Predicting factors of patient satisfaction after varicose vein surgery at a university hospital in Nepal

INTRODUCTION

Varicose veins are a common vascular problem with a high prevalence, yet they are often neglected. The main objective of this study was to explore the patient satisfaction after varicose vein surgery, along with its predicting factors. To our knowledge, no similar study has been conducted in Nepal to date.

METHODOLOGY

This retrospective cross-sectional study included patients who underwent varicose vein surgery at Dhulikhel Hospital from September 2019 to February 2020. The satisfaction level after the surgery was assessed using a 10-point Likert scale questionnaire during a telephone interview with their verbal consent. Descriptive statistics and linear regression were performed to identify the predicting factors of patient satisfaction.

RESULTS

Among a total of 84 patients interviewed, 53.6% were male. The mean age of the participants was 43.13 ± 13.62 years. The mean patient satisfaction score was 42 ± 5.5, with nursing service, discharge teaching and hospital service being the highest scoring items in terms of patient satisfaction. Linear regression revealed age ≤40 years as a predictor of higher patient satisfaction (β=0.258, p=0.015) while early stage of varicose veins (β=-0.233, p=0.026) and duration of post-operative follow-up (β=-0.25, p=0.021) were negative predictors of patient satisfaction. This means that patients with C2-C3 venous disease and longer duration of postoperative follow-up tended to have lower satisfaction scores.

CONCLUSION

The overall patient satisfaction following varicose vein surgery was very good, and the major predictors of better satisfaction were age ≤40 years, C4-C6 clinical classification of venous disease and the shorter duration of follow-up after surgery.

Coronary Artery Disease in Nepal: Current Perspective, Challenges, Need for National Practice Guidelines, and Potential Solutions

South Asians are estimated to have a 40% increased risk for coronary artery disease as compared to populations from other regions. Nepal, as a South Asian country, should also analyze the burden of coronary artery disease and its risk factors to minimize cardiovascular morbidity and mortality. We reviewed the barriers to cardiovascular care and its services in low- and middle-income countries, including Nepal. The identified barriers included coronary artery disease risk factors, access, cost, adherence to cardiovascular care, awareness, knowledge gaps, and socioeconomic and health system challenges. The possible strategies to reduce coronary artery disease included national, regional, and local perspectives. It also highlighted the involvement of community workers and local leaders, education, patient-centered intervention, easy access to drugs and treatments, rehabilitation and public health measures, innovation within the health care system, and multi-sectoral involvement. This review provides insights into the current situation of coronary artery disease and its possible solutions.

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.

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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.

Comparative Study between the Use of Pigtail Catheters and Traditional Chest Tube Drain in Cases with Pneumothorax

Background Pneumothorax is a condition in which air or other gas is present in the pleural cavity. Mainstay of management of pneumothorax is to remove the air from the pleural space usually done by chest tube insertion. There is still uncertainty whether minimal invasive management with pigtail catheter is sufficient for the management of pneumothorax. Objective To find the effectiveness, safety, tolerability, efficacy of pigtail catheters and large bore chest tubes. Method Prospective comparative study was done in Dhulikhel Hospital between August 2019 till August 2021. Chest tube insertion used to be the only available treatment modality till December 2020 (15 months). Following January 2021 after obtaining ethical clearance for use of pigtail insertion for pneumothorax, this treatment modality was done (8 months). Result Among 76 patients, 52(68.4%) underwent a large bore chest tube and 24 (34.6%) pigtail catheter patients. Mean age of the patients was 48 years (SD 18.01). Duration of hospital stay and length of hospital stay was more in large bore catheters and less in pigtail catheters. Eight hours post tube placement of the expansion of the lungs was present in pigtail and was statistically significant. Pain killer used in pigtail catheters was limited to Non-steroidal anti-inflammatory drugs, for large bore catheter opioids were added and were statistically significant. Conclusion Pigtail catheter is nearly effective as compared to traditional wide bore catheters.

Diagnostic Accuracy of Drop Hydrogen Peroxide Test as a Novel Bedside Diagnostic Test to Differentiate Transudative and Exudative Pleural Effusion Against Light's Criteria

Background Diagnostic evaluation of pleural fluid according to Light's criteria to differentiate between exudative and transudative fluid takes 1 or 2 working days. For rapid clinical management, especially in critically ill patients, a simpler bedside diagnostic test can be done which has similar diagnostic accuracy as that of Light's Criteria. Objective To determine the diagnostic accuracy of Drop Hydrogen Peroxide test to differentiate exudative and transudative pleural effusion in comparison to Light's criteria. Method A concurrent validity test was performed using a convenient sampling technique including patients presenting to the Department of Internal Medicine from January to September 2021, who had pleural effusion. Two milliliters of tapped pleural fluid of patients who underwent aseptic thoracocentesis was collected in a test tube to which one to two drops of 20% hydrogen peroxide was added. Presence of bubbles suggested an exudative type of fluid. Rest of the tapped pleural fluid was sent to the laboratory for further evaluation by Light's criteria, which was compared with the results by Drop Hydrogen Peroxide Test. Result There were 83 patients who had pleural effusion, of them a total of 43 patients had transudative pleural effusion while 40 patients had exudative pleural effusion based on Light's criteria and 37 patients had transudative pleural effusion while 46 patients had exudative pleural effusion based on drop hydrogen peroxide test. Conclusion The drop hydrogen peroxide test allows cost effective and prompt evaluation of the type of pleural effusion is exudative or transudative, thereby making it a convenient diagnostic bedside test.

