Mental health-related structural stigma and discrimination in health and social policies in Nepal: A scoping review and synthesis

AIMS

National policies can be used to reveal structural stigma and discrimination in relation to mental health. This review assesses how structural stigma and discrimination are manifested in the policies and legislations of Government of Nepal.

METHODS

Scoping review methodology was followed to review policy documents (acts of parliament, legislation, policies, strategies, guidelines and official directives) drafted or amended after 2010.

RESULTS

Eighty-nine policies were identified related to health, social welfare, development and regulations which were relevant to people with psychosocial and mental disabilities or have addressed the mental health agendas. Several critical policy failings and gaps are revealed, such as the use of stigmatizing language (e.g., 'insane' or 'lunatic'), inconsistencies within and between policies, deviation from international protocols defining legal capacity and consent, lack of inclusion of the mental health agenda in larger development policies and lack of cost-effective interventions and identification of financing mechanisms. Provisions for people living with mental health conditions included adequate standard of living; attaining standard mental health; the right to exercise legal capacity, liberty and security; freedom from torture or discrimination; and right to live independently. However, other policies contradicted these rights, such as prohibiting marriage, candidacy for and retention of positions of authority and vulnerability to imprisonment.

CONCLUSION

Mental health-related structural stigma and discrimination in Nepal can be identified through the use of discriminator language and provisions in the policies. The structural stigma and discrimination may be addressed through revision of the discriminating policies, integrating the mental health agenda into larger national and provincial policies, and streamlining policies to comply with national and international protocols.

Resiliencies of soil phosphorus fractions after natural summer fire are governed by microbial activity and cation availability in a semi-arid Inceptisol

The unintended impact of natural summer fire on soil is complicated and rather less studied than its above-ground impact. Recognising the impact of a fire on silvopastoral soils and their resilience can aid in improving the management of silvopastoral systems. We studied the immediate (after 1 week (W)) and short-term (after 3 months (M)) recovery of different soil biological and chemical properties after the natural fire, with specific emphasis on phosphorus (P) dynamics. Soil samples were collected from four different layers (0-15, 15-30, 30-45, and 45-60 cm) of Morus alba, Leucaena leucocephala, and Ficus infectoria based silvopastoral systems. In the 0-15 cm soil layer, soil organic carbon (SOC) declined by ∼37, 42, and 30% after the fire in Morus-, Leucaena-, and Ficus-based systems, respectively within 1W of fire. However, after 3M of fire, Morus and Leucaena regained ∼6 and 11.5% SOC as compared to their status after 1W in the 0-15 cm soil layer. After 1W of the fire, soil nitrogen (N), sulfur (S), and potassium availability declined significantly at 0-15 cm soil layer in all systems. Iron and manganese availability improved significantly after 1W of the fire. Saloid bound P and aluminium bound P declined significantly immediately after the fire, increasing availability in all systems. However, calcium bound P did not change significantly after the fire. Dehydrogenase and alkaline phosphatase activity declined significantly after the fire, however, phenol oxidase and peroxidase activity were unaltered. Resiliencies of these soil properties were significantly impacted by soil depth and time. Path analysis indicated microbial activity and cationic micronutrients majorly governed the resilience of soil P fractions and P availability. Pasture yield was not significantly improved after the fire, so natural summer fire must be prevented to avoid loss of SOC, N, and S.

Selection of Ideal Reference Genes for Gene Expression Analysis in COVID-19 and Mucormycosis

Selection of reference genes during real-time quantitative PCR (qRT-PCR) is critical to determine accurate and reliable mRNA expression. Nonetheless, not a single study has investigated the expression stability of candidate reference genes to determine their suitability as internal controls in SARS-CoV-2 infection or COVID-19-associated mucormycosis (CAM). Using qRT-PCR, we determined expression stability of the nine most commonly used housekeeping genes, namely, TATA-box binding protein (TBP), cyclophilin (CypA), β-2-microglobulin (B2M), 18S rRNA (18S), peroxisome proliferator-activated receptor gamma (PPARG) coactivator 1 alpha (PGC-1α), glucuronidase beta (GUSB), hypoxanthine phosphoribosyltransferase 1 (HPRT-1), β-ACTIN, and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) in patients with COVID-19 of various severities (asymptomatic, mild, moderate, and severe) and those with CAM. We used statistical algorithms (delta-CT [threshold cycle], NormFinder, BestKeeper, GeNorm, and RefFinder) to select the most appropriate reference gene and observed that clinical severity profoundly influences expression stability of reference genes. CypA demonstrated the most consistent expression irrespective of disease severity and emerged as the most suitable reference gene in COVID-19 and CAM. Incidentally, GAPDH, the most commonly used reference gene, showed the maximum variations in expression and emerged as the least suitable. Next, we determined expression of nuclear factor erythroid 2-related factor 2 (NRF2), interleukin-6 (IL-6), and IL-15 using CypA and GAPDH as internal controls and show that CypA-normalized expression matches well with the RNA sequencing-based expression of these genes. Further, IL-6 expression correlated well with the plasma levels of IL-6 and C-reactive protein, a marker of inflammation. In conclusion, GAPDH emerged as the least suitable and CypA as the most suitable reference gene in COVID-19 and CAM. The results highlight the expression variability of housekeeping genes due to disease severity and provide a strong rationale for identification of appropriate reference genes in other chronic conditions as well. IMPORTANCE Gene expression studies are critical to develop new diagnostics, therapeutics, and prognostic modalities. However, accurate determination of expression requires data normalization with a reference gene, whose expression does not vary across different disease stages. Misidentification of a reference gene can produce inaccurate results. Unfortunately, despite the global impact of COVID-19 and an urgent unmet need for better treatment, not a single study has investigated the expression stability of housekeeping genes across the disease spectrum to determine their suitability as internal controls. Our study identifies CypA and then TBP as the two most suitable reference genes for COVID-19 and CAM. Further, GAPDH, the most commonly used reference gene in COVID-19 studies, turned out to be the least suitable. This work fills an important gap in the field and promises to facilitate determination of an accurate expression of genes to catalyze development of novel molecular diagnostics and therapeutics for improved patient care.

