An exploratory metabolomic comparison of participants with fast or absent functional progression from 2CARE, a randomized, double-blind clinical trial in Huntington's disease

Huntington's disease (HD) is increasingly recognized for diverse pathology outside of the nervous system. To describe the biology of HD in relation to functional progression, we previously analyzed the plasma and CSF metabolome in a cross-sectional study of participants who had various degrees of functional impairment. Here, we carried out an exploratory study in plasma from HD individuals over a 3-year time frame to assess whether differences exist between those with fast or absent clinical progression. There were more differences in circulating metabolite levels for fast progressors compared to absent progressors (111 vs 20, nominal p < 0.05). All metabolite changes in faster progressors were decreases, whereas some metabolite concentrations increased in absent progressors. Many of the metabolite levels that decreased in the fast progressors were higher at Screening compared to absent progressors but ended up lower by Year 3. Changes in faster progression suggest greater oxidative stress and inflammation (kynurenine, diacylglycerides, cysteine), disturbances in nitric oxide and urea metabolism (arginine, citrulline, ornithine, GABR), lower polyamines (putrescine and spermine), elevated glucose, and deficient AMPK signaling. Metabolomic differences between fast and absent progressors suggest the possibility of predicting functional decline in HD, and possibly delaying it with interventions to augment arginine, polyamines, and glucose regulation.

Utility of outdoor central site monitoring in assessing exposure of school children to ultrafine particles

Epidemiological studies investigating the association between daily particle exposure and health effects are frequently based on a single monitoring site located in an urban background. Using a central site in epidemiological time-series studies has been established based on the premises of low spatial variability of particles within the areas of interest and hence the adequacy of the central sites to monitor the exposure. This is true to a large extent in relation to larger particles (PM_2.5, PM₁₀) that are typically monitored and regulated. However, the distribution of ultrafine particles (UFP), which in cities predominantly originate from traffic, is heterogeneous. With increasing pressure to improve the epidemiology of UFP, an important question to ask is, whether central site monitoring is representative of community exposure to this size fraction of particulate matter; addressing this question is the aim of this paper. To achieve this aim, we measured personal exposure to UFP, expressed as particle number concentration (PNC), using Philips Aerasense Nanotracers (NT) carried by the participants of the study, and condensation particle counters (CPC) or scanning mobility particle sizers (SMPS) at central fixed-site monitoring stations. The measurements were conducted at three locations in Brisbane (Australia), Cassino (Italy) and Accra (Ghana). We then used paired t-tests to compare the average personal and average fixed-site PNC measured over the same 24-h, and hourly, periods. We found that, at all three locations, the 24-h average fixed-site PNC was no different to the personal PNC, when averaged over the study period and all the participants. However, the corresponding hourly averages were significantly different at certain times of the day. These were generally times spent commuting and during cooking and eating at home. Our analysis of the data obtained in Brisbane, showed that maximum personal exposure occurred in the home microenvironment during morning breakfast and evening dinner time. The main source of PNC for personal exposure was from the home-microenvironment. We conclude that the 24-h average PNC from the central-site can be used to estimate the 24-h average personal exposure for a community. However, the hourly average PNC from the central site cannot consistently be used to estimate hourly average personal exposure, mainly because they are affected by very different sources.

The potential positive epigenetic effects of various mind-body therapies (MBTs): a narrative review

Mind-body therapies (MBTs), such as mindfulness, meditation, yoga, and tai-chi, are said to improve quality of life by contributing to positive thinking and reducing overall distress. MBTs not only play a role in reducing stress and anxiety, but they are also found to epigenetically affect genes and other areas in our genomes that are implicated in inflammation, stress, and distress. This review analyzes the role of MBTs in reducing the epigenetic changes as reported in five previously conducted controlled studies found in the NCBI PubMed database. The methylation of the tumor necrosis factor gene, implicated in psychological distress, was shown to significantly decrease for the women who performed yoga. For people who took part in mindfulness meditation, there was a significant alteration in a variety of modifications of histone deacetylase enzymes as well as their expression patterns when compared to the control group. Other studies found that long-term meditators had slower biomarkers of aging, known as epigenetic clocks, and methylation in genes associated with immune cell metabolism and inflammation. Different genomic regions known as CpG dinucleotide sites ("CpG islands") were also found to be epigenetically altered in participants of tai-chi. These controlled studies were promising evidence on the potential of MBTs to affect the epigenetics of an individual. This information will be useful in diagnostic, therapeutic, and preventative measures, and can be an addition to western medicine, in a way that is more holistic and beneficial to the individual.

Progress and prospects of C4 trait engineering in plants

Incorporating C₄ photosynthetic traits into C₃ crops is a rational approach for sustaining future demands for crop productivity. Using classical plant breeding, engineering this complex trait is unlikely to achieve its target. Therefore, it is critical and timely to implement novel biotechnological crop improvement strategies to accomplish this goal. However, a fundamental understanding of C₃ , C₄ , and C₃ -C₄ intermediate metabolism is crucial for the targeted use of biotechnological tools. This review assesses recent progress towards engineering C₄ photosynthetic traits in C₃ crops. We also discuss lessons learned from successes and failures of recent genetic engineering attempts in C₃ crops, highlighting the pros and cons of using rice as a model plant for short-, medium- and long-term goals of genetic engineering. This review provides an integrated approach towards engineering improved photosynthetic efficiency in C₃ crops for sustaining food, fibre and fuel production around the globe.