Perception Regarding Care of Attempted Suicide Patients among Nursing Students in Kathmandu University School of Medical Sciences

Background Suicide is an act of deliberately killing oneself. It is a global health problem and is the second leading cause of death in 15 to 29 years. Thus, studying nursing students' perception towards suicide attempters has paramount importance in understanding and addressing the existing gaps in healthcare delivery system. Objective To assess the nursing students' perception towards attempted suicide and to find out the association between perception and selected variables. Method A descriptive, cross sectional design was carried out to assess the nursing students' perception towards suicide attempters in Kathmandu University School of Medical Sciences. The respondents were 193 nursing students. A structured questionnaire was used in order to collect data. Descriptive statistics including frequency, percentage, mean and standard deviation were calculated to summarize the data and inferential statistics, Mann Whitney-U test was used for the association between perception and selected variables. Result A total 193 nursing students participated in this study. The scores between 1 and 2.4 were considered 'positive', 'unsure' or 'uncertain', between 2.5 and 3.4 and negative for 3.5 and above' over all nurses showed relatively negative perception towards suicide attempters. According to results from eight domains of perception, those who did not attend the courses on psychiatry nursing presented higher score, which was found to have significant association with permissiveness, unpredictability and incomprehensibility. A younger nursing student shows significant association with incomprehensibility. Younger nursing student showed statistically significant association with duration of suicide process. Conclusion Nursing students are frequently encountered with attempted suicide patients. Therefore, they must be aware of their attitudes toward this group of patients as part of their professional and therapeutic role. Thus a nurse's positive perception towards attempted suicide can play a key role in communicating and preventing a future suicide attempt.

Case report of eventration of diaphragm due to an unknown febrile illness causing phrenic nerve palsy and other multiple nerve palsies

INTRODUCTION

Diaphragmatic eventration can be congenital or acquired. Diagnosis is delayed due to no symptoms or very mild ones and is generally done by imaging modalities. This condition is managed by plication of the affected part of diaphragm by various surgical approaches.

PRESENTATION OF CASE

A forty seven years lady presented with one year long history of abdominal pain, bloating and fullness after meals who was being treated in line of peptic acid disorder. She had developed bilateral foot drop after typhoid fever at seventeen years of age. Clinical examination and imaging with chest x-ray, chest ultrasound and computed tomography scan suggested eventration of left hemidiaphragm. Plication of eventration of left hemidiaphragm was done via mini thoracotomy of the left thorax. There were no postoperative complications and she was discharged on the sixth postoperative day.

DISCUSSION

Acquired eventration of diaphragm is commonly due to traumatic phrenic nerve palsy but rarely can be associated with a history of infection causing nerve palsies. Thoracic ultrasound is an emerging modality for diagnosis supporting X-rays and CT Scans. Plication of eventration with minimally invasive techniques has less number of hospital stay and less pain compared to open approaches.

CONCLUSION

Non-traumatic diaphragmatic eventration due to acquired phrenic nerve palsy following an unknown febrile illness is a rare case to be reported in Nepal. The aim of treatment is expansion of intra-thoracic space which is done by plication of the diaphragm.

Recovery Pattern in Different Surgical Approaches on Thoracic Enhanced Recovery based Fourteen-Step Protocol in Patients Undergoing Cardio-thoracic Surgery at University Hospital of Nepal

Background Cardio-thoracic surgery involves open and minimally invasive techniques. Enhanced recovery after surgery is used for early recovery from surgery. Enhanced recovery after surgery decreases hospital stay duration. Patients undergoing Enhanced recovery after surgery after video assisted thoracic surgery use less pain killers and have less hospital cost. There has not been any study on outcomes on patient who follow physiotherapy protocol designed in our setting. Objective To find the physiotherapy outcomes in patients undergoing thoracic enhanced recovery after surgery (T-ERAS) based 14 step protocol locally designed at Dhulikhel Hospital, Kathmandu University Hospital (DH, KUH). Method This is a retrospective cross sectional observational study. All the cases who underwent cardiothoracic surgery were classified based on the approach of chest surgery performed into groups Sternotomy, Thoracotomy and Video Assisted Thoracic Surgery (VATS) groups. Patients were advised for Thoracic Enhanced recovery after surgery based on the protocol that has been devised at Dhulikhel Hospital. The recovery of patients based on activities they could perform was noted and analyzed. Result Both ICU stay and hospital stay in number of days were highest in thoracotomy (6.04 days) group while that was lowest in video assisted thoracic surgery group (1.67 days). There is a similar recovery until step 5, i.e. 2 days and rapid progression in further steps in video assisted thoracic surgery group while it is much slower in both sternotomy and thoracotomy groups. Conclusion Postoperative mobilization and physiotherapy enhance early healing and decrease hospital stay. Mean hospital stay and ICU stay were shorter for video assisted thoracic surgery cases compared to Thoracotomy and Sternotomy groups and the mean days to achieve different steps varied within the protocol between groups compared.

