Respiratory Morbidity and Mortality of Traumatic Cervical Spinal Injury

BACKGROUND

Traumatic cervical spinal injuries can severely affect respiratory function and cause significant morbidity and mortality. The typical respiratory morbidity in cervical spine injury is Atelectasis, Ventilator-associated pneumonia, acute respiratory distress syndrome and delayed weaning, etc. The study aims to see the prevalence of respiratory morbidity as well as mortality associated with cervical spine injury.

METHODS

Cross sectional study based on retrospective data was conducted on the X Sciences with the existing hospital record during the period of 3 years to find out the prevalence respiratory morbidity like Ventilatory Associated Pneumonia, delayed weaning, ARDS, atelectasis of traumatic cervical spine injury, determine the prevalence, type, and impact of respiratory morbidity and mortality in this population.

RESULTS

Total no 76 patients data meeting the inclusion criteria included in study. Male patients were more prone to develop traumatic cervical spinal injuries (SCI). The prevalence of respiratory morbidity in term of VAP(57.89), delayed weaning(46.05) and Atelectasis(22.36) was high. Patients with Asia A Neurology has higher association for VAP and delayed weaning, while Asia E Neurology patients had no respiratory morbidity. The study found a significant positive association between respiratory morbidity with hospital stay, and ventilator days (p-value: 0.019 and 0.048). A total of 15 patients died, 28.95% were discharged on request and 40.8% leaving the hospital against medical advice.

CONCLUSIONS

The prevalence of respiratory morbidity higher in cervical spine injury. Furthermore, it has associated with prolonged ICU and ventilator days and increase in mortality.

Changes in Clinical Practice amongst Nepalese Otolaryngologists during COVID-19 Pandemic

Background COVID-19 pandemic changed clinical practices more so for otolaryngologists due to inevitable risk of exposure. Objective To assess the changes in the clinical practice among Nepalese otolaryngologists during this pandemic. Method It was an observational study conducted as an online survey in the first two weeks of December 2020. A questionnaire pertaining to changes in clinical practice was mailed to 190 registered otolaryngologists working in various provinces of Nepal. Data were entered in Microsoft Excel 2007 and analysed in percentages. Result Out of the 77 (40.5%) who responded, nearly 50% resumed clinical practice after a month of national lockdown restarting everyday consultation by 64.9% mostly in hospital setting (81.8%) after screening patients via fever clinic by 87%. Modifications in clinical examinations was mostly done for neck (85.7%), oral cavity (44.2%) and nose (29.8%) examination with least with for ear examination (3.9%) Regular endoscopic evaluation was avoided by 19.4%. Only around 57% used adequate personal protective equipment. There was 93.5% reduction in elective operations. Mandatory COVID test was done by 89.6% mostly with reverse transcriptase polymerase chain reaction (95.9%) prior to semi-urgent case. Conclusion Changes in clinical practice were adapted to mitigate viral transmission. The changes were evident in the outpatient department where most patients were screened for fever and modifications made in the clinical examinations. Personal protective equipments were worn when available. Operative lists were limited to semi-urgent and urgent cases with covid testing customarily done for semi-urgent cases.

Teenage Pregnancy and Associated Risk Factors and Outcome in Nepal From 2000-2020: A Systematic Review and Meta-Analysis