Possible Role of Parvalbumin Interneurons in Meditation and Psychiatric Illness

Parvalbumin (PV) interneurons are present in multiple brain regions and produce complex influences on brain functioning. An increasing number of research findings indicate that the function of these interneurons is more complex than solely to inhibit pyramidal neurons in the cortex. They generate feedback and feedforward inhibition of cortical neurons, and they are critically involved in the generation of neuronal network oscillation. These oscillations, generated by various brain regions, are linked to perceptions, thought processes, and cognitive functions, all of which, in turn, influence human emotions and behavior. Both animal and human studies consistently have found that meditation practice results in enhancement in the effects of alpha-, theta-, and gamma-frequency oscillations, which may correspond to positive changes in cognition, emotion, conscious awareness, and, subsequently, behavior. Although the study of meditation has moved into mainstream neuroscience research, the link between PV interneurons and any role they might play in meditative states remains elusive. This article is focused primarily on gamma-frequency oscillation, which is generated by PV interneurons, to develop insight and perspective into the role of PV interneurons in meditation. This article also points to new and emerging directions that address whether this role of PV interneurons in meditation extends to a beneficial, and potentially therapeutic, role in the treatment of common psychiatric disorders, including schizophrenia.

Conchopexy Suture versus Bolgerization in preventing middle turbinate lateralisation following FESS

Background: Middle turbinate lateralisation is the most common minor post-operative complication following functional endoscopic sinus surgery. This study aimed to compare the outcome between Conchopexy suture and Bolgerization method in preventing middle turbinate lateralisation. Methodology: This was a prospective, comparative and interventional study conducted from May 2018 to November 2019 at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. A total of 68 patients were divided equally into two groups. Following functional endoscopic sinus surgery, the middle turbinate was medialised either by Conchopexy suture or Bolgerization technique. Postoperative assessment was done on the second and 12th week of surgery, where the position of the middle turbinate and status of the sinus cavity were assessed using perioperative sinus endoscopic (POSE) score. Chi-square test and unpaired t test were used for comparison of postoperative results between two groups taking p value of < 0.05 as statistically significant. Results: Lateralised middle turbinate and mean POSE score was 5/34 (14.8%) and 2.1±1.25, respectively, in Conchopexy group whilst in Bolgerization group it was 6/34 (17.6%) and 2.5±1.46. However, the observed differences were not statistically significant. Conclusion: Conchopexy suture and Bolgerization techniques were equally effective in preventing middle turbinate lateralisation. Hence, either of these techniques could be used as an adjunct to FESS to avoid middle turbinate lateralisation.

Ketamine in the Past, Present, and Future: Mechanisms, Metabolites, and Toxicity

PURPOSE OF REVIEW

While ketamine's analgesia has mostly been attributed to antagonism of N-methyl-D-aspartate receptors, evidence suggests multiple other pathways are involved in its antidepressant and possibly analgesic activity. These mechanisms and ketamine's role in the nociplastic pain paradigm are discussed. Animal studies demonstrating ketamine's neurotoxicity have unclear human translatability and findings from key rodent and human studies are presented.

RECENT FINDINGS

Ketamine's metabolites, and (2R,6R)-hydroxynorketamine in particular, may play a greater role in its clinical activity than previously believed. The activation of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) and the mammalian target of rapamycin by ketamine are mechanisms that are still being elucidated. Ketamine might work best in nociplastic pain, which involves altered pain processing. While much is known about ketamine, new studies will continue to define its role in clinical medicine. Evidence supporting ketamine's neurotoxicity in humans is lacking and should not impede future ketamine clinical trials.

Comparison of Outcomes of Conventional Septoplasty Versus Endoscopic Septoplasty using Freer's Incision in Symptomatic Deviated Nasal Septum

Background Septoplasty techniques have evolved over the years with endoscopic septoplasty gaining popularity in the recent times. Objective To compare the outcomes of conventional septoplasty with endoscopic septoplasty using Freer's incision in symptomatic deviated nasal septum. Method It was a prospective, randomized and comparative study done at Department of ENTHead and Neck Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal from July 2018 to August 2019. A total of 70 patients with symptomatic deviated nasal septum were allocated randomly into two groups. Group A underwent conventional septoplasty whilst Group B underwent endoscopic septoplasty using Freer's incision. Sino-nasal outcome test (SNOT-10) score was recorded pre-operatively and post -operatively between four to six weeks of surgery. Paired and independent 't' test for mean was used as a statistical tool. Result Out of 70 patients, 57(81.43%) were males and 13(18.57%) females. The age group mostly affected was in the third and fourth decades with total 47 patients (67.14%). In the conventional group, the pre-op mean SNOT-10 score was 11.46 (SD±3.6) while post-op mean SNOT-10 score was 2.60 (SD±1.9), the difference being statistically significant (p value 0.00001). Similarly, in the endoscopic group, pre-op mean SNOT10 score was 12.06 (SD±4.88) and post-op mean SNOT- 10 score was 3.37 (SD±2.71) with the difference being statistically significant (p value 0.00001). Comparison of post-operative mean SNOT-10 score between two techniques was not statistically significant (p value 0.17). Conclusion Both conventional and endoscopic septoplasty techniques using Freer's incision were equally effective in improving symptoms due to deviated nasal septum.