A rare case of persistent lateral marginal vein of Servelle in Klippel Trenaunay Syndrome: A successful surgical management

Introduction and importance

Klippel-Trenaunay Syndrome (KTS) is a rare congenital vascular disorder characterized by capillary malformation, varicosities, and tissue overgrowth. It usually affects the unilateral lower extremities manifesting commonly as pain, localized rise of temperature, and venous tortuosity. However, in severe cases, ulceration, cellulitis, and chronic lymphatic malformation may be present. Management is mostly supportive and involves the use of compression stockings.

Case presentation

Here, we report a case of KTS with a persistent lateral marginal vein of Servelle managed with radiofrequency ablation along with sclerotherapy of selected perforators. On a two-year follow-up, the symptoms had resolved and Doppler ultrasonography revealed resolution of the defective vein along with the absence of incompetent perforators.

Clinical discussion

In cases with venous malformation with the persistence of embryonic avalvular venous structures, like the lateral marginal vein of Servelle, surgical intervention is warranted especially at a younger age to reduce the risk of future thromboembolic events and recurrence.

Conclusion

Varicosities of the lateral marginal vein of Servelle can be managed successfully by radiofrequency ablation and adjunct sclerotherapy in selected cases.

•

Klippel-Trenaunay Syndrome (KTS) is a congenital vascular disorder which usually affects the unilateral lower extremities.

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Endovenous treatment of the greater saphenous vein is gradually becoming popular in the treatment of KTS.

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This case is managed by radiofrequency ablation of lateral marginal vein of Servelle.

A Cold Chain-Independent Specimen Collection and Transport Medium Improves Diagnostic Sensitivity and Minimizes Biosafety Challenges of COVID-19 Molecular Diagnosis

Equitable and timely access to COVID-19-related care has emerged as a major challenge, especially in developing and low-income countries. In India, ∼65% of the population lives in villages where infrastructural constraints limit the access to molecular diagnostics of COVID-19 infection. Especially, the requirement of a cold chain transport for sustained sample integrity and associated biosafety challenges pose major bottlenecks to the equitable access. Here, we developed an innovative clinical specimen collection medium, named SupraSens microbial transport medium (SSTM). SSTM allowed a cold chain-independent transport at a wide temperature range (15°C to 40°C) and directly inactivated SARS-CoV-2 (<15 min). Evaluation of SSTM compared to commercial viral transport medium (VTM) in field studies (n = 181 patients) highlighted that, for the samples from same patients, SSTM could capture more symptomatic (∼26.67%, 4/15) and asymptomatic (52.63%, 10/19) COVID-19 patients. Compared to VTM, SSTM yielded significantly lower quantitative PCR (qPCR) threshold cycle (Ct) values (mean ΔCt > -3.50), thereby improving diagnostic sensitivity of SSTM (18.79% [34/181]) versus that of VTM (11.05% [20/181]). Overall, SSTM had detection of COVID-19 patients 70% higher than that of VTM. Since the logistical and infrastructural constraints are not unique to India, our study highlights the invaluable global utility of SSTM as a key to accurately identify those infected and control COVID-19 transmission. Taken together, our data provide a strong justification to the adoption of SSTM for sample collection and transport during the pandemic. IMPORTANCE Approximately forty-four percent of the global population lives in villages, including 59% in Africa (https://unhabitat.org/World%20Cities%20Report%202020). The fast-evolving nature of SARS-CoV-2 and its extremely contagious nature warrant early and accurate COVID-19 diagnostics across rural and urban population as a key to prevent viral transmission. Unfortunately, lack of adequate infrastructure, including the availability of biosafety-compliant facilities and an end-to-end cold chain availability for COVID-19 molecular diagnosis, limits the accessibility of testing in these countries. Here, we fulfill this urgent unmet need by developing a sample collection and transport medium, SSTM, that does not require cold chain, neutralizes the virus quickly, and maintains the sample integrity at broad temperature range without compromising sensitivity. Further, we observed that use of SSTM in field studies during pandemic improved the diagnostic sensitivity, thereby establishing the feasibility of molecular testing even in the infrastructural constraints of remote, hilly, or rural communities in India and elsewhere.

Targeting endogenous gaseous signaling molecules as novel host-directed therapies against tuberculosis infection

Tuberculosis (TB) is a chronic pulmonary disease caused by Mycobacterium tuberculosis which is a major cause of morbidity and mortality worldwide. Due to the complexity of disease and its continuous global spread, there is an urgent need to improvise the strategies for prevention, diagnosis, and treatment. The current anti-TB regimen lasts for months and warrants strict compliance to clear infection and to minimize the risk of development of multi drug-resistant tuberculosis. This underscores the need to have new and improved therapeutics for TB treatment. Several studies have highlighted the unique ability of Mycobacterium tuberculosis to exploit host factors to support its survival inside the intracellular environment. One of the key players to mycobacterial disease susceptibility and infection are endogenous gases such as oxygen, nitric oxide, carbon monoxide and hydrogen sulfide. Nitric oxide and carbon monoxide as the physiological gaseous messengers are considered important to the outcome of Mycobacterium tuberculosis infection. The role of hydrogen sulfide in human tuberculosis is yet not fully elucidated, but this gas has been shown to play a significant role in bacterial respiration, growth and pathogenesis. This review will focus on the host factors majorly endogenous gaseous signaling molecules which contributes to Mycobacterium tuberculosis survival inside the intracellular environment and highlight the potential therapeutic targets.

Exploring salivary diagnostics in COVID-19: a scoping review and research suggestions

INTRODUCTION

Molecular diagnostics for SARS-CoV-2 infection characteristically involves the sampling of the throat or nasopharyngeal swab (NPS). However, these procedures are invasive, require necessary skills for sample collection, cause patient discomfort, and are non-conducive for extensive scale testing. Saliva is increasingly being suggested as an alternate diagnostic sample in SARS-CoV-2 infection.