Background Teenage pregnancy is considered a high-risk pregnancy in terms of reproductive outcome and the subsequent financial constraint. Objective To assess the prevalence of teenage pregnancy, associated risk factors, and outcomes in the context of Nepal. Method We searched electronic databases to search relevant articles published from January 2000 till October 2020 using the keywords with appropriate Boolean operators. All the data were extracted into a standardized form designed in Excel. We conducted a statistical analysis using Comprehensive Meta-Analysis Software (CMA) version 3. Data pooled for proportion with 95% confidence interval (CI). A Forest plot was used to visualize the degree of variation between studies. Result Fourteen studies were included in the analysis after the rigorous screening of 4425 studies. Prevalence of teenage pregnancy was 13.2% (Proportion, 0.132; CI, 0.077- 0.215). Among teenage pregnancies, 11.8% were already multigravida (Proportion, 0.118; CI, 0.029-0.374). Among teen pregnancies, 18.6% were illiterate; among the literate, only 25.9% were of education above grade 10,31.9% were unaware of contraceptive methods, and only 3.2% reported using any contraception methods. 75.4% of teenage pregnancies had a vaginal delivery with or without episiotomy, 6.5% by instrumental deliveries, and 21.5% by cesarean section. Preterm delivery was 12.0%, and post-term delivery was 8.2%. Abortion was reported in 11.1% of teenage pregnancies. Major tears were reported in 52.9%, obstructed labor was in 4%, and pre-labor rupture of the membrane was in 7.0% of teenage pregnancies. The low birth weight of newborns was 19.4%. Stillbirth and neonatal deaths were 1.7% and 1.4%, respectively. Conclusion The prevalence of teenage pregnancy in Nepal was 13.2%. The majority of them did not use any form of contraceptives; and had low education. Several maternal and neonatal complications were reported among teenage pregnancies.

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

BACKGROUND

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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

PIPKIγ and talin couple phosphoinositide and adhesion signaling to control the epithelial to mesenchymal transition

Epithelial cells acquire migratory/invasive and stemness traits upon conversion to the mesenchymal phenotype. The expression of E-cadherin is a key to this transition; yet precise understanding of the pathways involved in integrating E-cadherin loss to the gain of mesenchymal traits remains poorly understood. Here, we show that phosphoinositide-generating enzyme, PIPKIγ, expression is upregulated upon epithelial-mesenchymal transition (EMT) and together with the cytoskeletal protein talin assemble into a signaling complex upon E-cadherin loss. PIPKIγ and talin together control the adhesion and phosphoinositide signaling that regulates conversion to the mesenchymal phenotypes. PIPKIγ and talin regulate the stability of E-cadherin transcriptional repressors, snail and slug, induced by transforming growth factor-β1 or extracellular matrix protein. Loss of PIPKIγ or talin or their interaction impaired EMT and the acquisition of cell motility and stemness. This demonstrates a mechanism where a phosphoinositide-generating enzyme PIPKIγ couples with a cytoskeletal protein talin to control the acquisition of mesenchymal phenotypes.

Alcohol Consumption during Pregnancy and Postpartum Period and its Predictors in Sindhupalchowk District, Nepal

BACKGROUND

A substantial proportion of women in Nepal consume alcohol and homebrewed alcoholic beverages are the most common type of alcohol. Alcohol being a part of tradition and culture in Nepal and evidences suggesting even low to moderate dose of alcohol having impacts on the birth outcomes, we aimed at exploring the alcohol consumption pattern during pregnancy and postpartum period along with its predictors.

METHODS

We studied all pregnant and recently delivered women using quantitative methods in selected wards within selected Village Development Committees of Sindhupalchowk district in Nepal after purposively choosing the district. We present the findings on pregnancy and postpartum period drinking and its predictors as proportion and adjusted odds ratio along with 95% CI.

RESULTS

One-third of women drank alcohol during pregnancy and 43% during postpartum period. Nearly all drinking women mostly consumed homebrewed alcoholic beverages such as jaad/chhyang/localraksi. One-third consumed it daily during pregnancy, while three-quarters consumed daily during postpartum. One-fifth of currently drinking women drank ≥5 standard drinks on average per day in the last 30 days. Illiterate or women with low level of education were three times more likely to consume alcohol during pregnancy than women with secondary level education or higher. Similarly, women who didn't know that alcohol during pregnancy affects mother and child were four and half times more likely to consume alcohol during pregnancy than those who knew about it. Also, being dalits, disadvantaged and janajatis, husband's drinking and home brewing of alcohol were strongly associated with women's drinking during pregnancy and postpartum period.