Combining Ketamine, Brain Stimulation (rTMS) and Mindfulness Therapy (TIMBER) for Opioid Addiction

Opioid addiction in the United States currently presents a national crisis despite availability of different treatments. Prior findings suggest that both repetitive transcranial magnetic stimulation (rTMS) and subanesthetic dose of ketamine are efficacious in patients with opioid use disorders (OUD) when administered in isolation. However, their therapeutic value may be undermined by varying clinical responses that tend to dissipate with treatment cessation. There has been no study to date that has used a combination of both for OUD, and there are still many unanswered questions with respect to both. TIMBER (Trauma Interventions using Mindfulness Based Extinction and Reconsolidation of memories) therapy attempts to alter the expression of emotionally charged memories such as traumatic memories, and has been successfully tried in chronic post-traumatic stress disorder (PTSD) and in combination with memory-altering pharmacotherapy like ketamine infusion. By a combination of extinction and reconsolidation of memory approaches, TIMBER works to not over-flood and/or retraumatize as is seen in other treatment approaches. TIMBER involves a balanced combination of both the memory extinction and memory reconsolidation approaches (rather than extinction-only approaches) which explains its superior efficacy in PTSD and benefit in substance use disorders.

Comparison of outcomes of triamcinolone versus normal saline soaked polyvinyl alcohol pack following bilateral endoscopic sinus surgery

BACKGROUND

Steroids have been proven to be beneficial in improving post-operative outcomes following sinus surgery. The ideal mode of delivery is to increase local concentration in the sinuses with minimal systemic side effects. In this study, we used triamcinolone soaked polyvinyl alcohol packs immediately following sinus surgery, and assessed the effects on post-operative outcomes.

METHODOLOGY

This was a prospective, interventional, and comparative study. Following endoscopic sinus surgery, a polyvinyl alcohol pack was placed in both nasal cavities and 4 ml triamcinolone was infiltrated in one side and 4 ml of normal saline was infiltrated in the other. The pack was removed on the second post-operative day and nasal cavities and paranasal sinuses were evaluated using a flexible endoscope in the third post-operative week using Lund-Kennedy and Peri-operative sinus endoscopic scores.

RESULTS

There was a reduction in the average Lund-Kennedy score and Peri-operative sinus endoscopy score in the treatment site compared to the control site which was statistically significant. There was a greater reduction in crusting, oedema and scarring in the treatment site compared to the control site. However, only the reduction in oedema was statistically significant.

CONCLUSIONS

Triamcinolone soaked polyvinyl alcohol pack following endoscopic sinus surgery improves post-operative outcomes.

Transcranial electrical and magnetic stimulation (tES and TMS) for addiction medicine: A consensus paper on the present state of the science and the road ahead

There is growing interest in non-invasive brain stimulation (NIBS) as a novel treatment option for substance-use disorders (SUDs). Recent momentum stems from a foundation of preclinical neuroscience demonstrating links between neural circuits and drug consuming behavior, as well as recent FDA-approval of NIBS treatments for mental health disorders that share overlapping pathology with SUDs. As with any emerging field, enthusiasm must be tempered by reason; lessons learned from the past should be prudently applied to future therapies. Here, an international ensemble of experts provides an overview of the state of transcranial-electrical (tES) and transcranial-magnetic (TMS) stimulation applied in SUDs. This consensus paper provides a systematic literature review on published data - emphasizing the heterogeneity of methods and outcome measures while suggesting strategies to help bridge knowledge gaps. The goal of this effort is to provide the community with guidelines for best practices in tES/TMS SUD research. We hope this will accelerate the speed at which the community translates basic neuroscience into advanced neuromodulation tools for clinical practice in addiction medicine.

Therapeutic Drug Monitoring of Antiepileptic Drugs at a Tertiary Care Hospital of Eastern Nepal

Background Therapeutic drug monitoring (TDM) is the process of measuring drug level in body fluids. It is done to maintain plasma concentration of the drug under therapy within a specific target range for maximum therapeutic efficacy without unnecessary exposure to adverse effects. Objective This study aims to evaluate necessity of therapeutic drug monitoring in Phenytoin, Carbamazepine and Lamotrigine therapy among epileptic patients. Method A prospective, cross-sectional study was conducted for a period of one year at BP Koirala Institute of Health Sciences, Dharan, Nepal. After taking detailed history, blood samples were collected from epileptic patients on monotherapy with the selected drugs. Plasma levels of these drugs were analyzed using High Performance Liquid Chromatography technique (HPLC). Out of total 42 selected patients, 21 were tested for phenytoin, 17 for carbamazepine and four for lamotrigine. The result was categorized into therapeutic, sub-therapeutic and above-therapeutic groups based on reference range. Result Out of total 21 samples tested for phenytoin, 15(71.4%) had plasma drug level within therapeutic range, 5(23.8%) had within subtherapeutic range and 1(4.8%) had above therapeutic range. Analysis of carbamazepine plasma level showed 14(82.3%) at therapeutic level, 1(5.9%) at sub-therapeutic level and 2(11.8%) at above-therapeutic level. Lamotrigine testing in four samples showed 2(50% in) both within therapeutic range and above-therapeutic range. Conclusion Therapeutic drug monitoring of phenytoin, carbamazepine and lamotrigine showed variation in plasma level irrespective of the therapeutic dose. It is suggested that dose adjustment of antiepileptic drugs should be done after establishing 'individual therapeutic range' following regular plasma monitoring.

