Evaluation of prognostic markers in patients infected with SARS-CoV-2

Prognostic markers are the biomarkers used to measure the disease progression and patient outcome regardless of treatment in coronavirus disease 2019 (COVID-19). This study aimed to analyze laboratory parameters as prognostic markers for the early identification of disease severity. In this study, 165 patients attending Sukraraj Tropical and Infectious Disease Hospital with COVID-19 were enrolled and divided into severe and non-severe groups. The demographic data, underlying co-morbidities, and laboratory findings were analyzed and compared between severe and non-severe cases. The correlation between the disease criticality and laboratory parameters was analyzed. Cut-off values of parameters for severe patients were speculated through the receiver operating characteristics (ROC) curve, and regression analysis was performed to determine the risk factors. Patients with severe COVID-19 infection had significantly higher absolute neutrophil count, neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR), ferritin, positive carbohydrate reactive protein (CRP), glucose, urea, creatinine, and aspartate aminotransferase, while lower absolute lymphocyte count, absolute eosinophil count (AEC), and red blood cell count in comparison to non-severe infection. ROC analysis gave a cut-off value (sensitivity, specificity) of age, AEC, NLR, PLR, and ferritin as 47.5 years (70.2, 64.7%), 335 cells/mm3 (74, 67%) 3.3 (68.4, 63.7%), 129 (77.2, 51%), and 241 ng/mL (74.0%, 65.0%) respectively. Risk factor analysis showed higher age, low AEC, high ferritin, and positive CRP as independent risk factors associated with severe COVID-19 infection. Hematological and inflammatory markers, including novel NLR and PLR, should be assessed to aid clinicians in the early identification of severe cases, prioritization of cases, and effective management to decrease the mortality of COVID-19 patients.

Experiences of COVID-19 patients admitted in a government infectious disease hospital in Nepal and its implications for health system strengthening: A qualitative study

INTRODUCTION

The COVID-19 pandemic has affected the health systems in many ways. It has put unprecedented strain on health systems worldwide and exposed gaps in public health infrastructure. A health system comprises all institutions and resources working towards improving and maintaining health. Among the different aspects of health system strengthening, a patient's experiences and expectations play a crucial role in determining how well the health facilities function. This study aims to explore health system strengthening's implications based on experiences and feedback provided by COVID-19 patients admitted to a government tropical and infectious disease hospital in Nepal.

METHODS

In this qualitative study, we collected the voluntary handwritten feedback by the admitted COVID-19 patients to document the feedback and experiences from a book, maintained by the hospital. We performed thematic content analysis using the World Health Organization's six building blocks of health system as a theoretical framework which included service delivery, health workforce, information, leadership and governance, financing, and access to medicines.

RESULTS

Most patients in this study had positive experiences on service delivery and health workforce. Some also highlighted the gaps in infrastructure, cleanliness, and hygiene. Many suggested positive experiences on other dimensions of the health system such as financing, governance and leadership, and access to medicines reflected upon by the patients' thankfulness to the hospital and the government for the treatment they received. The responses also reflected the inter-connectedness between the different building blocks of health system.

CONCLUSION

This study approached a unique way to strengthen the health system by exploring patients' feedback, which suggested an overall positive impression on most building blocks of health system. However, it also highlighted certain gaps in infrastructure, cleanliness, and hygiene. It reinforces the hospital management and government's role to continue its efforts to strengthen the health system.

Clinical Profile of End Stage Renal Disease Patients Undergoing Hemodialysis in Chitwan, Nepal

BACKGROUND

There are very few researches from Nepal that have evaluated clinical profile of end stage renal disease patients. Our main objective was to study the clinical profile of end stage renal disease patients, who were under maintenance hemodialysis for at least three months duration in two dialysis centers located in Chitwan Nepal.

METHODS

This was a descriptive, cross-sectional study conducted among 138 end stage renal disease patients, who were undergoing maintenance hemodialysis at two government centers located in Chitwan, Nepal.

RESULTS

Among 138 patients in our study, 42 (30.4%) patients had diabetic nephropathy and 11 (8%) patients had hypertensive nephropathy as the leading causes of end stage renal disease; however the cause could not be ascertained in 63 (45.7%) patients. 47 (34.1%) patients had started hemodialysis within one month of diagnosis of their kidney disease. Fatigue and musculoskeletal pain were the commonest symptoms found in 78 (56.6%) patients, whereas hypotension and fever were the two most common intra-dialytic complications found in 73 (52.9%) and 61 (44.2%) patients respectively. Anemia was present in 127 (92%) patients, 41 (29.7%) had hyperkalemia, 54 (39.1%) had hypocalcemia, 116 (84.1%) had hyperphosphatemia and 43 (31.2%) had hyperuricemia. Regular use of erythropoietin analogs was significantly associated with higher hemoglobin levels (p value- 0.000) and lesser frequency of blood transfusions (p value- 0.000) in our study.

