Pattern of Pediatric Admissions in a Tertiary Care Hospital of Central Nepal

INTRODUCTION

An understanding of the epidemiological trend in hospital admissions, including morbidity and mortality patterns and the economic impact, is critical for healthcare planning and appropriate resource allocation. As we find very few literature on the pattern of paediatric admissions outside Kathmandu Valley, it is essential to conduct studies in the various parts of the country to determine the paediatric inpatient burden as well resource allocations.

METHODS

A retrospective study was carried out at Department of Pediatrics, College of Medical Sciences-Teaching Hospital, Bharatpur, Chitwan, Nepal over a period of one year. All the admissions were analyzed for age, sex, address, seasonal variation, frequency of diseases according to the organ system involved, duration of hospital stay, and the outcome.

RESULTS

Out of the total 814 cases admitted 68.8% of the patients were younger than five years. There was male preponderance with male to female ratio of 1.9:1. Majority (43.6%) admissions were from Chitwan itself. Respiratory, gastrointestinal and neurologic conditions were the main cause for admission. The mean duration of hospital stay was 5.28 days and the mortality was only 0.1%.

CONCLUSIONS

In this study under five-year patients contributed to 2/3rd of the hospital admissions. Respiratory, gastrointestinal and neurologic conditions were the main cause for admission with pneumonia, URTI and acute gastroenteritis being the most common diseases.

MicroRNA signatures differentiate preserved from reduced ejection fraction heart failure

Aims

Differentiation of heart failure with reduced (HFrEF) or preserved (HFpEF) ejection fraction independent of echocardiography is challenging in the community. Diagnostic strategies based on monitoring circulating microRNA (miRNA) levels may prove to be of clinical value in the near future. The aim of this study was to identify a novel miRNA signature that could be a useful HF diagnostic tool and provide valuable clinical information on whether a patient has HFrEF or HFpEF.

Methods and results

MiRNA biomarker discovery was carried out on three patient cohorts, no heart failure (no-HF), HFrEF, and HFpEF, using Taqman miRNA arrays. The top five miRNA candidates were selected based on differential expression in HFpEF and HFrEF (miR-30c, −146a, −221, −328, and −375), and their expression levels were also different between HF and no-HF. These selected miRNAs were further verified and validated in an independent cohort consisting of 225 patients. The discriminative value of BNP as a HF diagnostic could be improved by use in combination with any of the miRNA candidates alone or in a panel. Combinations of two or more miRNA candidates with BNP had the ability to improve significantly predictive models to distinguish HFpEF from HFrEF compared with using BNP alone (area under the receiver operating characteristic curve >0.82).

Conclusion

This study has shown for the first time that various miRNA combinations are useful biomarkers for HF, and also in the differentiation of HFpEF from HFrEF. The utility of these biomarker combinations can be altered by inclusion of natriuretic peptide. MiRNA biomarkers may support diagnostic strategies in subpopulations of patients with HF.

Multi-exposure cancer and non-cancer risk assessment of trihalomethanes in drinking water supplies - A case study of Eastern region of India

The lifetime cancer risk and the hazard index of trihalomethanes (THMs) through oral ingestion, dermal absorption, and inhalation exposure from supply water of five WTPs were analysed. THMs concentration varied from plant to plant and was found to be in the range of 274-511µg/l, which is much higher than the prescribed USEPA standards of 80µg/l. Chloroform was the most dominant THM followed by bromodichloromethane (BDCM), and dibromochloromethane (DBCM). Cancer risk analysis through multi-pathways exposure reveals that residents had a higher cancer risk through oral ingestion than other two routes of exposure. The lifetime cancer risks of THMs from supply water were 100 times higher than prescribed USEPA guidelines. The higher cancer risk found for Indian context than those reported for other countries like USA, UK, Japan, Australia, is mainly due to the higher concentration level of THMs, water intake and average body weight. The study also revealed that amongst different THMs, chloroform is the major THMs causing cancer risk through both oral and dermal route of exposure whereas in case of inhalation it was mainly because of BDCM. Average lifetime cancer risk analysis indicated that females are more prone to cancer risk than males. Oral ingestion is a major route indicating the potential impact of non-cancer risk while it was insignificant through dermal exposure. Sensitivity analysis of THMs revealed that chloroform is the predominant parameter followed by body weight and exposure duration influencing cancer risk.