Clinico-epidemiological Profile of Extra Hepatic Portal Vein Obstruction: A Tertiary Care Hospital Based Retrospective Study

Background Extra hepatic portal vein obstruction (EHPVO) is a common cause of portal hypertension in the developing countries (up to 30% of all variceal bleeders) and is second to cirrhosis in the West (up to 5-10%). Our understanding of the disease is poor compared with other illnesses. Objective To undertake a retrospective study of the clinicoepidemiological profile of Extra hepatic portal vein obstruction in a tertiary care hospital in eastern Nepal. Method All consecutive adult patients whose features were consistent with the diagnosis of extra hepatic portal vein obstruction from June 2014 to June 2016 were retrospectively analyzed to explore the various clinico-epidemiological parameters. Result A total of 58 patients were enrolled in the study with a median age of 24 years (20.5- 40). Portal vein thrombosis was the most common cause of extrahepatic portal vein obstruction. Hematemesis followed by melena were the most common presenting symptoms. All patients had splenomegaly on examination. None of the patients had clinical, biochemical or radiological evidence of chronic liver disease. Conclusion The diagnosis of extra hepatic portal venous obstruction and differentiation from cirrhosis can be easily made by characteristic clinical features, normal liver function tests and doppler ultrasound. Portal vein thrombosis (PVT) is the predominant cause of extra hepatic portal vein obstruction in Nepali patients, as seen at this tertiary care hospital in Nepal.

Role of Repetitive Transcranial Magnetic Stimulation (rTMS) in Treatment of Addiction and Related Disorders: A Systematic Review

BACKGROUND

Addiction and related disorders are devastating with their tremendous social, psychological, and physical consequences for which development of optimally effective treatments is long overdue. Repetitive Transcranial Magnetic Stimulation (rTMS) is relatively safe and is becoming an emerging therapeutic tool for these conditions.

METHODS

This systematic review was conducted using PubMed, PsycINFO, PsychiatryOnline and Cochrane Library ranging from year 2001 to 2017.

RESULTS

Our search selected 70 related articles of which, based on the Strength of Recommendation Taxonomy (SORT) guidelines, 11 indicated Level-1 study quality and class-B strength of recommendation for rTMS in nicotine addiction (effective in 218/289 subjects who received rTMS as found in 11 studies). Level-2/Class-B evidence was found for alcohol and cocaine addictions (Alcohol: effective in 126/193 subjects who received rTMS as found in 8 studies; Cocaine: effective in 86/128 subjects, as found in 5 studies). For food cravings, Level-3/Class-B evidence was noted (effective in 134/169, found in 7 studies). However, the evidence was limited to Level-3/Class-C for heroin (10/20 subjects received active rTMS, effective in 1 study), methamphetamine (33/48 subjects received active rTMS, effective in 2 studies), cannabis (18/18 subjects received active rTMS, effective in 1 study), and pathological gambling (31/31 subjects received active rTMS, effective in 2 studies).

CONCLUSION

rTMS may serve as an emerging therapeutic option for addiction and related disorders. The major lacunae include important methodological limitations and dearth of knowledge about precise mechanism of action that need to be addressed in the future studies.

d-Serine is a potential biomarker for clinical response in treatment of post-traumatic stress disorder using (R,S)-ketamine infusion and TIMBER psychotherapy: A pilot study

Post-traumatic stress disorder (PTSD) is a chronic and debilitating condition that is often refractory to standard frontline antidepressant therapy. A promising new approach to PTSD therapy is administration of a single sub-anesthetic dose of (R,S)-ketamine (Ket). The treatment produces rapid and significant therapeutic response, which lasts for only 4-7 days. In one of our studies, the mean duration of response was increased to 33 days when Ket administration was combined with a mindfulness-based cognitive therapy, Trauma Interventions using Mindfulness Based Extinction and Reconsolidation (TIMBER). We now report the results from a 20-patient study, which examined the duration of sustained response with combined TIMBER-Ket therapy, TIMBER-K arm, relative to the response observed in a placebo-controlled arm, TIMBER-P. A significant difference in the duration of response was observed between TIMBER-K and TIMBER-P arms: 34.44 ± 19.12 days and 16.50 ± 11.39 days, respectively (p = 0.022). Previous studies identified a negative correlation between antidepressant response to Ket and basal plasma concentrations of d-serine (DSR). In this study, the basal DSR levels positively correlated with the pre-treatment severity of PTSD symptoms (Pearson's r = 0.42, p = 0.07) and patients with basal DSR level ≥ 3.5 μM displayed not only higher PTSD severity but also shorter duration of response. The data indicate that basal DSR levels may serve as a biomarker of the severity of PTSD symptoms and as a predictor of clinical response. This article is part of a Special Issue entitled: d-Amino acids: biology in the mirror, edited by Dr. Loredano Pollegioni, Dr. Jean-Pierre Mothet and Dr. Molla Gianluca.

Acute Total Uterine Inversion: A Life Threatening Obstetrics Emergency

Acute total uterine inversion is a rare and life threatening obstetric emergency. Prompt diagnosis and aggressive management reduces maternal mortality and morbidity .We report a case of 28 year old primi, who had total uterine inversion immediately after normal delivery of full term baby weighing 3150gm. Immediate manual repositioning was done by Johnson’s maneuver under general anesthesia. She recovered well and was discharged after 5 days.