Open Surgical Management of Abdominal Aortic Aneurysm at a Community Based University Hospital in Nepal

Aortic aneurysms are abnormal dilatation of aorta. The risk factors include male sex, age > 65, smoking, coronary artery disease and hypertension. Here we report a case of infra-renal abdominal aortic aneurysm (AAA) of diameter 6 cm. The patient sucessfully underwent aorto-biiliac bypass surgery using Dacron Y graft. During abdominal aortic aneurysm surgery anesthetic challenge is also of paramount importance and should be considered.

A case of thymoma in myasthenia gravis: Successful outcome after thymectomy

INTRODUCTION

Thymic abnormalities occur as hyperplasia and thymoma. Myasthenia gravis is commonly present in thymoma. Thymectomy possesses risk due to anatomical proximity with vital thoracic structures and myasthenia crisis.

PRESENTATION OF CASE

Forty five years female with complaints of difficulty swallowing and weakness of upper limb muscles upon investigation showed mass in mediastinum and antibody test for myasthenia gravis positive. Medical management was done for a month followed by thymectomy. There were no intra and postoperative complications. Medical management was stopped one month after surgery and she is symptom free.

DISCUSSION

Thymectomy is the standard of care where median sternotomy is the mainstay approach to surgery. Various other surgical approaches and complications revolving around surgery has been discussed.

CONCLUSION

Surgical removal of thymoma cured myasthenia gravis in our case. We focused on proper preoperative optimization of myasthenia gravis symptoms before thymectomy.

Prevalence of Exclusive Breast Feeding and its Associated Factors among Mothers

Background Breast feeding is the priceless gift given by mother to her newborn. It also has benefits to both mothers and baby. Prevalence of exclusive breast feeding varies from 26.4% in one study to that of 82.2% in another study. Objective To assess the factors associated with exclusive breast feeding among mothers. Method A prospective cross-sectional study using systematic random sampling method, was carried out in Dhulikhel Municipality for two months in November and December 2017 after taking permission from KUSMS IRC and from Dhulikhel Municipality. The study sample was 218 mothers whose infants between 6 months to 1 year were included in the study. A structured and semi-structured interview schedule was used in order to collect the information. Descriptive statistics including frequency and percentage was calculated to summarize mothers' socio-demographic information. Chi-square test was used for non-parametric categorical data in order to find out the association between variables. P-value less than 0.05 were considered significant. Result The prevalence of exclusive breast feeding was 75.7% in the present study. Maternal age found to be varied from 17 years to 40 years. Maternal age, parity of mother and types of family found to be significantly associated with the practice of exclusive breast feeding (p < 0.05). Mothers' occupation and education level was not associated with the practice of exclusive breast feeding. Conclusion Majority of the mothers practice exclusive breast feeding (75.7%). Finding of this study i.e. the factors influencing the practice of exclusive breast feeding will help the health care workers to plan the community awareness program on it.

Prevalence and Associated Factors of Low Birth Weight among Newborns in a Tertiary Level Hospital in Nepal

Background A United Nations Children's Fund reported that the global low birth weight was 15.5%, more than 95.6% of them being from developing countries. Low Birth Weight is a major factor associated with neonatal deaths in developing countries. Also, birth weight is one of the major factor in determining child survival, growth and development. Objective The objective of the study was to identify the prevalence and associated factors of low birth weight among newborns delivered in Dhulikhel Hospital. Method A cross sectional research design was carried out among all newborns delivered at the maternity ward of Dhulikhel Hospital within a period of one year. Data were collected using delivery record register as well as its electronic version which was available in the ward. The collected data were entered and analyzed using software SPSS 20 version with descriptive and inferential statistics. Result Total 2,798 numbers of newborns delivered in the hospital during the period of one year met the inclusion criteria for the study. Among them, 21.6% had low birth weight. We found that low birth weight of newborns was significantly affected by younger age of the mother and lesser weeks of gestation at birth. There were no significantly affected by antenatal clinic visit, parity, sex of the baby, type of delivery. Conclusion The study found that more than one fifth of babies had Low Birth Weight. The study findings suggest that special emphasis should be given to minimize early pregnancy to avoid low birth weight babies.

Study of factors affecting contraceptive use among married women of reproductive Age

Background The use of contraception can prevent pregnancies related complication and helps in improving the women’s health and quality of their lives. Objective To explore reproductive characteristics among married women of reproductive age. To find out method of contraceptive use and side effects among married women of reproductive age. To uncover factors related to contraceptive use among married women of reproductive age. Methods This cross-sectional was carried out among (369) married couples of reproductive age group in ward number 5, 6 and 7 of Dhulikhel Municipality using purposive sampling. Those who fell in between the age group of (14-49 years) and willing to participate were included and pregnant women were excluded from the study. Questionnaire was used to obtain informations. Results Among 369(81.3%) of the respondents of reproductive age were using a modern contraceptive method. Regarding education 331(89.5%) of women’s and 352(95.1%) of husbands were literate and 275(91.6%) of women were found to be involved in decision making and had good inter-spousal communication that is 280(93.3%). Among the temporary method of family planning, Depo-Provera was the choice 150(54.5%) of contraceptive method. Conclusion The present study put more emphasis on increase in women’s literacy, women’s involvement in decision making and inter-spousal communication which helps to promote the effective use of contraceptive methods. As women play an important role in the decision making, women should be included in all aspects of reproductive health and family planning programs. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-4, 24-29 DOI: http://dx.doi.org/10.3126/jcmsn.v9i4.10233