OBJECTIVES

This scoping review was done with the objective of exploring the evidence on the role of saliva as an alternate diagnostic sample in SARS-CoV-2 condition.

METHODS

Thorough search of the literature in major databases was undertaken in June 2020 using free text and MESH terms, followed by PRISMA to identify 17 studies for data extraction.

RESULTS AND CONCLUSIONS

Evidence was summarised for study characteristics, salivary sampling characteristics, viral load, and longevity of virus in saliva. The literature supports that saliva offers a simple sample collection method compared to technique-sensitive NPS and has the advantage of point-of-care testing for initial screening in community or hospital-based set-up. The additional highlights of this review are heterogeneity in the current literature and the gaps in methodology. Therefore, a robust study design to generate higher levels of evidence has been proposed.

Development of a highly effective low-cost vaporized hydrogen peroxide-based method for disinfection of personal protective equipment for their selective reuse during pandemics

BACKGROUND

Personal Protective Equipment (PPE) is required to safely work with biological agents of bacterial (i.e. Mycobacterium tuberculosis) or viral origin (Ebola and SARS). COVID-19 pandemic especially has created unforeseen public health challenges including a global shortage of PPE needed for the safety of health care workers (HCWs). Although sufficient stocks of PPE are currently available, their critical shortage may develop soon due to increase in demand and depletion of existing supply lines. To empower our HCWs and ensure their continued protection, proactive measures are urgently required to develop procedures to safely decontaminate the PPEs to allow their "selective reuse" during contingency situations.

METHODS

Herein, we have successfully developed a decontamination method based on vaporized hydrogen peroxide (VHP). We have used a range of concentration of hydrogen peroxide to disinfect PPE (coveralls, face-shields, and N-95 masks). To ensure a proper disinfection, we have evaluated three biological indicators namely Escherichia coli, Mycobacterium smegmatis and spores of Bacillus stearothermophilus, considered as the gold standard for disinfection processes. We next evaluated the impact of repeated VHP treatment on physical features, permeability, and fabric integrity of coveralls and N-95 masks. Next, we performed Scanning Electron Microscopy (SEM) to evaluate microscopic changes in fiber thickness of N-95 masks, melt blown layer or coverall body suits. Considering the fact that any disinfection procedure should be able to meet local requirements, our study included various regionally procured N-95 masks and coveralls available at our institute All India Institute of Medical Sciences (AIIMS), New Delhi, India. Lastly, the practical utility of VHP method developed herein was ascertained by operationalizing a dedicated research facility disinfecting used PPE during COVID-19.

RESULTS

Our prototype studies show that a single VHP cycle (7-8% Hydrogen peroxide) could disinfect PPE and PPE housing room of about 1200 cubic feet (length10 ft × breadth 10 ft × height 12 ft) in less than 10 min, as noted by a complete loss of B. stearothermophilus spore revival. The results are consistent and reproducible as tested in over 10 cycles in our settings. Further, repeated VHP treatment did not result in any physical tear, deformity or other appreciable change in the coverall and N-95 masks. Our permeation tests evaluating droplet penetration did not reveal any change in permeability post-VHP treatments. Also, SEM analysis indeed revealed no significant change in fiber thickness or damage to fibers of coveralls or melt blown layer of N-95 masks essential for filtration. There was no change in user comfort and experience following VHP treatment of PPE. Based on results of these studies, and parameters developed and optimized, an institutional research facility to disinfect COVID-19 PPE is successfully established and operationalized with more than 80% recovery rate for used PPE post-disinfection.

CONCLUSIONS

Our study, therefore, successfully establishes the utility of VHP to effectively disinfect PPE for a possible reuse as per the requirements. VHP treatment did not damage coveralls, cause physical deformity and also did not alter fabric architecture of melt blown layer. We observed that disinfection process was successful consistently and therefore believe that the VHP-based decontamination model will have a universal applicability and utility. This process can be easily and economically scaled up and can be instrumental in easing global PPE shortages in any biosafety facility or in health care settings during pandemic situation such as COVID-19.

The Study of Burden of Family Caregivers of Patients Living with Psychiatric Disorders in Remote Area of Nepal

Background Family caregivers of psychiatric disorders likely to face burden. There is a paucity of data regarding the caregiver burden in psychiatric disorders in context of Nepal. Objective To study the caregiver burden in families with psychiatric illness and to find association between socio-demographic variables and caregiver burden in families with psychiatric illness. Method This is an analytical cross-sectional study. The participants (n=96) were caregiver of patients visiting outpatient department of two government of Nepal primary health care centers namely, Panchkhal Primary Health Care Center (PHC) Kavre District and Barhabise Health Care Center Sindhupalchowk district. The sample size has been determined by using statistical formula. Family burden assessment schedule (FBIS) was used for the study. Result The majority of the caregivers were females 56.3%. Most of the caregivers were aged below 45 years 54.2%. The large number of participants were single or separated 74%. The mean score of family burden assessment schedule was 27 ± 9.8 (range 0 to 48) with positive rate of 59.4%.Among the objective burden domains disruption of family leisure 61.5% was the most frequently reported burden. The subjective burden was reported in 95%. There were significant differential demographic associations with different domains of caregivers' burden. Conclusion Caregivers of Psychiatric patients experience different kind of burden of care. Our findings highlight the support to the family members to reduce their burden.