Epidemiological Study of Tobacco Smoking Behaviour amongst Residents of the Hill Region of Nepal

Background Tobacco use is still a serious public health problem in the world and represents a major cause of morbidity and mortality in most parts of the world. Objective To measure the prevalence of tobacco use and to identify the factors associated with tobacco use among the residents of Dhankuta Municipality. Method The cross-sectional study was conducted among the residents of the Dhankuta Municipality where 205 households were taken as subjects. Pretested semistructured questionnaire was used for data collection and face to face interview was conducted. Univariate and multivariate logistic regression was used to see the association between various factors and tobacco use and identify the predictor variables. Result Overall prevalence of tobacco consumption in Dhankuta Municipality was found to be 57.1%. Prevalence of tobacco consumption among the male was significantly higher (67%) than female (47.1%) (p<0.05). Most of the respondents (56.4%) started consuming tobacco due to peer pressure and for recreation (24.8%). The multivariate logistic regression showed that the people with illiterate have higher chances of consuming tobacco than above School Leaving Certificate (OR 38.395, 95% CI=3.209- 459.417). The respondents below poverty line (<1.25 US$) was consuming tobacco more than above poverty line (> 1.25 US $) (OR 6.814, 95% CI= 1.255-36.986). Conclusion The aims of this study was to measure the prevalence of tobacco use and to identify the factors associated with tobacco use among the residents of the Dhankuta Municipality. We conclude that the prevalence rate of tobacco consumption in the Dhankuta Municipality was found to be moderately high. Factors like male in gender, Brahmin/Chhetri in ethnicity, lack of education, poor occupation like farmer and housewife, poor economic status were associated with tobacco use.

Megakaryocytic alterations in thrombocytopenia: A bone marrow aspiration study

Background: Megakaryocyte morphology plays an important role in thrombopoiesis. A defect in any stage of megakaryocytopoiesis can lead to dysmegakaryocytopoiesis and thrombocytopenia. This study was conducted to understand megakaryocytic alterations and their contribution in the diagnosis of cases of thrombocytopenia.Materials and Methods: This was a cross-sectional study was conducted on all consecutive cases of bone marrow aspirates of thrombocytopenia over a duration of one year in BPKIHS. Megakaryocyte morphology was studied with a 100X objective. Data were entered into Microsoft excel 10 and analysed with SPSS version 11.5. Descriptive statistics charted and Chi-square tests were done for inferential statistics to find any association at 95% Confidence Interval.Results: Among the 38 subjects, megakaryocytic thrombocytopenia (44.7%) was the most common cause of thrombocytopenia.  Hypolobated megakaryocytes (63.2%), bare megakaryocytic nuclei (57.9%) were the common morphological changes in megakaryocytes. Odds of increased megakaryocyte count in megakaryocytic thrombocytopenia was found to be 12.5 times than for other causes of thrombocytopenia and the presence of bare megakaryocytic nuclei in MTP was statistically significant. (p –value<0.05)Conclusion: Many similarities were observed in megakaryocytic morphology among different hematological diseases. However, increased megakaryocyte count and presence of bare megakaryocytic nuclei, hypolobated forms were significant in megakaryocytic thrombocytopenia.

Nonconventional interventions for chronic post-traumatic stress disorder: Ketamine, repetitive trans-cranial magnetic stimulation (rTMS), and alternative approaches

It is alarming that only 59% of those who have post-traumatic stress disorder (PTSD) respond to selective serotonin reuptake inhibitors. Many existing treatments, both pharmacological and nonpharmacological, do not directly target trauma memories that lay at the core of the PTSD pathogenesis. Notable exceptions are medications like ketamine and propranolol and trauma-focused psychotherapies like eye-movement desensitization and reprocessing therapy (developed by Shapiro) and Trauma Interventions using Mindfulness Based Extinction and Reconsolidation (TIMBER) for trauma memories (developed by Pradhan). Although the antidepressant effects of ketamine are no longer news, ketamine's effects on treatment refractory PTSD (TR-PTSD) is a recent concept. As TR-PTSD has a marked public health burden and significant limitations in terms of treatment interventions, a thorough assessment of current strategies is required. Research to bring clarity to the underlying pathophysiology and neurobiology of TR-PTSD delineating the chemical, structural, and circuitry abnormalities will take time. In the interim, in the absence of a 1-size-fits-all therapeutic approach, pragmatically parallel lines of research can be pursued using the pharmacological and nonpharmacological treatments that have a strong theoretical rationale for efficacy. This article aims to review the current literature on interventions for PTSD, most notably ketamine, trans-cranial magnetic stimulation treatment, yoga and mindfulness interventions, and TIMBER. We present an outline for their future use, alone as well as in combination, with a hope of providing additional insights as well as advocating for developing more effective therapeutic intervention for this treatment-resistant and debilitating condition.

Rapunzel syndrome due to ingested hair extensions: Surgical and psychiatric considerations

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Consuming hair extensions can lead to intestinal obstruction.

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Massive gastric trichobezoar extending into the duodenum is termed Rapunzel syndrome.

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Rapunzel syndrome often requires surgical intervention.

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Patients with Rapunzel syndrome require close psychiatric follow-up.

Introduction

Rapunzel syndrome is a unique clinical manifestation of trichotillomania and trichophagia. The resulting gastric trichobezoar can be massive and necessitate surgical extraction.

Presentation of case

We present a case involving a 15 year-old female with a known history of trichotillomania. The patient possessed symptoms of nausea and early satiety, and admitted that she had recently consumed a large number of hair extensions. Computed tomography imaging revealed a massive gastric bezoar not amenable to endoscopic extraction. The patient underwent surgical laparotomy, and a large gastric trichobezoar was removed through an anterior gastrotomy. The trichobezoar extended past the pylorus into the duodenum, thus confirming a diagnosis of Rapunzel syndrome.