CONCLUSIONS

Diabetic nephropathy was the leading cause of end stage renal disease in our study. Cause of ESRD could not be ascertained in nearly half of the total patients.

Anaemia among Patients of Heart Failure in a Tertiary Care Centre of Nepal: A Descriptive Cross-sectional Study

Introduction: Anaemia is an important comorbidity common in patients with heart failure and is associated with poor clinical status and worse outcomes. In Nepal few studies have evaluated anaemia amongst patients suffering from heart failure. We intended to find out the prevalence of anaemia in patients with heart failure in a tertiary care centre. Methods: This is a descriptive cross-sectional study conducted among patients of heart failure presenting to tertiary care hospital in eastern Nepal from April 2017 to January 2018. Ethical approval was taken from the Institutional Review Committee of a tertiary care centre (reference number: IRC/0842/016). Using the convenience sampling method, 100 patients were enrolled in the study. Blood samples from the patients were taken for haemoglobin and serum iron studies. Data was analysed using Statistical Package for Social Sciences version 11. Point estimate at 95% Confidence Interval was calculated, with frequency and percentage. Results: Among 100 patients with heart failure, 82 (82%) (74.47-89.53 at 95% Confidence Interval) had anaemia. Mean haemoglobin level of the study population was 10.40±2.73 g/dl. Fifty four (54%) of patients had iron deficiency status irrespective of presence or absence of anaemia. Conclusions: Prevalence of anaemia among patients of heart failure in our study was found to be higher than various other homologous international studies.

SARS-CoV-2 and Orientia tsutsugamushi co-infection in a young teen, Nepal: Significant burden in limited-resource countries in Asia?

Scrub typhus is caused by Orientia tsutsugamushi, transmitted through bites of infected chiggers (larval mites). During the coronavirus disease 2019 (COVID-19) pandemic, reports of co-infections with endemic pathogens are increasing around the world. Disease with similar clinical presentation may mask other disease diagnosis and increase the morbidity and mortality of the patients. We report co-infection between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and O. tsutsugamushi in a patient in Nepal presenting with fever, headache, retro-orbital pain, generalized body ache, and knee joints pain with a history of dry cough and dyspnea at night. Since scrub typhus is prevalent and considerate as one of the public health consents in Asian countries and the possible overlapping clinical manifestation with other infections including COVID-19, a further investigation required to determine the burden of SARS-CoV-2 and O. tsutsugamushi co-infection in scrub typhus-endemic countries in Asia.

Persistent Symptoms in Post-COVID-19 Patients Attending Follow-Up OPD at Sukraraj Tropical and Infectious Disease Hospital (STIDH), Kathmandu, Nepal

The long-term effects of COVID-19 among survivors is a matter of concern. This research aimed to study persistent symptoms in post-COVID-19 patients attending a follow-up clinic at a tertiary care hospital in Nepal. All patients, presenting to the outpatient clinic during the study duration of six weeks, with history of positive reverse transcriptase- polymerase chain reaction for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) at least two weeks prior to presentation, were included. The duration of follow-up ranged from 15 till 150 days with the mean duration of 28 days after diagnosis of COVID-19. Of 118 patients, 43 (36.4%) had a history of mild COVID-19, 15 (12.8%) had moderate, and 60 (50.8%) had severe. At the time of presentation, 97 (82.2%) patients reported that they had at least one persistent/new symptom beyond two weeks from the diagnosis of COVID-19. Dyspnea, fatigue, chest heaviness, and cough were the commonest persistent complaints in 48 (40.7%), 39 (33.1%), 33 (28%), and 32 (27.1%) patients, respectively. The findings in our study highlight the need for extended monitoring of post-COVID-19 patients following discharge, in order to understand and mitigate long-term implications of the disease.

Prevalence of Vitamin D Deficiency among Patients of Acute Coronary Syndrome in a Tertiary Care Center of Eastern Nepal

INTRODUCTION

Vitamin D deficiency is an emerging risk factor for cardiovascular diseases. Very few studies have been done to find out vitamin D deficiency status among cardiovascular patients in Nepalese setup. This research aims to find out the prevalence of vitamin D deficiency among patients of acute coronary syndrome admitted in a tertiary care center of eastern Nepal.

METHODS

This was a descriptive cross-sectional study conducted among patients of acute coronary syndrome admitted in a tertiary care hospital from 1st February 2018 to 31st July 2018. Ethical clearence was taken from Institutional Review Committee of B.P. Koirala Institute of Health Sciences (Reference number: 259/074/075-IRC). Convenience sampling method was used. Data was entered in Microsoft Excel and analyzed using Statistical Package for the Social Sciences version 25. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.