Long-term in situ moisture conservation in horti-pasture system improves biological health of degraded land

In situ moisture conservation practices can conserve fertile topsoil and enhance available water in soil profile. We hypothesised that reclaiming degraded land ecologically through tree + pasture + in situ moisture conservation practices would significantly improve soil organic carbon (SOC) and health. Hence, the objectives were a) to identify changes in nutrient cycling enzymes and SOC status due to different in situ soil moisture conservation options in surface and subsurface soil layers, and b) to test the potentiality of soil enzymes to determine long-term nutrient availability. We conducted a long-term experiment involving aonla (Emblica officinalis) trees + pasture (Cenchrus ciliaris + Stylosanthes seabrana) + in situ soil moisture conservation measures viz. staggered contour trenches (T1), continuous contour trenches (T2), stone mulch (T3), vegetative barriers (T4), control (T5) and fallow land (T6) since 2007. Recommended dose of nitrogen (N), phosphorus (P) and potassium (K) were added to all treatments, except T6. SOC concentration increased by ~51 and 31% in T1 and T2, respectively, over T5 in surface (0-15 cm) soil. Culturable bacterial and fungal populations increased by ~20 and 95% in T1 over T5 in surface soil. Activities of all soil enzymes increased in T1 and T2 (ranging from 42 to 289%) over T5 and T6 in both surface and sub-surface (15-30 cm) layers. However, specific activity of phenol oxidase was ~25% lower for T1 than T6, suggesting more efficient SOC sequestration in T1. Moreover, geometric mean enzyme activity of T1 was ~65 and 33% higher than T5 and T3, respectively, in surface soil. Treated soil quality index (T-SQI) of T1 was ~184% higher than T5. Soil functional diversity was also ~1.24 and 1.22 times higher in T1 and T2 than T5, respectively. Peroxidase was the major C degrading enzyme in this ecosystem. Protease, urease and phosphatase significantly influenced N and P availability along with fruit and pasture yields. Importantly, ~96, 62 and 82% variability of SOC, N and P concentrations, respectively, could be attributed to their corresponding enzyme activities. Principal components analysis (PCA) revealed one-way operational role of soil enzymes. Thus, enzymes are potentially important for recycling nutrients from litters, root biomass of fruit trees and grasses to boost their availability in the long run. Adoption of horti-pasture system combined with moisture conservation practices and staggered contour trenches or continuous contour trenches ensured higher above ground biomass yield, SOC, nutrient availability and soil quality. Thus, long-term use of these practices could be recommended for reclamation and improving soil health and crop productivity of degraded lands of central India.

On the stability of carbon sequestration in an anisotropic horizontal porous layer with a first-order chemical reaction

Carbon dioxide (CO₂) sequestration in deep saline aquifers is considered to be one of the most promising solutions to reduce the amount of greenhouse gases in the atmosphere. As the concentration of dissolved CO₂ increases in unsaturated brine, the density increases and the system may ultimately become unstable, and it may initiate convection. In this article, we study the stability of convection in an anisotropic horizontal porous layer, where the solute is assumed to decay via a first-order chemical reaction. We perform linear and nonlinear stability analyses based on the steady-state concentration field to assess neutral stability curves as a function of the anisotropy ratio, Damköhler number and Rayleigh number. We show that anisotropy in permeability and solutal diffusivity play an important role in convective instability. It is shown that when solutal horizontal diffusivity is larger than the vertical diffusivity, varying the ratio of vertical to horizontal permeabilities does not significantly affect the behaviour of instability. It is also noted that, when horizontal permeability is higher than the vertical permeability, varying the ratio of vertical to horizontal solutal diffusivity does have a substantial effect on the instability of the system when the reaction rate is dominated by the diffusion rate. We used the Chebyshev-tau method coupled with the QZ algorithm to solve the eigenvalue problem obtained from both the linear and nonlinear stability theories.

Perceptions and Attitudes towards Evidence Based Practice among Nurses and Nursing Students in Nepal

Background As the evidence based practice (EBP) movement expands, there is a need for health leaders and educators in each country to assess the extent to which health professional students and practitioners are prepared to locate, evaluate, and apply evidence to guide their practice. Objective The study objective was to explore nurses' and nursing students' perceptions and attitudes towards EBP. Method This was a descriptive cross-sectional survey administered to all 273 nurses and nursing students from Nepal who attended an EBP conference. The survey instrument that was used by Majid in Singapore was adapted for use in this study with permission from the author. Result In total, 121 nurses participated in the study. The majority (93%) of respondents reported that they had no previous training in EBP. The respondents' perceptions of their EBP knowledge and skills were variable, but most of them demonstrated positive attitudes toward EBP. Respondents identified a number of barriers that limit the implementation of EBP in Nepal. The greatest barriers were lack of time and resources, difficulty understanding research articles and translating the findings to practice, and limited autonomy to change practice based on evidence. Conclusion Although respondents had positive attitudes towards EBP, their knowledge and skills were limited and barriers to implementation existed. Nursing faculty can use the findings to guide implementation of EBP into curricula, and nursing administrators and clinicians can use the findings to guide practice to promote EBP.

Insights into metabolism and sodium chloride adaptability of carbaryl degrading halotolerant Pseudomonas sp. strain C7

Pseudomonas sp. strain C7 isolated from sediment of Thane creek near Mumbai, India, showed the ability to grow on glucose and carbaryl in the presence of 7.5 and 3.5% of NaCl, respectively. It also showed good growth in the absence of NaCl indicating the strain to be halotolerant. Increasing salt concentration impacted the growth on carbaryl; however, the specific activity of various enzymes involved in the metabolism remained unaffected. Among various enzymes, 1-naphthol 2-hydroxylase was found to be sensitive to chloride as compared to carbaryl hydrolase and gentisate 1,2-dioxygenase. The intracellular concentration of Cl^- ions remained constant (6-8 mM) for cells grown on carbaryl either in the presence or absence of NaCl. Thus the ability to adapt to the increasing concentration of NaCl is probably by employing chloride efflux pump and/or increase in the concentration of osmolytes as mechanism for halotolerance. The halotolerant nature of the strain will be beneficial to remediate carbaryl from saline agriculture fields, ecosystems and wastewaters.