Discussion

Trichobezoars formed from the consumption of hair extensions is a rare cause of Rapunzel syndrome. Surgical extraction is often necessitated due to the sheer size of the gastric bezoar that results from consuming hair extensions. If not previously established, psychiatric consultation should be pursued in the immediate post-operative course as these patients may require pharmacologic management along with behavioral therapy to avoid further episodes of trichotillomania.

Conclusion

This case presents a unique and modern manifestation of Rapunzel syndrome. Surgical treatment most often is required when a patient presents with a massive gastric trichobezoar. Regular post-operative psychiatric follow-up is necessary to prevent recurrent episodes.

Puerperal Sepsis and its Cause in Patan Hospital

Aims: This study was done to find out morbidity related with puerperal pyrexia/sepsis and its risk factors. Methods: This was retrospective study conducted from January 2011 to December 2012 at Department of Obstetrics and Gynaecology, Patan Hospital, Kathmandu, Nepal. All women who delivered in this hospital within 42 days of delivery with puerperal pyrexia/sepsis diagnosed on clinical examination and relevant investigations were included in the study. Women with malaria, typhoid fever and ??other fever were excluded. The data was recorded in predesigned proforma and analyzed. Results: During this period, there were 122 cases of puerperal pyrexia. Puerperal pyrexia accounted for 6.28% of 1945 admissions. Most of the women were aged between 20-29 years, primiparous and booked cases with absent membranes. The causes of puerperal pyrexia in our study were urinary tract infection (47.5%), wound infection (20.5%), endometritis (19.7%) retained product of conception (8.2%), pyoperitoneum (2.5%) and septicemia (1.6%). Conclusions: Puerperal pyrexia/sepsis is one of the causes of preventable maternal morbidity and mortality though in our study it was not proved to be very high in number. Optimal aseptic measures during labour can prevent most of the cases. 

The Study of Prevalence of Helicobacter Pylori in Patients with Acne Rosacea

Background Acne rosacea is an inflammatory disease affecting the central part of the face characterized by erythema, papules, papulo pustules and telangiectasias of unknown etiology. More recently numerous studies have described an association with Helicobacter pylori (Hp) and the extra gastric symptoms of cutaneous origin. Objectives To establish the prevalence of Helicobacter pylori (Hp) infection in the stomach in patients with rosacea based on standard Hp serological test. Methods All patients with the clinical staging of 2, 3 and 4 rosacea attending the Dermatology Out Patient Department from May 2009 – April 2010 were included in the study. Quantitative serological test using the SERION ELISA classic Helicobacter pylori IgG was done. Result A total of 26 patients were enrolled in the study with the age ranging from 26- 82 years. There were 14 males and 12 females and the male: female ratio was 1.6:1. Three (11.53%) patients presented with Grade IV rosacea, a severe clinical presentation and symptoms suggestive of acid peptic diseases were found in 14/26 (53.8%) patients. A positive serology to H. pylori was found in 17/26 (65.4%) of patients. A statistically significant correlation was found when association of H.pylori positivity in patients of rosacea compared with the seropositivity in controls. However correlation in the seropositivity was not found amongst the patients having gastritis and rosacea. Conclusion There still proves to find a correlation of Hp infection with patients with rosacea but it can still be hypothesised as a cutaneous manifestation of an internal peptic ulcer disease . DOI: http://dx.doi.org/10.3126/kumj.v10i4.10995 Kathmandu Univ Med J 2012;10(4):49-52

Risk factors for stunting among children: a community based case control study in Nepal

BACKGROUND

Stunting, a chronic condition, is an underlying cause of child morbidity and mortality in Nepal. This study intends to identify the factors causing stunting among children that will help to prioritize the strategies at the district level.

OBJECTIVE

The objective of the study was to identify the risk factors for stunting among children of age between 6 to 59 months.

METHODS

The study was based on community-based case control design in the mid-west, Surkhet Nepal from August to September 2010. The cases were stunted children and controls were the children without stunting. Data was collected by interviewing those children's mothers and measured length/height of 118 children as cases and 236 children as controls. Logistic regression analysis was performed to identify the best model of factors leading to stunting. Odds ratio and 95% confidence interval were used as a measure of association.

RESULTS

Socio-economic risk factors for stunting comprised mothers without earning (OR=3.11, 95% CI 1.26-7.65), food deficit families (OR=4.26, 95% CI 1.73-10.45) and care taker of the children other than mother (OR=3.02, 95% CI 1.19-7.70). Environmental risk factors for stunting consisted of kitchen without ventilation and children exposed to pesticide. Inappropriate exclusive breast feeding (OR=6.90, 95% CI 2.81-16.97), complementary feeding less than four times a day (OR=3.60, 95% CI 1.32-9.95) and dietary diversity below WHO standard (OR=4.06, 95% CI 1.70-9.67) were factors of stunted children. Diarrhea was found significantly associated with stunting (OR=7.46, 95% CI 2.98-18.65).

CONCLUSIONS

Stunting was found to be as a result of multiple factors such as socio-economic, environmental and inappropriate feeding practices.

Chondrosarcoma of posterior nasal septum

Chondrosarcoma is a rare non-epithelial tumor comprising of 10-20% of primary bone tumor. The nasal septum is a rare site for its occurrence. We present one such case of chondrosarcoma of the nasal septum who was treated with endoscopic removal followed by post operative radiotherapy and discuss the relevant clinical presentation, diagnosis and treatment and review the literature also.