Assessment of bacterial load in broiler chicken meat from the retail meat shops in Chitwan, Nepal

INTRODUCTION: Keeping quality of meat and meat related food hazard relates to microbes present in the meat during processing or storage. The poultry slaughtered and dressed under Chitwan conditions carrying high initial contamination would be present in meat as inherent contamination in the finished products. MATERIALS AND METHODS: This cross-sectional study included 26 fresh broiler meat samples from registered retail shops. The samples were subjected to bacteriological analysis such as total viable count (TVC), total enterobacteriaceae count (TEC), total coliform count (TCC) and total staphylococcal count (TSC). Also, the samples were analyzed for the detection of Salmonella spp. and identified by different biochemical tests. RESULTS: The mean counts in log10±SE colony forming units per gram (cfu/g) for Bharatpur, Ratnanagar and Institute of Agriculture and Animal Science (IAAS) vicinity were obtained as 11.1±0.3, 11.5±0.3 and 12.2±0.5 TVC; 8.5±0.2, 9.2±0.3 and 10.2±0.4 TEC; 6.5±0.3, 7.6±0.3 and 8.4±0.5 TCC; 6.5±0.2, 6.8±0.3 and 7.7±0.4 TSC respectively. No samples were found to be within the permissible limits given by different agencies. Prevalence of Salmonella spp. in retail broiler meat in Chitwan was found 46.2%. CONCLUSION: The retail broiler meat samples from the locations contain high count of bacteria suggesting deplorable state of hygienic and sanitary practices. The presence of Salmonella and Staphyloccus aureus organisms over the permissible limits are of special concern because these account for potential food borne intoxication. So, the need for microbial assessment of fresh meats can be emphasized. DOI: http://dx.doi.org/10.3126/ijim.v2i3.8671   Int J Infect Microbiol 2013;2(3):99-104

Nutritional status and morbidity pattern in school age children in Nepal

School Health has been regarded as a high priority intervention in developing countries. However it has not been prioritized in Nepal for many years. The objectives of the study are to find out the nutritional status and morbidity pattern in school age children. To arouse importance of personal hygiene and healthful surrounding through information, education and communication (IEC). This cross-sectional study was administered in two schools located in Bolde phedeche and Mahure of Kavrepalanchowk. From the selected schools, a total number of 160 students studying from Grade 1 to V were enumerated in the study using census survey method. Among 160 students, the most important three problems were pediculosis 42(26.2 %), dental caries 29(18.1%), and waxy ear 27(17.1 %). Thus the school health education should put more emphasis on oral care, nutrition, personal hygiene and others. Applying classification of Indian Academy of Pediatrics: based on weight for age, 36(55.3%) boys and 34(35.8%) girls fall under 1st degree malnutrition and 15(23.07%) boys and 44(46.3%) girls fall under IInd degree malnutrition, 7(7.2 %) girls fall under IIIrd degree malnutrition.The health and nutritional standards of school children in this study were found to be unsatisfactory. Among different morbidity pediculosis is found more in girls. The present study put more emphasis on the need for initiation of school health program in the school with more on improving personal hygiene, prevention of disease like parasitic infection/infestation and improvement of their nutritional status. Journal of College of Medical Sciences-Nepal,2012,Vol-8,No-2, 12-16 DOI: http://dx.doi.org/10.3126/jcmsn.v8i2.6832

Intestinal parasitic infection among school age children

BACKGROUND

World Health Organization estimates one-fourth of world's population harbors one or more intestinal parasites. Intestinal parasites are among the most common infections of school age children causing-nutritional deficiency, chronic dysentery, rectal prolapse, poor weight gains, retarded growth and mental retardation.

METHODS

The stool samples were collected from school going children and examined for intestinal parasite by normal saline wet mount, formalin ether sedimentation technique was performed for the concentration.

RESULTS

Among 360 school age students, the prevalence of intestinal parasite was found 40%. Among the positive cases of which 60% were female. It was observed that the rate of parasitic infection among positive cases, Newar was 35(36.84%), Chettri 31(32.97%) and Brahmin and others 29(33.72%) respectively. The study detects an association between intestinal parasitic infection and drinking tape water.

CONCLUSIONS

The findings of this study showed that intestinal parasitic infections remain prevalent in the study area. The high prevalence of parasitic infections seems directly related to the unhygienic living conditions. This strongly indicates a need for intervention measures likely-to take up sustained health education, provision of safe drinking water and improvement in environmental sanitation and to provide the school student with health education.