RESULTS

A total of 33 (64.7%) at 95% Confidence Interval (51.58-77.82) patients of acute coronary syndrome had vitamin D deficiency in our study with 19 (37.3%) having mild deficiency and 14 (27.4%) having moderate deficiency. None of the patients had severe vitamin D deficiency in our study. The mean vitamin D levels were lower in diabetics (23.57±9.28ng/ml) as compared to non-diabetics (31.91±12.50ng/ml), in hypertensive patients (24.36±7.67ng/ml) as compared to non-hypertensive patients (30.97±13.72ng/ml), and in patients with dyslipidemia (22.86±6.44ng/ml) as compared to those without dyslipidemia (37.68±13.15ng/ml).

CONCLUSIONS

Prevalence of vitamin D deficiency among patients of acute coronary syndrome in our study was comparable to various other homologous international studies.

Bell's palsy as a possible neurological complication of COVID-19: A case report

COVID-19 has been associated with several neurological complications. We presented a case of Bell's palsy as a possible neurological complication of COVID-19 infection. Further research should be conducted to clarify the association, correlation, or causality between COVID-19 and neuroimmunological diseases.

Recurrent Positivity of SARS-CoV-2 RNA in a Clinically Recovered COVID-19 Patient with End Stage Renal Disease: A Case Report

Recurrent or persistent positivity of SARS-CoV-2 RNA in clinically recovered COVID-19 patients have been reported worldwide. However, replication competent live viruses were not recovered beyond two to three weeks from onset of symptoms in mild to severe cases of COVID-19. End stage renal disease is characterized by uremia induced immune dysfunction that increases the risk of infectious diseases including COVID-19. The clinical implications of recurrent or persistently positive SARS-CoV-2 RNA in immunocompromised patients are difficult to be generalized to findings as in immunocompetent patients. We report a case of end stage renal disease with recent history of recovered COVID-19 pneumonia, who again presented with positive reverse transcriptase- polymerase chain reaction (RT-PCR) test for SARS-CoV-2 RNA.

The Grim Reality of Health System Uncovered with COVID-19 Pandemic in Nepal

With advent of community transmission of COVID-19 in Nepal, the number of cases continues to rise and poses threat to the fragile health system of our country. 'Trace, isolate, test and treat' is the strategy advocated by World Health Organization to fight against COVID-19. Despite the efforts for last nine months, Nepal lacks in some aspect of this strategy. Lack of prompt testing facilities and substandard quarantine and isolation centers, have led to mismanagement of cases. The panic regarding COVID-19, lack of adequate protective measures to healthcare workers in early stage of the pandemic, and nation-wise lockdown, has led to collateral damage in the form of increased morbidity and mortality due to non-COVID related illnesses. COVID-19 pandemic has uncovered the grim reality of the debilitated health system of our country. With mass influx of Nepali migrant workers, the epidemic is expected to grow exponentially. We need to understand that the health system of Nepal must be prepared to function to its maximum capacity in the coming days. Keywords: COVID-19; health; Nepal; pandemic.

Stigmatization Towards Healthcare Workers During the COVID-19 Pandemic in Nepal

COVID-19 is a novel disease that accompanies itself with anxiety, fear and social stigma. As the numbers of COVID-19 cases continue to rise in Nepal, many instances of stigmatization towards healthcare workers have come into light. Rather than motivating healthcare workers to work during these adverse times, they are being ostracized as carriers of COVID-19. Despite the risks, healthcare workers are bearing for themselves and for their families, very little has been done to protect them. Stigmas can be counteracted by awareness regarding this novel disease. It is important to aware people about correct practices and makes them realize that this battle against COVID-19, can’t be won without healthcare workers. Ensuring safety of healthcare workers must be the foremost priority of the state. Healthcare workers are the most valuable asset for every country, who must be protected from acts of stigmatization at the earliest.

The Myriad of Clinical Presentations of COVID-19: a Short Review

The ongoing pandemic of Coronavirus disease- 2019 is yet to be defeated. It is primarily a viral respiratory illness, with a myriad of clinical presentations being reported, since it was first identified towards the end of 2019 in China. Apart from the classical symptoms of fever, cough, and dyspnea, atypical presentations in COVID-19 patients, have puzzled healthcare workers worldwide. Patients with isolated non- respiratory complaints like diarrhea, vomiting, abdominal pain, skin rash, and confusion, have tested positive for severe acute respiratory syndrome coronavirus-2. The symptoms of olfactory and gustatory dysfunction have recently been added to the list for screening suspected cases after their prevalence was found to be high among COVID-19 patients. This article elaborates on the system-wise manifestations of COVID-19 and discusses the clinical implications of these aberrant presentations to healthcare workers.