Child-Turcotte-Pugh versus model for end stage liver disease score for predicting survival in hospitalized patients with decompensated cirrhosis

BACKGROUND

Short term and medium term survival predictive value of the Child-Turcotte-Pugh (CTP) and Model for End Stage Liver Disease (MELD) score has been established but their usefulness in predicting survival of hospitalized patients with decompensated cirrhosis is lacking. We compared the survival predictive value of these scoring systems in hospitalized patients of decompensated cirrhosis and other associated factors.

METHODS

A prospective, observational study in 216 consecutive cases of decompensated cirrhosis admitted in medical ward, were enrolled if the inclusion criteria were fulfilled. All cases were investigated and treated as per standard guidelines and clinician's judgment. CTP and MELD score were calculated for each case at the time of admission and followed throughout the hospital stay till discharge/death. The accuracy of the different score systems for predicting survival was evaluated through the area under ROC curve.

RESULTS

CTP and MELD score were higher (12.44 ± 1.07, 31.91 ± 4.92) in expired cases than who improved and discharged (11.32 ± 1.28, 23.97 ± 5.36) respectively with significant p-value (<0.001). Area under ROC curve for serum creatinine, MELD score, blood urea and CTP score for predicting hospital survival were 0.887, 0.864, 0.836 and 0.738 respectively.

CONCLUSIONS

MELD score is superior to CTP score in predicting survival at the time of discharge in hospitalized patients with decompensated cirrhosis. Renal failure in patients with decompensated cirrhosis carries poor prognosis and has a good outcome prognostic value, even superior to MELD/CTP scoring.

Clinical profile of diabetic ketoacidosis in adults

Introduction: Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Recent epidemiological studies indicate that hospitalizations for DKA in the U.S. are increasing. Epidemiological studies from India are limited. We undertook this observational study to analyse the clinical profiles of DKA in adults in south India.Methods: This study was conducted in at a tertiary care center in Andhra Pradesh for one year from Aug 2010 to July 2011. Diagnosis of DKA was made by the presence of (1) Plasma glucose level of 250mg/dl or higher (2) Serum bicarbonate level of 15mEq/lt or lower (3) Arterial blood pH of 7.3 or lower or a venous blood pH of 7.25 or lower (4) Presence of moderate or large urine ketones. All the patients were treated with institutional treatment protocol.Results: Of 27 patients, 22(81%) had type2 diabetes and 5(19%) had type 1 DM .10 were females and 17 males. Age of the patients ranged between 18 to 70 years, with an average of 45.3 years. Precipitating factors were present in 60% of the admissions. Non-compliance or discontinuation of drug therapy was seen in fifty per cent of patients. Average length of hospital stay was slightly longer in type 1 than type 2 DM patientsConclusion: A significant proportion of DKA occurs in patients with type 2 diabetes and many of these cases can be prevented with proper patient education and effective communication with a health care provider during an inter-current illness.DOI: http://dx.doi.org/10.3126/hren.v10i2.6569 Health Renaissance 2012; Vol 10 (No.2); 80-86 

Isolation and characterization of aerobic culturable arsenic-resistant bacteria from surfacewater and groundwater of Rautahat District, Nepal

Arsenic (As) contamination of groundwater is a serious Environmental Health Management issue of drinking water sources especially in Terai region of Nepal. Many studies have reported that due to natural abundance of arsenic in the environment, various bacteria have developed different resistance mechanisms for arsenic compound. In this study, the culturable arsenic-resistant bacteria indigenous to surfacewater as well as groundwater from Rautahat District of Nepal were randomly isolated by standard plate count method on the basis of viable growth on plate count agar amended with arsenate ranging from 0, 0.5, 10, 40, 80 to 160 milligram per liter (mg/l). With respect to the morphological and biochemical tests, nine morphologically distinct potent arsenate tolerant bacteria showed relatedness with Micrococcus varians, Micrococcus roseus, Micrococcus luteus, Pseudomonas maltophilia, Pseudomonas sp., Vibrio parahaemolyticus, Bacillus cereus, Bacillus smithii 1 and Bacillus smithii 2. The isolates were capable of tolerating more than 1000 mg/l of arsenate and 749 mg/l of arsenite. Likewise, bioaccumulation capability was highest with M. roseus (85.61%) and the least with B. smithii (47.88%) indicating the potential of the organisms in arsenic resistance and most probably in bioremediation.

Postoperative complications of septal quilting and BIPP packing following septoplasty

BACKGROUND

Septoplasty is one of the most common surgeries in otorhinolaryngology. After septal surgery nasal packing is usually done to prevent complications like haemorrhage, septal haematoma. However it is associated with many postoperative complications such as pain, hypoxia, dryness in throat, headache, epiphora, vestibular stenosis, crusting, synaechiae, secondary infection etc. In order to prevent these complications quilting has been developed. No study has been done in our country to compare the postoperative complications after septoplasty.

METHODS

This study was carried out to compare postoperative crusting, oedema, synaechia and infection in patients who underwent septal quilting and BIPP packing following septoplasty from August 2008 to July 2011 in the Department of ENT-Head and Neck Surgery, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal.

RESULTS

There were 44 patients in quilting and 41 patients in BIPP packing group. Out of 44 patients of quilting group, crusting occurred in 3 patients, oedema in 4 patients, synechia in 1 patient and infection in 3 patients. Out of 41 patients of BIPP packing group, 9 patients had crusting, oedema was present in 7 patients, 6 patients had synaechia and 5 patients had infection. Crusting and synaechia was found to be statistically significant while oedema and infection was not significant between two groups.

CONCLUSIONS

Complications like excessive crusting, oedema, synaechia and infection can be minimized by quilting suture following septoplasty.