Nurses’ Views on Need for Professional Development in Nepal

INTRODUCTION: This study explores the nurses' views on need for professional development and barriers in Nepal. METHODS: This is a qualitative content analysis study conducted among nurses from different health institutes. In-depth interviews and focus group discussions were used to obtain their views on need of professional development and major barriers against professional development in Nepal. Eleven nurses for in-depth interviews and three groups of six nurses each for focus group discussions were selected purposefully from Kathmandu University Hospital, Dhulikhel and Tribhuban University Teachng Hospital, Kathmnadu. RESULTS: Five themes emerged from qualitative data. "Continuing professional development", "supportive management", "nursing leadership", "recognition and respect" and "professional networking" were considered as essential factors for professional development. Lack of "commitment by the nurses", "female gender professional" and "lack of autonomy" were felt as barriers for the nursing professioanl development. CONCLUSIONS: Continuing professional development and supportive working environment are crucial to make nursing profession more dynamic and appealing in Nepal. Keywords: continuing professional development, professional development, supportive managment

Nurses' views on need for professional development in Nepal

INTRODUCTION

This study explores the nurses' views on need for professional development and barriers in Nepal.

METHODS

This is a qualitative content analysis study conducted among nurses from different health institutes. In-depth interviews and focus group discussions were used to obtain their views on need of professional development and major barriers against professional development in Nepal. Eleven nurses for in-depth interviews and three groups of six nurses each for focus group discussions were selected purposefully from Kathmandu University Hospital, Dhulikhel and Tribhuban University Teachng Hospital, Kathmnadu.

RESULTS

Five themes emerged from qualitative data. "Continuing professional development", "supportive management", "nursing leadership", "recognition and respect" and "professional networking" were considered as essential factors for professional development. Lack of "commitment by the nurses", "female gender professional" and "lack of autonomy" were felt as barriers for the nursing professioanl development.

CONCLUSIONS

Continuing professional development and supportive working environment are crucial to make nursing profession more dynamic and appealing in Nepal.

Kinetic studies of corn stover saccharification using sulphuric acid

The kinetics of crystalline cellulose and hemicellulose hydrolysis in corn stover were studied with a nonisothermal technique. Reactions were arrested at temperatures between 160 and 240 degrees C and product sugars were analyzed using a Bio-Rad HPX-85 liquid chromatographic column. A simple first-order series reaction model was used for both cellulose and hemicellulose hydrolysis reactions. Kinetic parameters were obtained for three different sulphuric acid concentrations (0.49, 0.92, and 1.47 wt %). Activation energies remained constant over this acid concentration range but the preexponential factors showed an increase with acid concentration. Relationships were obtained between the preexponential factors and acid concentrations. Cellulose hydrolysis and glucose degradation reactions were observed to be of higher order with respect to acid concentration in comparison with the previous studies with other raw materials.

Fumonisin B1-induced localized activation of cytokine network in mouse liver

Fumonisin B1 (FB1), a mycotoxin produced primarily by Fusarium veticillioides and related fungi, is a carcinogen and causative agent of various animal diseases. Our previous studies indicated the involvement of tumor necrosis factor-alpha (TNFalpha) in FB1-induced hepatotoxicity. Male B6,129 mice (five/group) were injected subcutaneously with vehicle or 2.25 mg/kg/day of FB1 for 5 days and sampled 1 day after the last treatment. FB1 treatment caused an increased expression of TNFalpha, interferon gamma (IFNgamma) and interleukin (IL)-12 p40 in liver without any changes in kidney or spleen, suggesting the localized site of their production. IL-1beta cytokine expression was increased in liver and kidney after FB1 exposure. Cells involved in TNFalpha production after FB1 treatment in liver were identified as Kupffer cells. FB1 increased alanine aminotransferase in plasma and increased apoptotic cells in liver. Selective increase in proinflammatory T helper (Th)1-cytokines (IL-12 and IFNgamma) and TNFalpha with no alteration in Th2-cytokines (IL-4, IL-6 and IL-10) suggest the involvement of IL-12, produced by Kupffer cells, in induction of IFNgamma production by natural killer (NK) cells and/or NK1+ T cells, which can undergo a positive amplification loop with TNFalpha produced by macrophages or other hepatic cells to elicit the toxic reaction.

Persistence and reversibility of the elevation in free sphingoid bases induced by fumonisin inhibition of ceramide synthase

These studies determined (1) the time course for sphingoid base elevation in the small intestines, liver, and kidney of mice following a single 25 mg/kg body weight (bw) oral dose (high dose) of fumonisin B(1) (FB(1)), (2) the minimum threshold dose of FB(1) that would prolong the elevated sphingoid base concentration in kidney following the single high dose, and (3) the importance of the balance between the rate of sphingoid base biosynthesis and degradation in the persistence of sphingoid base accumulation. Following the high dose of FB(1), there was an increase in sphinganine in intestinal cells and liver that peaked at 4 to 12 h and declined to near the control level by 48 h. In kidney, sphinganine peaked at 6-12 h but remained elevated until 72 h, approaching control levels at 96-120 h. Oral administration of 0.03 mg FB(1)/kg bw (low dose) for 5 days had no effect on the sphingoid bases in kidney. However, following an initial high dose, daily administration of the low dose prolonged the elevation in kidney sphinganine compared to mice receiving a single high dose. Thus, a single exposure to a high dose of FB(1) followed by daily exposure at low levels will prolong the elevation of sphinganine in kidney. In cultured renal cells FB(1) was rapidly eliminated, but elevated sphinganine was persistent. This persistence in renal cells was rapidly reversed in the presence of the serine palmitoyltransferase inhibitor (ISP-1), indicating that the persistence was due to differences in the rates of sphinganine biosynthesis and degradation. The in vivo persistence in kidney may be due to similar differences.

