workers; there is a need to further assess infection prevention and control capacity; expand the network of virus diagnostic laboratories in the private sector with adequate surge capacity;implement participatory community engagement interventions and plan for a phased lockdown exit strategy enabling sustainable suppression of transmission at low-level and enabling in resuming some parts of economic and social life.

Emergency medicine, globally, is a developing specialty. The President of International Federation for Emergency Medicine penned down in a 2007 editorial that emergency medicine is rapidly becoming a global specialty. There are an increasing number of countries which are exploring ways to further build emergency medicine. The Hybrid International Emergency Medicine Training Program is the first collaborative international Emergency Medicine training developed in the UK. A Memorandum of Understanding has been signed among Doncaster and Bassetlaw Teaching Hospital, UK, International Centre for Emergency Medicine UK, International Academy of Medical Leadership, UK and Chitwan Medical College, Nepal.The HIEM program has been executed by CMC from November 15, 2018. As per the MOU, the International Training Registrars of HIEM Program will undergo 1st and 4rth Year of training at CMC, Nepal and the 2nd year and 3rd year of training at DBTH, UK. The HIEM Training Program is the first of its kind in the country; HIEM is the first post graduate emergency medicine program in Nepal which also has an international recognition and is unique in the sense that the programme is integrated with training in leadership and management.The HIEM Training Program is recognized by Royal College of Emergency Medicine, UK. CMC has committed to improving emergency care in Nepal by pioneering the HIEM Training Program. We are committed to fulfilling our moral and social responsibility to improve emergency care systems in the country through building up of a cadre of adequately trained Emergency Physicians. Keywords: Emergencies; emergency care; emergency medicine; Nepal.

Background: Sickle cell and thalassemia are the inherited disorders of globin chain synthesis, and are the most common monogenic disease worldwide. This study aims to find the distribution of hemoglobinopathies (sickle cell and thalassemia) cases in Nepal using laboratory based data., Methods: A retrospective study was carried out at five different sites of Nepal Government that uses capillary electrophoresis for screening of hemoglobin disorders from January 2019 to March 2019. All the cases diagnosed positive for hemoglobinopathy till December 2018 were collected from laboratory record at each sites, and analyzed using Statistical Package for Social Sciences (SPSS version 20.0)., Results: Out of total 4018 patients tested during the period in all five different sites, 1470 were diagnosed positive for hemoglobinopathy. Sickling disorder was the most predominant hemoglobinopathy followed by ?-thalassemia. Province 5, province 6 and province 7 were mostly affected by sickling disorder while the other provinces by ?-thalassemia., Conclusions: Sickle cell is the commonest cause of hemoglobinopathy followed by B thallesmias in Nepalese population. Sickle cell is more concentrated towards western part of Nepal and especially in Tharu ethnic population. In contrast, the distribution of ?-thalassemia is found throughout the country and among all ethnic groups of population.

Background: The liver is most frequently injured solid organ in abdominal trauma. The non-operative management is the standard treatment for hemodynamically stable patients. This study analyse the epidemiological aspects, injury patterns, treatment modalities and outcome in patients with liver injuries only and associated injuries outside the liver., Methods: This was a retrospective study in patients with liver injuries admitted from 1st March 2014 to 31st January 2019 at Chitwan Medical College and Hospital, Nepal. The patients were divided into two groups. Group A consisted of isolated liver injury and Group B liver injury with associated injury of other organs. Data were analysed by using descriptive statistics and Mann-Whitney U test., Results: A total of 61 patients were admitted with liver injury. There were 18 (29.5 %) patients with liver injury alone (group A) and 43 (70.5 %)liver injury associated with other organs (group B). Low grade liver injuries were 48 (78.7 %) and high grade 13 (21.3 %). The operative management was done for one liver injury with biliary peritonitis in group A. In group B, 16 patients required laparotomy and operative management for associated abdomen injuries., Conclusions: Non-operative treatment modality in hemodynamically stable patients with isolated liver injuries was safe and effective.

The need of subspecialty training has been acutely felt in Nepal now with the rapid advancement in the field of medical sciences, the changing burden of diseases, the acute shortage of highly specialized health professionals, the evolving concept of learning and medical education and the ever-increasing focus on right and safety of patients.Fellowship Training is obtained in a specific specialty or subspecialty. Fully academic 3-year Fellowship programsin Pulmonary and Critical Care Medicine, Hepatopancreatobiliary Surgery and Cardiologyhavebeen initiated for certification of the training for the first time in Nepal at Chitwan Medical College (CMC) and all three are recognized by the Nepal Medical Council.The three Fellowship training programs, run in affiliation with Lincoln University, at the CMC have all the training criteria of DM/MCh included along with extra requirement of one more paper publication and the trainees are paid adequate stipend without any tuition fee or bond. The high volume of cases and procedures in CMC, exposes the FCMC Fellows to an increased chance of appropriate skill development along with appropriate postings in various other institutions for adequate experience of hands on training.Fellowship programs are the cornerstone of providing super specialized patient care.The need today is to focus on the basic training concepts and criteria, rather than on various names like diploma, MD, MS, DM/MCh of training.Nepal should focus onthe prerequisites, infrastructure and human resource for expanding the quality Fellowship trainingprograms in the country and thereby enhancing the standard of patient care. Keywords: Cardiology; DM; FCMC; fellowship; hepatopancreatobiliary surgery; MCh; PCCM.