Extraction, isolation and evaluation Trigonella foenum-graecum as mucoadhesive agent for nasal gel drug delivery

The purpose of the study is to formulate and evaluate a new, cheap and effective natural mucoadhesive agent that can be used as an effective alternative for traditional mucoadhesive agent. The study procedure involved extraction of mucoadhesive agent from the Trigonella foenum-graecum (fenugreek) seeds, solubility testing of the mucilage obtained, phytochemical testing, determination of swelling index, preparation of nasal gel, measurement of viscosity, The study showed that the extraction of fenugreek seeds had 36% w/w of mucoadhesive agent. The natural mucoadhesive agent was soluble in hot water and cold water. The swelling index was found to be 160%.Fenugreek seeds produce high viscosity mucilage at low concentration levels. DOI: http://dx.doi.org/10.3126/jnpa.v27i1.12149 Journal of Nepal Pharmaceutical Association 2014 Vol.XXVII: 40-45

Triple hanging in filicide-suicide: an unusual case report

Filicide-suicide is a special category of homicide-suicide event where the victim(s) are children and the perpetrator is one of the parents or both. It is not extensively documented or adequately defined in literature. In developed countries, shooting is a common method of homicide and suicide. Uses of knives, blunt objects, strangulation, poisoning and drowning are other methods frequently employed by the perpetrator. Homicide by hanging in filicide-suicide is rarely reported in forensic literature. We present a rare case of filicide-suicide, where the mother killed both her children by hanging them one by one from a ceiling fan in the same room and later committed suicide by hanging in another room.

Phenotypic expression of blast resistance gene Pi54 is not affected by its chromosomal position

This is a novel report in which chromosomal position of the rice blast resistance gene Pi54 was not found to affect significantly the resistance phenotype or morphological traits. Blast disease caused by Magnaporthe oryzae is a serious constraint in rice production at global level. Pi54 gene imparts resistance against M. oryzae. Three different transgenic lines containing Pi54 and its orthologue Pi54rh were shown to be resistant to different races of M. oryzae. To determine the chromosomal location of Pi54 gene in transgenic lines, inverse PCR was performed. Our analysis showed that in two transgenic lines, Pi54 gene was integrated on chromosomes 6 and 10 at 12.94 and 22.30 Mb, respectively. Similarly, Pi54rh allele was integrated on chromosome 1 at 16.25 Mb. The Pi54 gene present on chromosome 6 was located in a non-coding region whereas in the other TP-Pi54 line, the gene was introgressed on chromosome 10 in between the coding region of SAP domain gene. The Pi54rh was also located in the non coding region flanked by the retrotransposon genes. These rice lines were evaluated for eight different traits related to seed and plant morphology and agronomic features for two consecutive years. The transgenic lines containing Pi54 gene have higher tiller number, grain weight, epicotyl length, and yield compared to the non-transgenic control. Multivariate correlation analysis shows that blast resistance was positively correlated with the number of tillers; thousand grain weight and epicotyl length. These results will facilitate precise utilization of Pi54 gene and its orthologue in breeding programs for the development of rice cultivars with broad spectrum and durable resistance to M. oryzae.

Lepromatous leprosy: An Unusual Presentation

A 25 year old man presented with loss of sensations over both hands and feet and extreme difficulty in passing urine. On examination, an indurated sclerotic plaque was present on shaft of penis and scrotum in addition to other features of lepromatous leprosy. Skin biopsy from the penile lesion showed presence of a large number of acid fast bacilli with a BI of 6+ extending into the epidermis and histopathology showed absence of Grenz zone and presence of foamy macrophages in the dermis up to the dermo-epidermal junction.