Effect of vitamin A administered at Expanded Program on Immunization contacts on antibody response to oral polio vaccine

OBJECTIVE

Vitamin A supplementation to mothers in the postpartum period and to their infants at routine immunization contacts is being considered to reduce vitamin A deficiency in infancy. This study was conducted to determine the impact of maternal and infant vitamin A supplementation on antibody response to oral polio vaccine (OPV).

DESIGN

Randomized, double blind, placebo-controlled trial.

INTERVENTIONS

Mothers in the intervention group received 60 mg retinol equivalent (RE) vitamin A 3-4 weeks after delivery and their infants 7.5 mg RE with each OPV dose at 6, 10 and 14 weeks of age. The control group mothers and their infants received a placebo at each of these contacts.

MAIN OUTCOMES

Geometric mean (GM) titer of neutralizing antibodies and proportion of children with protective titer to the three polioviruses at 26 weeks of age.

RESULTS

Vitamin A supplementation increased the proportion of infants with protective antibody titer against poliovirus type 1 (relative risk (RR) 1.15, 95% confidence interval (CI) 1.03-1.28) and the GM antibody titer (ratio of GM 1.55, 95% CI 1.03-2.31) following immunization. The proportion of infants with protective antibody titer against poliovirus type 2 (RR 0.99, 95% CI 0.94-1.05) or type 3 (RR 1.05, 95% CI 0.96-1.15) was not significantly different in vitamin A and placebo groups. The GM antibody titer for poliovirus type 2 (ratio of GM 0.99, 95% CI 0.64-1.54) or poliovirus type 3 (ratio of GM 1.10, 95% CI 0.69-1.75) also did not differ across groups.

CONCLUSIONS

Vitamin A given to the mothers in the postpartum period and their infants with OPV did not interfere with the antibody response to any of the three polioviruses and enhanced the response to poliovirus type 1.

Gender-related differences in subacute fumonisin B1 hepatotoxicity in BALB/c mice

Fumonisin B1 (FB1), a potent mycotoxin prevalent in corn, is a carcinogen and causative agent of various animal diseases. Species and sex variations to chronic FB1 toxicity have been reported. Free sphingoid bases and cytokine levels are the two major biochemical alterations of FB1 in vivo and may explain any sex differences in FB1 toxicity. Male and female BALB/c mice (5/group) were injected subcutaneously with either saline vehicle or 2.25 mg/kg/day of FB1 for 5 days. One day after the last injection females showed a greater increase in circulating alanine aminotransferase and greater number of apoptotic cells in liver after FB1 treatment than males, indicating greater hepatotoxicity. Peripheral leukocytic counts, including neutrophils, were increased in females only after FB1 treatment. The increased toxicity in females correlated with a greater increase of sphinganine and sphingosine levels in liver after FB1 treatment compared to males. No sex differences in kidney sphinganine or sphingosine levels were observed after FB1 treatment. Previously we have shown the induction of tumor necrosis factor alpha (TNFalpha) in FB1-induced hepatotoxicity. While in males FB1 treatment caused increased expression of TNFalpha, interleukin (IL)-12 p40, interferon gamma (IFNgamma), IL-1beta, IL-6 and IL-10, females showed an increased expression of IL-6 only, and a downward modulation of IFNgamma, indicating gender differences in cytokine pathways in liver activated by FB1. The basal expression of TNFalpha, IL-12 p40, IL-1beta and IFNgamma in liver of females was higher compared to males. Gender differences in alterations of free sphingoid bases and cytokine modulation after FB1 treatment suggest their possible involvement in sex-dependent differential hepatotoxicity in mice.

Food supplementation with encouragement to feed it to infants from 4 to 12 months of age has a small impact on weight gain

It is unclear whether a substantial decline in malnutrition among infants in developing countries can be achieved by increasing food availability and nutrition counseling without concurrent morbidity-reducing interventions. The study was designed to determine whether provision of generous amounts of a micronutrient-fortified food supplement supported by counseling or nutritional counseling alone would significantly improve physical growth between 4 and 12 mo of age. In a controlled trial, 418 infants 4 mo of age were individually randomized to one of the four groups and followed until 12 mo of age. The first group received a milk-based cereal and nutritional counseling; the second group monthly nutritional counseling alone. To control for the effect of twice-weekly home visits for morbidity ascertainment, similar visits were made in one of the control groups (visitation group); the fourth group received no intervention. The median energy intake from nonbreast milk sources was higher in the food supplementation group than in the visitation group by 1212 kJ at 26 wk (P < 0.001), 1739 kJ at 38 wk (P < 0.001) and 2257 kJ at 52 wk (P < 0.001). The food supplementation infants gained 250 g (95% confidence interval: 20--480 g) more weight than did the visitation group. The difference in the mean increment in length during the study was 0.4 cm (95% confidence interval: -0.1--0.9 cm). The nutritional counseling group had higher energy intakes ranging from 280 to 752 kJ at different ages (P < 0.05 at all ages) but no significant benefit on weight and length increments. Methods to enhance the impact of these interventions need to be identified.