Hydrops fetalis secondary to supradiaphragmatic extrapulmonary sequestration with congenital cystic adenomatoid malformation

Congenital cystic adenomatoid malformation is a hamartomatous lesion. A 30 year old woman, G2P1L1, in the 29th week of gestation presented with pain abdomen, chest pain, cough with expectoration, fever and inability to appreciate fetal movements of 2 days duration. Clinically, she had pneumonia. An ultrasound revealed a single fetus in breech presentation with features of hydrops fetalis, hypoplastic left lung, mediastinal shift to the left and poor diastolic and systolic flow in the umbilical artery.A still born male baby delivered subsequently was found at autopsy to have hydrops fetalis, supradiaphragmatic right sided extralobar sequestration with associated congenital cystic adenomatoid malformation.The right lung also showed congenital cystic adenomatoid malformation. There were no other associated anomalies. We present a rare case of extralobar sequestrationwith congenital cystic adenomatoid malformation.

Blood Lead Level among school children in an Industrial city of Nepal

Background: Widespread use of lead has caused extensive environmental contamination and health problems in many parts of the world. Children are particularly vulnerable and even relatively low levels of exposure can cause serious health conditions. Our objective was to determine the prevalence of blood lead level in children in industrial city of Nepal, Birgunj.Materials and Methods: The cross sectional study was done on 50 school going student in Birgunj city, Nepal from November 2016 to January 2017. Questionnaire was used to collect data. Capillary blood was drawn and Blood Lead Level was measured immediately. SPSS ver. 22 was used to analyze the data.Results: The mean age of children in study was 12.5 ± 1.11 years.Among 50 children, 54% were male and 46% were female. The mean blood lead level was 20.33±9.36 μg/dl (male 21.08±8.87μg/dl, female 19.46±10.92 μg/dl). All the children in the study have elevated blood lead level and 84% of them have >10 μg/dl. About 26% of children have blood lead level between 15-20 μg/dl, 12% have level 20-25 μg/dl and 4% of them have more than 35 μg/dl.Conclusion: The prevalence of blood lead level in children from the industrial city of Nepal is alarmingly high. Children exposed with chipped paints have high level of blood lead level. However, further study in large population is required to address the current situation regarding the lead exposure to children.  

Morphological changes in the Heart in unrelated deaths

Background: Cardiovascular diseases are the major cause of morbidity and mortality worldwide. In the Indian subcontinent, they account for more than 25% of deaths. Numerous studies have been conducted on the cardiovascular system in cases of sudden death; but there has been a major neglect to study the heart in cases of people who died of unrelated causes.In the present study, we have attempted to study the CVS in detail in those individuals who died of unrelated causes and have tried to assess the prevelance of atherosclerosis, conduction system lesions, inflammatory and valvular pathologies in them.Materials and Methods: The present study was a prospective one conducted from June 2007 to June 2009 in the department of Pathology, Kasturba Medical College, Mangalore. The hearts of persons who died of unrelated causes were studied.Results: Various lesions encountered in the heart were coronary artery disease (70.58%), medial hyperplasia of SAnode (38.23%) and AV node (55.88%), chronic inflammation of the conduction system (55.88%) and calcification (11.76%). Malarial myocarditis was seen in 5.88% and pulmonary stenosis was seen in 2.94% of the cases. No cardiac pathology was detected in 5.88% cases.Conclusion: Our study highlights the prevelace of atherosclerotic changes and conduction system abnormalities in the general population. Hence, we conclude that examination of the CVS is extremely important in cases of sudden death; but it should also be made mandatory in unrelated deaths too, as it can diagnose a lot of hidden pathology.  

Glusoce-6-phosphate dehydrogenase- History and diagnosis

Glucose-6-phosphate dehydrogenase deficiency is the most common enzymatic defect of red blood cells, which increases the vulnerability of erythrocytes to oxidative stress leading to hemolytic anemia. Since its identification more than 60 years ago, much has been done with respect to its clinical diagnosis, laboratory diagnosis and treatment. Association of G6PD is not just limited to anti malarial drugs, but a vast number of other diseases. In this article, we aimed to review the history of Glucose-6-phosphate dehydrogenase, the diagnostic methods available along with its association with other noncommunicable diseases. 

Knowledge of Maternal and Newborn Care Among Primary Level Health Workers in Kapilvastu District of Nepal

BACKGROUND

Higher maternal and neonatal deaths are common in low- and middle-income countries; due to less access to skilled help. Adequate knowledge and skills on maternal and newborn care (MNC) of community health workers can improve maternal and newborn health.

AIMS

To identify the knowledge of primary level health workers on some components of MNC.

SUBJECTS AND METHODS

Respondents were selected using simple random sampling method. For collecting the data, enumerators visited health institutions for 2 months from 1(st) October to 31(st) November 2012, and structured interview schedule was used to gather the information. A cross-sectional study was conducted in a total of one hundred and thirty-seven primary level health workers in Kapilvastu district, Nepal. The Chi-square test was employed to examine the association between the knowledge of health workers on MNC and designation and work experience. Data were analyzed using SPSS version 17.

RESULTS

In a total of 137 primary level health workers, more than half 53.2% (73/137) were senior auxiliary health workers/health assistant. Health workers having correct knowledge on contents of MNC were-registration 32.1% (44/137), major components of antenatal care 57.7% (79/137), danger signs of pregnancy 39.4% (54/137), five cleans 59.1% (81/137), postnatal health problems 54.0% (74/137), majority to health action to newborn care, newborn bath and meaning of exclusive breastfeeding. There was a statistical association between designation of health workers and above-mentioned components of MNC (P < 0.05).

CONCLUSIONS

The differentials in the knowledge of MNC among primary level health suggest improving knowledge of the grass root level health workers with appropriate training and development programs.