Enhanced thermoelectric properties of selenium-deficient layered TiSe(2-x): a charge-density-wave material

In the present work, we report on the investigation of low-temperature (300-5 K) thermoelectric properties of hot-pressed TiSe2, a charge-density-wave (CDW) material. We demonstrate that, with increasing hot-pressing temperature, the density of TiSe2 increases and becomes nonstoichiometric owing to the loss of selenium. X-ray diffraction, scanning electron microscopy, and transimission electron microscopy results show that the material consists of a layered microstructure with several defects. Increasing the hot-press temperature in nonstoichiometric TiSe2 leads to a reduction of the resistivity and enhancement of the Seebeck coefficient in concomitent with suppression of CDW. Samples hot-pressed at 850 °C exhibited a minimum thermal conductivity (κ) of 1.5 W/m·K at 300 K that, in turn, resulted in a figure-of-merit (ZT) value of 0.14. This value is higher by 6 orders of magnitude compared to 1.49 × 10(-7) obtained for cold-pressed samples annealed at 850 °C. The enhancement of ZT in hot-pressed samples is attributed to (i) a reduced thermal conductivity owing to enhanced phonon scattering and (ii) improved power factor (α(2)σ).

Thermoelectric performance of layered SrxTiSe2 above 300 K

In this paper we report the thermoelectric performance of Sr intercalated TiSe(2) above 300 K. Refined x-ray diffraction, high resolution transmission electron microscopy and scanning electron microscopy images show well oriented polycrystalline grains along a (0 0 l) direction and layered growth of the sample. Intercalation of Sr in TiSe(2) shows an improved Seebeck coefficient (α) value without altering the polarity of the majority charge carrier. A drastic reduction in the thermal conductivity (κ) from 3.8 W m K(-1) to 1.2 W m K(-1) (at 650 K) was observed which is ascribed to the: (i) scattering of the phonon by natural layer interfaces, grain boundaries and lattice defects and (ii) rattling of intercalated Sr atoms among weakly bound TiSe(2) layers. This led to the maximum ZT of ~0.08 at 650 K for Sr(x)TiSe(2) (x > 0.1) which is almost twice as high as the parent TiSe(2).

Circulating long noncoding RNATapSaki is a predictor of mortality in critically ill patients with acute kidney injury

BACKGROUND

Long noncoding RNAs (lncRNAs) are novel intracellular noncoding ribonucleotides regulating gene expression. Intriguingly, these RNA transcripts are detectable and stable in the blood of patients with cancer and cardiovascular disease. We tested whether circulating lncRNAs in plasma of critically ill patients with acute kidney injury (AKI) at inception of renal replacement therapy were deregulated and might predict survival.

METHODS

We performed a global lncRNA expression analysis using RNA isolated from plasma of patients with AKI, healthy controls, and ischemic disease controls. This global screen revealed several deregulated lncRNAs in plasma samples of patients with AKI. lncRNA-array-based alterations were confirmed in kidney biopsies of patients as well as in plasma of 109 patients with AKI, 30 age-matched healthy controls, and 30 disease controls by quantitative real-time PCR.

RESULTS

Circulating concentrations of the novel intronic antisense lncRNA TrAnscript Predicting Survival in AKI (TapSAKI) (P < 0.0001) were detectable in kidney biopsies and upregulated in plasma of patients with AKI. Cox regression and Kaplan-Meier curve analysis revealed TapSAKI as an independent predictor of 28-day survival (P < 0.01). TapSAKI was enriched in tubular epithelial cells subjected to ATP depletion (P = 0.03).

CONCLUSIONS

The alteration of circulating concentrations of lncRNAs in patients with AKI supports TapSAKI as a predictor of mortality in this patient cohort.

Clinical Profile of Neonates with Perinatal Asphyxia in a Tertiary Care Hospital of Central Nepal

INTRODUCTION

Birth asphyxia is a serious clinical problem worldwide. It claims approximately 9 million deaths each year. It can lead to serious neurological sequaele, such as cerebral palsy, mental retardation, and epilepsy.

METHODS

All babies admitted in College of Medical Sciences Teaching Hospital, Chiwan, Nepal, NICU from January 2013 to December 2013 with a diagnosis of birth asphyxia (5 min Apgar<7 or those with no spontaneous respirations after birth) were included in the study (n=125). This was a descriptive observational study. Clinical information was collected (gravida, hour at presentation, mode of delivery, sex of baby, gestational age of the baby, requirement of resuscitation). Neonates were admitted to NICU, observed for complications and managed as per hospital protocol.

RESULTS

Among the 722 neonates admitted to NICU, 125 had perinatal asphyxia (17.3%). Babies with Hypoxic ischemic encephalopathy(HIE) Grade I had a very good outcome but HIE III was associated with a poor outcome. Outborn neonates had higher grades of perinatal asphyxia as compared to inborns (p=0.018). Term gestation, Males and Multigravida were associated with a higher rate of birth asphyxia. 22.4% neonates were delivered via caesarean section and 74.4% required bag and mask ventilation at birth.