Effect of micronutrient supplementation on linear growth of children

This review summarizes the results of published, randomized clinical trials that have examined the impact of administration of micronutrients, singly or in combination to infants, preschool and school children on linear growth. Supplementation of single micronutrients resulted in small or no benefits on linear growth. A meta-analysis of zinc supplementation trials confirmed that zinc has a significant but small impact (0.22 sd units) on length gain in children 0-13 years of age. However, a recent study reported a substantially greater benefit (>1 sd) in stunted and non-stunted breast-fed infants 6-12 months of age. With iron supplementation, a beneficial effect was found only in anemic children. Vitamin A supplementation trials have reported little or no benefit on linear growth. Data currently available suggest some impact in children with clinical or biochemical vitamin A deficiency, but this issue needs confirmation. Few studies could be identified where a combination of micronutrients was given as a supplement or as fortified food; in the latter set of studies energy availability was assured. The impact on length without multiple micronutrient supplementation was no greater than that observed with single micronutrients. In conclusion, zinc and iron seem to have a modest effect on linear growth in deficient populations. Vitamin A is unlikely to have an important effect on linear growth. Limited available evidence does not allow us to conclude whether a combination of micronutrients, with or without additional food, would have a greater impact than that seen with zinc alone.

Decreased fumonisin hepatotoxicity in mice with a targeted deletion of tumor necrosis factor receptor 1

Fumonisin B1 (FB1), a mycotoxin produced by Fusarium verticillioides and related fungi infests corn and other cereals, and causes a variety of toxic effects in different mammalian species. Hepatotoxicity is a common toxic response in most species. The cellular responses of FB1 involve inhibition of ceramide synthase leading to accumulation of free sphingoid bases and a corresponding induction of tumor necrosis factor alpha (TNFalpha). We recently reported that FB1 hepatotoxicity was considerably reduced in a mouse strain lacking tumor necrosis factor receptor 2 (TNFR2 or TNFR1b). To further investigate the relative contribution of the two TNFalpha receptors (TNFR1 and TNFR2 or P55 and P75 receptors) we evaluated the hepatotoxicity of FB1 in male C57BL/6J mice (WT) and a corresponding TNFR1 knockout (TNFRKO) strain, genetically modified by a targeted deletion of this receptor. The hepatotoxic effects of five daily injections of 2.25 mg/kg per day of FB1 were observed in WT but were reduced in TNFRKO, evidenced by the microscopic evaluation of the liver and increased concentrations of circulating alanine aminotransferase and aspartate aminotransferase. FB1 induced the expression of TNFalpha, and similar increases in free sphinganine and sphingosine in livers of both WT and TNFRKO mice. Results indicated that both P55 and P75 receptors are required for FB1-induced hepatotoxicity and TNFalpha plays an important role in such response in mouse liver.

Prognostic factors for persistent diarrhoea managed in a community setting

Two hundred and five cases (mean age 13.4, SD 9.5) of persistent diarrhoea (PD) of 14-28 days duration, attending an urban slum clinic and treated according to standard WHO guidelines, were monitored at weekly intervals to obtain an estimate of treatment failure rates and to identify its clinical predictors. Vitamin and micronutrients (daily 2RDA) were additionally provided. Only 9 (8.2%) of 109 children with criteria for hospital care accepted in-patient care. Weight gain was considered inadequate if the daily increment between enrollment and day 7 of follow up was < 10 g at age 0-3 months, < 5 g at 4-6 months, and any weight loss for those older than 6 months. Recovery was considered delayed if diarrhoea ceased 7 days after enrollment. Overall, 28.3% cases had inadequate weight gain and 25.6% had delayed recovery. The non-breast milk calorie intake was 11.2% during infancy and 40.6% at later ages of the recommended intakes. In a logistic regression model, initial watery stool frequency greater than median (adjusted OR 2.30, p = 0.01), age < or = 6 months (adjusted OR 2.24, p = 0.04) and low consumption of micronutrient mixture (adjusted OR 2.62, p = 0.01) were associated with an increased risk of delayed recovery. In a Cox proportional hazards model for time to recovery from diarrhoea, low consumption of the micronutrient mixture and age < or = 6 months reduced the chances of recovery by 29% and 37% respectively. Low consumption of the prescribed micronutrient mixture (adjusted OR 2.21, p = 0.04), fever (adjusted OR 1.91, p = 0.05) and diarrhoea continuing beyond study day 7 (adjusted OR 2.29, p = 0.03) increased the risk of inadequate weight gain. Breast feeding status and animal milk consumption did not influence weight gain or recovery. Due to the low compliance for advised hospitalisation, approaches for care at community level itself need to be evolved. Focus should be on increasing the overall dietary intake and provision of generous but safe amount of micronutrients; our findings do not support need for routine elimination of animal milk. The efficacy of individual micronutrients needs evaluation in controlled trials.