Cardiac conduction system- A detailed study in 46 cases of sudden death

Background: Atherosclerotic coronary artery disease is the modern pandemic and is said to be responsible for a major chunk of sudden cardiac deaths. However, in few cases; especially among the young, conduction system abnormalities were found to be the cause of death with absence of significant coronary lesions. These days, examination of the cardiac conduction system during autopsy has been abandoned as it is said to be a time consuming process. The present study was undertaken to highlight the importance of examining the cardiac conduction system in all sudden death cases.Materials and Methods: This study was a prospective one, conducted from June 2007 to June 2009 in the department of Pathology, Kasturba Medical College, Mangalore. Forty six hearts of persons who died suddenly were studied.Results: Our study showed that even though atherosclerotic coronary lesions were the most common cause of sudden death, cardiac conduction defects also contributed to a significant number of cases; especially in the young. In our study of 46 cases; 6 cases showed only conduction system abnormalities. These were young adults who had died suddenly. The predominant lesion identified in them was fibromuscular dysplasia of the nodal arteries.Conclusion: A detailed examination of the coronaries and the cardiac conduction system should be made mandatory in all sudden death cases, especially in the young as they will help to throw some light into the cause of death.Journal of Pathology of Nepal (2015) Vol. 5, 709-716

Anti-Nuclear antibodies: Current concepts and future direction for diagnosing connective tissue disease

Identification of antinuclear antibodies has been used for the diagnosis of connective tissue diseases for more than fifty years. Indirect immunofluorescence on human epithelial (HEp-2) cells is considered the gold standard screening method for the detection of antinuclear autoantibodies. As the demand of ANA testing increased, the need for automation and standardization has also come forth. A high level of false positive and false negative cases is seen in various populations making it difficult to take clinical decisions. Newer technologies were introduced for the antibody detection to ensure high sensitivity and specificity. This article intends to provide an overview of the concepts on ANA testing, the different diagnostic methods available, the various patterns and clinical utility, the clinical guidelines to be followed, the drawbacks and what lies ahead in the future of ANA testing.Journal of Pathology of Nepal (2015) Vol. 5, 766-773

Leiomyoma on the penile shaft

Primary soft tissue tumors of the penis, such as leiomyomas, are very rare. To the best of our knowledge, less than ten cases have been reported till date. The lesion gradually increases in size and can mimic a malignant lesion. Excisional biopsy and histopathological examination can provide the diagnosis as well as cure, both physical and psychological. We report a case of a penile shaft leiomyoma in a 49 year old male.DOI: http://dx.doi.org/10.3126/jpn.v4i8.11598 Journal of Pathology of Nepal; Vol.4,No. 8 (2014) 680-681

Correlation of Clinico-pathological Classification of Hansen's Disease in a South Indian City

Hansen's Disease (HD) presents itself in different forms depending on the individual's immune status, and based on this Ridley-Jopling classified the disease into five sub-groups. The aim of this study was to evaluate the role of histopathology and bacteriological index (BI) in accurate staging of HD with clinical correlation. Fifty HD patients with clinical diagnosis confirmed by histopathology were included. Patients in reaction and on treatment were excluded. Case records and histopathological slides were viewed and BI was recorded. In 10/50 cases, a diagnosis of HD was made or suspected, but were not clinically classified. In these, histopathology proved useful in diagnosis and classification. Indeterminate HD was the most common histopathological diagnosis (6 cases). The remaining 40 patients, were clinically classified using the Ridley-Jopling classification, as Indeterminate Leprosy (IL) in 10/40 (25%), Tuberculoid Leprosy (TT) 5/40 (12.5%), Borderline Tuberculoid (BT) 16/40 (40%), Borderline Lepromatous (BL) 4/40 (10%) and Lepromatous Leprosy (LL) 5 (12.5%). HD was common in males with male to female ratio of 1.66:1 and affected the younger individuals (maximum in 21 to 30 years). On histopathology BT was the most common type (40%) followed by IL (27.5%), BL (12.5%), TT (10%) and LL (10%). No case of Mid-Borderline (BB) type was diagnosed clinically or histopathologically. Overall concordance between clinical and histopathological diagnosis was 65% (26/40 cases) and for each type was IL = 80%, TT = 20%, BT = 75%, BL = 50% and LL = 60%. Where classification seemed difficult as in cases of BT and BL, II played an important role. The overall concordance between clinical classification and histopathological diagnosis of DO is 65% in this study. Th *discordance that is observed is between BT and TT, the paucibacillary type and BL andILL the multibacillary type and hence the treatment is not affected. Overall, IL was a common diagnosis on histopathology in this study'(11/40 cases and 6/10 cases). If clinically warranted, a repeat deeper punch of skin biopsyrmay be required for a proper categorization of the cases.

Automated urinalysis: First experiences and comparison of automated urinalysis system and manual microscopy

Background: Urinary tract infection is a common condition which needs laboratory evaluation of urine to substantiate the clinical diagnosis and initiate treatment. The conventional urinalysis consists of using a test strip for chemical examination to identify the various urine sediments after which visual microscopy is done. We evaluate the analytical performance of automated microscopic technique (UF 500i) and compare results with those from manual microscopy. Materials and Methods: A total of 382 urine specimens were collected during a period of one month out of which 128 samples which had abnormal cell counts were analyzed for cells and particles by manual and automated microscopy by UF-500i flow cytometer. Results: The concordance of UF 500i and the manual microscopy which is considered to be the gold standard for urine microscopic examination was 90.6% for white blood cells, red blood cell, epithelial cells, cast and bacterial count. Conclusion: Automated urine sediment analyzer, UF 500i was considered reliable in the measurement of white blood cells, red blood cells, epithelial cells, cast and bacteria. Automation will surely reduce the work load, increase accuracy and reliability, and increase the throughput and turn-around time of the laboratory DOI: http://dx.doi.org/10.3126/jpn.v4i7.10316 Journal of Pathology of Nepal (2014) Vol. 4, 576-579  

Clinicopathological features of pilomatricoma cases: Analysis of 21 cases

Background: Pilomatricoma is a slow-growing, asymptomatic tumour originating from outer sheath cells of hair follicle. In this study, we describe the clinical presentation and histopathological features of pilomatricoma. Materials and Methods: This was a hospital based retrospective study carried out in all patients who were diagnosed as pilomatricoma over a period of January 2001 to December 2013. The study was done in department of pathology, Manipal Teaching Hospital, Nepal. Results: A total of 21 cases of pilomatricoma were reported with age range of 9-53 years (mean age 23.7) and male female ratio of 1:1.1. The most common site of occurrence was neck and preauricular region. The size of the tumour ranged from 0.3 to 4.7cm with a mean of 1.2cm. Multiple occurrences were seen in 3 patients and ossifying pilomarticoma was seen in 4 cases. Conclusion: Pilomatricoma is a benign skin neoplasm of hair follicle matrix cells. Calcification is a common finding while dystrophic ossification also can occur in the tumour. Histopathology gives the definite diagnosis as fine needle aspiration cytology and clinical impression may be misleading. DOI: http://dx.doi.org/10.3126/jpn.v4i7.10293 Journal of Pathology of Nepal (2014) Vol. 4, 530-533