CONCLUSIONS

Birth asphyxia was one of the commonest causes of admission NICU. Babies with HIE Grade III had a very poor prognosis. Outborn neonates with birth asphyxia had a higher mortality. Males were frequently affected than females.

Sustainability Characterization for Additive Manufacturing

Additive manufacturing (AM) has the potential to create geometrically complex parts that require a high degree of customization, using less material and producing less waste. Recent studies have shown that AM can be an economically viable option for use by the industry, yet there are some inherent challenges associated with AM for wider acceptance. The lack of standards in AM impedes its use for parts production since industries primarily depend on established standards in processes and material selection to ensure the consistency and quality. Inability to compare AM performance against traditional manufacturing methods can be a barrier for implementing AM processes. AM process sustainability has become a driver due to growing environmental concerns for manufacturing. This has reinforced the importance to understand and characterize AM processes for sustainability. Process characterization for sustainability will help close the gaps for comparing AM performance to traditional manufacturing methods. Based on a literature review, this paper first examines the potential environmental impacts of AM. A methodology for sustainability characterization of AM is then proposed to serve as a resource for the community to benchmark AM processes for sustainability. Next, research perspectives are discussed along with relevant standardization efforts.

Molecular Epidemiology of Pasteurella multocida Circulating in India by Multilocus Sequence Typing

Multilocus sequence typing (MLST), a sequence-based typing method for bacterial pathogens, is currently the best method for long-term epidemiological study and to understand the population structure of the bacteria. This investigation was carried out to study the diversity of Pasteurella multocida isolates circulating in India. Ten different sequence types (ST) identified in this study are ST 122 from cattle, goat, mithun and pig; ST 50 from pig; ST 9 from cattle and sheep; ST 229 from cattle and goat; ST 71 and ST 277 from cattle; and ST 129, ST 280, ST 281 and ST 282 from avian species. Of these, ST 277, ST 280, ST 281 and ST 282 were identified for the first time. The analysis of results provides novel epidemiological information on the circulation of multiple STs across India. The majority of STs or their variants identified in this study have already been reported from different parts of the globe. This suggests that probably transboundary spread of strains across countries and continents has occurred across evolutionary time and is still happening. The isolation of ST 122 from small ruminants and pigs suggests that these species may be included in the preventive vaccination policy for effective control of haemorrhagic septicaemia in India.

Correlation of Computerized Tomography density patterns of lymph nodes with treatment results and outcome in head and neck cancer patients treated by 2 different chemoradiotherapy schedules

AIMS/BACKGROUND

Tumor necrosis is visualized on CT scan as non enhancing hypodense area. Necrotic areas contain less oxygen and results in poor response of chemo-radiotherapy. Literature review (1) has shown that for hypodense lesions in head and neck cancer the complete response rate is lower than the isodense lesions. Locally advanced head and neck cancer require the addition of surgery but after a radical dose of radiation that is, 7000 cGy, surgery become difficult but there is no tool initially that can be used for selection of patients after delivery of 4500 cGy, that is the dose after which surgery can be performed without much difficulty. The hypothesis is that, hypodense lymph nodes even when they are small will show less response to various schedules of chemoradiotherapy so hypodensity of lymph nodes can be used as a tool to select patient, who will go for surgery after initial 4500 cGy of radiotherapy. Surgery is usually performed 2 to 3 weeks after radiotherapy, so primary can be treated to full dose while the skin in region of lymph nodes radiation field will recover from acute radiation reaction. Correlation of C T density patterns of lymph nodes in head and neck cancer patients with treatment results when two different chemoradiotherapy schedules are used is studied.

MATERIALS AND METHODS

Eighty three patients with locally advanced head and neck cancer were treated with two schedules of concurrent chemoradiotherapy prospectively from August 2010 to July 2011. CT Scans of the entire neck region including primary were performed. An iodine based contrast material (150 ml) was injected intravenously starting with a bolus of 50 ml (3 ml/s), followed by a slow (1 ml/s) infusion of the remaining dose. The total tumor volume of the primary and involved neck nodes was calculated as a cuboid volume using maximum dimension in each plane: Vc= (a x b x c). Nodal density was graded.