Multiple drug resistance in bacterial isolates from liquid wastes generated in central hospitals of Nepal

BACKGROUND

Healthcare liquid wastes are the reservoirs of harmful infectious agents such as the pathogens and multiple drug resistant microorganisms. Potential infectious risks include the spread of infectious diseases and microbial resistance from health-care establishments into the environment and thereby posing risks of getting infections and antibiotic resistance in the communities.

OBJECTIVES

The objectives of this study were to assess the bacterial load of healthcare liquid waste generated in central hospitals and to explore the antimicrobial resistance pattern of these bacterial isolates.

MATERIALS AND METHODS

A descriptive study was carried out in 10 conveniently selected central hospitals of Nepal during the period of May to December 2008. Effluent specimens from each hospital were subjected to total viable count studies by spread plate method in nutrient agar plate and incubated for 24 hours at 37 °C using standard laboratory protocol. Similarly, all the specimens were cultured in Mac Conkey Agar media supplemented with 30 μg/ml of Chloramphenicol and 20 μg/ml of Gentamycin for the enumeration of multiple drug resistant (MDR) bacteria, which were further subjected to in-vitro antibiotic susceptibility test by modified Kirby Bauer disc diffusion technique for resistance patterns.

RESULTS

Total viable counts of hospital effluents significantly exceeded the standard heterotrophic plate count (p=0.000). Similarly, the numbers of multiple drug resistant bacteria were alarmingly high in three (more than 30% in 2 and 50% in 1) hospitals of this study. Drug resistant hospital effluent isolates showed simultaneous resistance for most of the antibiotics including Penicillin, Cephalosporin, Cotrimoxazole, Gentamycin and Quinolones.

CONCLUSION

Healthcare liquid wastes were laden with MDR bacteria and seemed to pose a huge public health threat in the transfer of such resistance to the bacterial pathogens causing community acquired infections, thereby limiting our antibiotic pool.

Health care waste management practice in a hospital

BACKGROUND

Health-care waste is a by-product of health care. Its poor management exposes health-care workers, waste handlers and the community to infections, toxic effects and injuries including damage of the environment. It also creates opportunities for the collection of disposable medical equipment, its re-sale and potential re-use without sterilization, which causes an important burden of disease worldwide. The purpose of this study was to find out health care waste management practice in hospital.

METHODS

A cross-sectional study was conducted in Narayani Sub-Regional Hospital, Birgunj from May to October 2006 using both qualitative and quantitative methods. Study population was four different departments of the hospital (Medical/Paediatric, Surgical/Ortho, Gynae/Obstetric and Emergency), Medical Superintendent, In-charges of four different departments and all sweepers. Data was collected using interview, group discussion, observation and measurement by weight and volume.

RESULTS

Total health-care waste generated was 128.4 kg per day while 0.8 kg per patient per day. The composition of health care waste was found to be 96.8 kg (75.4%) general waste, 24.1 kg (8.8%) hazardous waste and 7.5 kg (5.8%) sharps per day by weight. Health staffs and sweepers were not practicing the waste segregation. Occupational health and safety was not given due attention. Majority of the sweepers were unaware of waste management and need of safety measures to protect their own health.

CONCLUSIONS

Health care waste management practice in the hospital was unsatisfactory because of the lack of waste management plan and carelessness of patients, visitors and staffs. Therefore the hospital should develop the waste management plan and strictly follow the National Health Care Waste Management Guideline.

Chronic Cough in Thymoma

Cough is one of the most common symptom for which patients seek medical attention from primary care physicians and pulmonologists. Although tuberculosis and other lung infections are common throughout the developing world, they are not among the most common causes of chronic cough. We report a case of a 23 years old male who presenting to the outpatient clinic with chronic cough not responding to regular and symptomatic treatment that was diagnosed to have thymoma. After all the common causes for chronic cough have been ruled out, unusual causes should also be considered in the differential diagnosis. KEYWORDS: Chronic cough, Thymoma, Anterior Mediastinum.

Chronic cough in thymoma

Cough is one of the most common symptom for which patients seek medical attention from primary care physicians and pulmonologists. Although tuberculosis and other lung infections are common throughout the developing world, they are not among the most common causes of chronic cough. We report a case of a 23 years old male who presenting to the outpatient clinic with chronic cough not responding to regular and symptomatic treatment that was diagnosed to have thymoma. After all the common causes for chronic cough have been ruled out, unusual causes should also be considered in the differential diagnosis.

Healthcare liquid waste management

BACKGROUND

The management of healthcare liquid waste is an overlooked problem in Nepal with stern repercussions in terms of damaging the environment and affecting the health of people. This study was carried out to explore the healthcare liquid waste management practices in Kathmandu based central hospitals of Nepal.

METHODS

A descriptive prospective study was conducted in 10 central hospitals of Kathmandu during the period of May to December 2008. Primary data were collected through interview, observation and microbiology laboratory works and secondary data were collected by records review. For microbiological laboratory works,waste water specimens cultured for the enumeration of total viable counts using standard protocols.

RESULTS

Evidence of waste management guidelines and committees for the management of healthcare liquid wastes could not be found in any of the studied hospitals. Similarly, total viable counts heavily exceeded the standard heterotrophic plate count (p=0.000) with no significant difference in such counts in hospitals with and without treatment plants (p=0.232).

CONCLUSIONS

Healthcare liquid waste management practice was not found to be satisfactory. Installation of effluent treatment plants and the development of standards for environmental indicators with effective monitoring, evaluation and strict control via relevant legal frameworks were realized.