Interpretation of bone marrow aspiration in hematological disorder

Background: Hematological disorders are quite frequent in all age group. Most of this hematological disorder first present as anemia. Bone Marrow Aspiration plays a major role in the diagnosis of its underlying cause. The aim of this study was to analyze the causes of hematological disorders, its spectrum and to interprete the bone marrow aspiration findings.Materials and Methods: This was a retrospective and prospective study carried out in the department of Pathology of Nepal Medical College in a period of two years. (July 2010 - June 2012). Bone marrow examination of 57 cases of suspected hematological disorders was carried out. All details of the patients were obtained from the record file in the department of pathology.Results: Out of 57 cases of bone marrow aspiration, erythroid hyperplasia was seen in 12 cases (21%). Megaloblastic anemia was seen in 7 cases (12.3%) and microcytic anemia was seen in 4 cases (7%). There were 6 cases (10.5%) of Idiopathic Thrombocypenic Purpura. Acute leukemia was diagnosed in 7 cases (12.3%) and among this acute myeloid leukemia (10.5%) was more common than acute lymphoid leukemia (1.8%). Myelodysplastic syndrome and multiple myeloma was seen in 3.5 % cases each. Aplastic anemia and kalaazar was seen in 5.3% and 1.8% cases respectively.Conclusion: Bone marrow examination is an important step to arrive at the confirmatory diagnosis of many hematological disorders.Journal of Pathology of Nepal (2012) Vol. 2, 309-312DOI: http://dx.doi.org/10.3126/jpn.v2i4.6885

Studies on extended spectrum beta lactamase (ESBL) producing salmonella isolates from clinical samples of Nepal

Present study was carried out among the patients of age 2-60 years from November 2009 to November 2011 to assess the production of Extended Spectrum Beta Lactamase (ESBL) by salmonella enterica serotype (Typhi and paratyphi A) at Kanti Children's Hospital (KCH), Nepal Medical College (NMC), Kathmandu Medical College (KMC), National Public Health Laboratory (NPHL) and Sankata Laboratory (SKL) of Nepal. Blood cultures were obtained from 4,820 patients with febrile illnesses. 400 strains of salmonella enterica were isolated. Antibiotic susceptibility testing was carried out using disk diffusion method by Kirby-Bauer technique and ESBL screening were done by Double Disk Synergy Test (DDST), following the Clinical and Laboratory Standard Institute (CLSI) recommendations for Escherichia coli. Male had higher infection (56%) than female (44%). Highest number of culture positive cases were (37%) in 10-19 years of age groups. Highest episodes of enteric fever cases occurred during April - June (45%) followed by July-September (35%). Among the total isolates 286 (72%) were Multidrug resistance (MDR). All the Multidrugs resistance salmonella, resistant to third generation Cephlospornis were ESBL producers.

Antibiotic susceptibility of organisms causing urinary tract infection in patients presenting to a teaching hospital

BACKGROUND

Urinary tract infections (UTI) are common. It causes severe morbidity and mortality, and it is important to know the causative organisms in the hospital and community for optimum management of UTI.

METHODS

This is a prospective hospital based study to identify the organisms causing UTI and their antibiotic susceptibility. Consecutive patients presenting with symptoms of UTI had their clean catch midstream urine analysed. Antibiotic susceptibility was tested by Kirby-Bauer's disc diffusion method as described by National Committee for Clinical Laboratory Services (NCCLS) guidelines.

RESULTS

Out of 1726 patients, 549 (31.8%) showed bacterial growth. Escherichia coli was most common (72.5%), followed by Klebsiella pneumoniae (11.3%), Staphylococcus aureus (3.1%), coagulase negative Staphylococcal species (2.7%) and others (10.1%). There was a female dominance of 3.2:1 compared to males, except in the 61 and above age range. Infections were most common in young adults (21-30 years). The most effective antibiotic was Nitrofurantoin followed by Norfloxacin, Ciprofloxacin and Ofloxacin. Some isolates were resistant to Norfloxacin, Ampicillin, Cotrimoxazole and Ciprofloxacin.

CONCLUSIONS

The most common causative organism for UTI was Escherichia coli, and the best first line antibiotic was Nitrofurantoin. Organisms are developing resistance to antibiotics such as Norfloxacin, Ampicillin and Ciprofloxacin.

Errors on a handwritten cardex: is it time for a change?

A medical order is a medical and legal document and careful writing of this document is necessary. In Nepal the medical order in the admitted patients is written on a cardex which is utilised by the nurses to dispense medicines and to follow the doctor's orders. However, with the dawn of the electronic age this is being replaced by a computerized system, which is suggested to be better. The aim of this study was to identify if the existing cardex was adequate for the purpose of writing orders, or whether this needed modification. This was a prospective observational study were 240 cardexes from eight different Departments from the same Medical College Hospital were randomly looked into for errors. Thirteen different parameters were looked into including the legibility/readability of the handwriting. The results suggested the error rates to be high in certain parameters viz. utilization of the columns (77.9%), documentation of allergy history (77.5%), writing the prescribers name (89.6%) and writing date of discontinuation of medicines (62.5%). The handwriting was unreadable or difficult to read in 49.2% of the documents. However, the other parameters also had errors and no parameter was error free. The study suggested the need of the hour was to modify the existing cardex and also to educate the doctors to minimise errors. However, in the future we may have to move towards a computerized system in order to avoid errors related to bad handwriting.