Disruption of sphingolipid metabolism in small intestines, liver and kidney of mice dosed subcutaneously with fumonisin B(1)

Fumonisin B(1) is a fungal inhibitor of ceramide synthase, a key enzyme in the de novo biosynthesis of sphingolipids. The resulting increase in tissue free sphinganine (and sometimes sphingosine) is used as a biomarker for fumonisin exposure. This study determined whether a single subcutaneous injection of fumonisin B(1) could cause an increase in free sphingoid bases in the intestinal epithelial cells of mice over 24 hr. It was hypothesized that fumonisin administered subcutaneously would be excreted into the small intestine via biliary excretion, and this should be detectable by increased sphingoid bases in the intestine. A significant time-dependent increase in sphingoid bases occurred in the intestine and liver peaking at 4-8 hr and declining to control levels by 24 hr. In the kidney the increase in free sphinganine was persistent. The parallel time course of the change in sphinganine in the intestine and liver suggested fumonisin B(1) was rapidly excreted into the small intestine. Rapid cell turnover in the intestine could account for the reversal of the sphinganine increase. The rapid return to the control level in liver was unexpected since ceramide synthase inhibition in cultured cells is persistent suggesting that liver handles fumonisin B(1) or sphingoid bases quite differently than kidney.

Fumonisin hepatotoxicity is reduced in mice carrying the human tumour necrosis factor alpha transgene

Our previous studies have indicated that tumour necrosis factor alpha (TNFalpha) is involved in fumonisin B1 (FB1)-induced toxic responses. To investigate the role of TNFalpha in FB1 toxicity further we employed male transgenic mice expressing human TNFalpha gene (TG) and their wild-type equivalent C57BL/6 (WT). It was hypothesized that TG animals would have enhanced response to FB1. Repeated subcutaneous treatment of animals with 2.25 mg/kg per day of FB1 for 5 days caused minimal changes in body weight, organ weights, blood cell counts, and TNFalpha levels in plasma 1 day after the last injection. The mRNA for TNFalpha in liver increased in both TG and WT after FB1 treatment, providing evidence that FB1 induces hepatic TNFalpha expression. Liver and kidney lesions were found in TG after FB1 treatment; however, liver lesions seen in FB1-treated TG were considerably less than those observed in WT. The decreased hepatotoxicity in TG after FB1 treatment correlated with plasma concentrations of alanine aminotransferase and aspartate aminotransferase. Free sphinganine levels increased significantly in both the liver and kidney of WT and TG mice treated with FB1. The increase of free sphinganine in the liver from TG mice was 40% less than in WT mice and paralleled the changes in serum liver enzymes. Regional brain neurotransmitters and their metabolites were increased to a similar extent by FB1 in both WT and TG mice. Since the data did not support the original hypothesis, we investigated the levels of NFkappaB in liver. The cytosolic NFkappaB was significantly higher in TG compared with WT. Induction of NFkappaB, caused by increased endogenous production of TNFalpha, is a possible explanation of decreased FB1 hepatotoxicity in TG. The results suggest a protective role for NFkappaB in FB1-induced liver damage.

Fumonisin toxicity in a transgenic mouse model lacking the mdr1a/1b P-glycoprotein genes

The toxicity of fumonisin B(1) (FB(1)) was investigated in male mdr1a/1b double knockout (MDRK) mice, lacking the drug-transporting P-glycoproteins. These transgenic animals are deficient in their blood:brain barrier and accumulate different drugs in brain and other tissues. The MDRK and their wild-type counterparts, FVB mice, were injected subcutaneously with 2.25 mg/kg per day of FB(1) for 5 days and sampled one day after the last treatment in a protocol that has resulted in marked hepatic and renal damage in other strains. FB(1) caused liver enlargement in both FVB and MDRK. Hematological parameters were not affected in either strain. Plasma levels of alanine aminotransferase and aspartate aminotransferase, measures of liver damage, were increased by FB(1) in both FVB and MDRK mice. Histopathological evaluation of liver corroborated this finding. Kidney lesions were induced by FB(1) in both types of mice. Concentrations of free sphingosine and sphinganine increased in liver and kidney of both strains after the FB(1) treatment, although the increase in liver sphingoid bases was half as much in MDRK as compared to FVB. The levels of sphinganine-containing complex sphingolipids were increased in kidney. The levels of sphingosine-containing complex sphingolipids in kidney were unaffected by FB(1) treatment but were significantly lower in control MDRK than in FVB mice. The levels of neurotransmitters and their metabolites were similarly affected in both strains by FB(1), suggesting no influence of disrupted blood:brain barrier on FB(1)-induced neurotoxicity. In both strains, the liver mRNA for tumor necrosis factor alpha was increased; however, the increase was statistically significant only in FVB. It was apparent that mice deficient in P-glycoprotein do not exhibit greater sensitivity to FB(1), the cellular or brain transport of FB(1) appears to be independent of this multidrug transporting system.