RESULTS AND CONCLUSION

No statistically significant association between recovery and CT density was found (X 2 = 0.306; P > 0.05).

Augmented post-induction therapy for children with high-risk acute lymphoblastic leukemia and a slow response to initial therapy

BACKGROUND

Children with high-risk acute lymphoblastic leukemia (ALL) who have a slow response to initial chemotherapy (more than 25 percent blasts in the bone marrow on day 7) have a poor outcome despite intensive therapy. We conducted a randomized trial in which such patients were treated with either an augmented intensive regimen of post-induction chemotherapy or a standard regimen of intensive post-induction chemotherapy.

OBJECTIVE

To compare the effect of augmented therapy with standard intensive post induction therapy in children with high-risk ALL who entered remission after a slow response to initial therapy.

METHODS

Between January 2005 and December 2011, 311 children with newly diagnosed ALL who were either 1 to 9 years of age with white cell counts of at least 50,000 per cubic millimeter or 10 years of age or older, had a slow response to initial therapy, and entered remission at the end of induction chemotherapy were randomly assigned to receive standard therapy (156 children) or augmented therapy (155). Those with lymphomatous features were excluded. Event-free survival and overall survival were assessed from the end of induction treatment.

RESULTS

The outcome at five years was significantly better in the augmented-therapy group than in the standard-therapy group. The difference between treatments was most pronounced among patients one to nine years of age, all of whom had white-cell counts of at least 50,000 per cubic millimeter (P<0.001). Risk factors for an adverse event in the entire cohort included a white-cell count of 200,000 per cubic millimeter or higher (P=0.004). The toxic effects of augmented therapy were considerable but manageable.

CONCLUSION

Augmented post-induction chemotherapy results in an excellent outcome for most patients with high-risk ALL and a slow response to initial therapy.

Teaching community medicine to medical undergraduates-learning by doing: our experience of rural posting at All India Institute of Medical Sciences, New Delhi, India

BACKGROUND

The goal of medical education is to ensure that the medical graduate has acquired broad public health competencies needed to solve the health problems of the community. We present the current teaching of community medicine to medical students of the All India Institute of Medical Sciences (AIIMS), New Delhi during their 5-week posting at the rural centre at Ballabgarh, Haryana.

METHODS

The teaching activities consist of field visits to different levels of health facilities and meeting with health workers, epidemiological exercises, a community-based exercise, posting in inpatient and outpatient departments of a secondary hospital, and domiciliary visits to families of patients. These are spread over 80 sessions of about 200 hours. There is very little didactic teaching and the assessment is broad-based. The evaluation of the posting was based on comparison of blinded pre- and post-posting assessments as well as anonymous feedback of the posting by the students.

RESULTS

There was a significant increase in the mean scores of all components of the posting-epidemiology (5.1 to 8.4), health systems (6.8 to 9.3) and clinical (8.0 to 10.8). The posting did not result in a better understanding of a public health approach as compared to a clinical approach. The feedback provided by students was generally positive for all activities with 94% of them rating it as good or very good.

CONCLUSION

The teaching of community medicine can be made more practical and interesting without compromising on learning. However, despite such a programme, getting medical students to develop a public health approach is a daunting task.

Determination of Physico-chemical Parameters for Prediction of MSW Leachate Transport through Vadose Zone by Breakthrough Curve in a Realistic Undisturbed Soil Column

The studies were carried out to find out transport parameters to predict leachate transport and contaminant plume profile underneath a municipal solid waste(MSW) dump. For this, both theoretical and practical avenues were explored. Batch experiments with disturbed soil were carried out with a tracer dye Brilliant Blue FCF to obtain the adsorption isotherm of the tracer. Column experiments with undisturbed realistic soil column were carried out to determine physico-chemical transport parameters using the tracer dye. MSW leachate transport were simulated and sensitivity analysis for MSW leachate transport was carried out for different Darcy velocity for pulse input.For determination of mass-transfer coefficient between the immobilized and mobilized water phase, we usedthe concept of number of transfer units (NTUs) and height of transfer units (HTUs) frequently used by Chemical Engineers. The obtained value of mass transfer coefficient calculated by this method was in excellent agreement with the value obtained from inverse calculation of parameter values by a standard software package (CXTFIT).