Clinicopathological association between BPH and prostatitis

This was a prospective study done in Nepal Medical College Teaching Hospital, Kathmandu, Nepal to find out the relationship between BPH and BPH associated with prostatitis as regards their symptoms and histopathology. We looked at the symptoms of both disease processes and tried to establish whether we could differentiate between the two entities on a clinical basis. Our study included thirty six patients who were operated for symptoms suggestive of LUTS due to BPH. Prior to the operation they were asked about their symptoms and we correlated these for the two conditions. We analysed the results of the symptoms statistically according to the odd's ratio. We found that the most common symptom associated with BPH with prostatitis was dysuria, however, there was a lot of overlap of the symptoms. So unless there is a high degree of suspicion on the part of the health care worker it is difficult to make a diagnosis of prostatitis based on symptoms alone and it is difficult to distinguish between the two conditions. The histopathological specimens were analysed and it was found that 19 of the 36 patients had prostatitis associated with BPH. This was done by scrutinising the received histopathological specimens. Here it was found that the most common type of prostatitis associated with BPH was the stromal inflammatory pattern.

Continually improving governance

What can governance do to ensure the continual improvement of organizational performance? This article explores this question, with particular emphasis on two central considerations. First, what constitutes good governance? Second, what are the sources of and opportunities for leveraging performance available to governance? We argue that focusing on strategy, evaluating performance, and developing the means to learn are the key venues available to governance for leveraging its own and organizational performance.

Insiders and business directors on hospital boards and strategic change

Many hospitals are eager to incorporate practices of boards in business organizations. Yet little evidence exists on the desirability of "corporate" board features in hospital settings. We examined the effects of two characteristics of corporate boards--the relative dominance of insiders and of directors with business-related occupations on strategic changes within hospitals. We studied 335 hospitals in California immediately following legislative reforms in 1982. We found that hospital boards with a higher proportion of insiders and business directors made more changes in their mix of services in response to legislative reform. In addition, this relationship held for nonproprietary hospitals but not for proprietary hospitals. Limitations and implications of the results are discussed.

An empirical comparison of rural and urban safety-net hospitals

This study compares the characteristics of rural hospitals with urban safety-net hospitals and with "other urban hospitals" (non-teaching, non-safety-net urban hospitals that provide mainstream care in the United States). The objective is to examine if there are similarities between rural and urban safety-net hospitals, both of which serve underserved populations. The authors also wish to study if there are areas in which rural and urban safety-net hospitals are closer together compared to "other" urban hospitals. Based on the results, some potential areas of cooperation between rural and urban safety-net hospitals are discussed.

Financial performance of safety-net hospitals in a changing health care environment

Safety-net hospitals serving the poor and indigent in inner-cities have received inadequate research attention regarding the determinants of their financial performance in the changing health care environment. We analyze how the 1990-92 financial performance of 275 such hospitals is related to exogenous and endogenous factors such as payer mix, service mix, staffing and ownership. Models of hospital financial performance are developed using operating margin, cost per discharge and revenue per discharge as measures of performance. Stepwise regression is used to test the model with data from the American Hospital Association (AHA) and Health Care Investment Analysts (HCIA). Results suggest that: 1) The profitability of inner-city hospitals appears positively related with technical complexity of care; 2) High interest and low operating surplus may constrain the addition of technically sophisticated services to enhance profitability; 3) There is some evidence that new governmental programs, e.g. Medicaid managed care and Medicaid Diagnosis Related Groups (DRGs), may not have improved operating margins, though Medicaid DRGs appear to have contained costs. Follow-up research is needed on this issue; 4) Given external fiscal realities, internal management strategies for inner-city hospitals require research, e.g. developing appropriate managed care systems and timely expansion of sub-acute services and; 5) Services such as AIDS treatment and community health education represent opportunities to respond to community needs, especially since unit cost of such services will decline with high volume.

Inner-city hospitals: a call for research

Inner-city hospitals serve as safety nets for poor and underserved populations. They cope with serious issues of uncompensated care, aging facilities, and inadequate reimbursement. Yet, little research exists on their needs and problems. The authors argue that research on inner-city institutions is necessary to obtain "policy" attention, legitimize demand for resources, reframe inner-city health issues as a delivery problem, and gain insights on better ways to manage inner-city hospitals. They provide data-based illustrations of future research questions related to issues of inefficiency, overstaffing, case severity, and facility renovation that can contribute to better policymaking on inner-city hospitals. The authors recognize systemic barriers to research including the unpopularity of access issues, lack of data, and absence of input from practitioners working in inner-city institutions. To remove such barriers, they suggest creation of a representative forum, original databases, increased linkage with research and policy agencies, and increased cooperation between inner-city professionals and researchers.

Granulomatous lesions of the skin

Background: Granulomatous skin lesions often present as a diagnostic challenge to dermatopathologists due to various modes of presentation and identical histological picture produced by several causes. The aim of the study was to study different granulomatous skin lesions and to determine the relative frequency, the level of clinicopathologic concordance and to compare our results with those of other workers. Materials and Methods: A retrospective analysis of skin biopsies received over a period of two years from January 2007 to December 2008; was performed, and cases of granulomatous dermatitis reported on histopathological examination were reviewed along with special stains. Results: Out of a total of 1590 skin biopsies 106 (6.67%) cases were found to have a granulomatous reaction. It was common in males (63.21%) with most occurring in the fourth to fifth decades. Majority of cases (79 cases, 74.5%) were categorized as infectious granulomatous lesions with predominance of leprosy (63 cases, 79.7%) followed by tuberculosis (6 cases, 7.6%). An overall clinicopathologic concordance was seen in 97% of cases of leprosy. Conclusion: In this study leprosy is the most common cause of granulomatous skin lesions. It can be concluded that histopathology plays an important role in classification of leprosy, and in diagnosis and management of a variety of granulomatous skin diseases. Special stains play a supportive role in infectious granulomas. Keywords: Granulomatous skin lesion; Leprosy; Skin biopsy DOI: http://dx.doi.org/10.3126/jpn.v1i2.5397 JPN 2011; 1(2): 81-86