CONCLUSIONS

A substantial proportion of women consumed alcohol during pregnancy and postpartum period with high consumption frequency. Findings suggested, increasing awareness about consequences of drinking during pregnancy and postpartum period would be helpful probably as one of the components of routine antenatal care with a special focus to ethnic groups such as dalits, disadvantaged janajatis including relatively advantaged janajatis as well as the women with lower levels of education. Culture sensitive behavior change communication interventions aimed at reducing home brewing and husband's drinking would also be important Keywords: Alcohol consumption; home brewed; Nepal; postpartum period; pregnancy; predictor.

Rhabdomyosarcoma of urethra a rare case presentation

Rhabdomyosarcoma of urethra is extremely a rare presentation. Only few cases were found documented and published in literature. We present a case of rhabdomyosarcoma in the urethra presenting with history of gross heamaturia. Diagnosis of this case was made cystoscopically and confirmed by histopathologically. Complete radical surgery followed by six cycle chemotherapy was given in this case.

Gestational Diabetes Mellitus - A Public Health Concern in Rural Communities of Nepal

BACKGROUND

Gestational Diabetes Mellitus (GDM) is in increasing trend recently. It is associated with adverse effects on both mother and fetus. Thus, diagnosis of GDM is an important public health issue. This study aimed to determine the frequency of gestational diabetes mellitus in three rural districts of Nepal.

METHODS

A hospital based study was conducted in three districts representing mountain, hill and Terai belts of Nepal during the period of July 2009 to June 2010. A total of 564 pregnant women were interviewed and tested for blood glucose as per WHO guideline Results: In Nepal, only 2.5% of pregnant women had GDM according to WHO criteria while it was 6.6% according to IADPSG criteria. Overall mean blood glucose among pregnant women was 72.1 (fasting) and 95.8 (after 2 hrs of 75 gm glucose intake) in which it was 62.8, and 75.1 in Dhading, 78.7 and 88.9 in Dhangadhi, and 98.3 and 99.3 in Solukhumbu districts respectively. Pregnant women with increased age were significantly at high risk of having GDM than those of younger women (p=0.04). There were non-significant differences in GDM by District, Ethnic group and family history of DM.

CONCLUSIONS

Gestational diabetes in the rural areas of Nepal is variable with two different criterias (2.5% vs 6.56%). Increasing age was an important influencing factor. Special attention should be given on women with increasing age. There was no significant difference in prevalence of GDM in three ecobelts of Nepal despite of altitude and cultural variability.

Nepalese Homebrewed Alcoholic Beverages: Types, Ingredients, and Ethanol Concentration from a Nation Wide Survey

BACKGROUND

Despite the enormous public health problems related to traditional alcohol consumption practice in Nepal, this area has been ignored and the information at the national level is limited. Thus this study is designed to explore the readily available commonly practiced Nepalese homebrewed alcoholic beverages, the ingredients used and alcohol strength (ethanol concentration).

METHODS

This study was carried out as a part of ongoing household survey on "Alcohol consumption practice among married women of reproductive age in Nepal". A total of 284 homebrewed alcoholic beverage (distilled 175, non-distilled:109) samples were collected from the 16 survey districts of Nepal during the period of April to August, 2013. Ethanol percentage was tested in research lab by using standard procedure.

RESULTS

Readily available homebrewed alcoholic beverages in practice were mainly of two types "Distilled" (local Raksi) and "Non-distilled" (Jand, Chhyang, Tumba). Rice, wheat, barley, millet, maize, fruits, and pure sugar were the commonly used ingredients to prepare alcohol. Ethanol concentration in homebrewed alcohol was 14.0% (IQR: 10.0-19.0) ranging from 3% to 40% for distilled, and 5.2% (IQR: 3.5-9.8) ranging from 1% to 18.9% for nondistilled. A significant difference (P<0.05) was found in alcohol strength by residence, development regions, types of alcohol, and the ingredients used.

CONCLUSIONS

The median concentration of ethanol in readily available home brewed alcoholic beverages in Nepal was more than the strength of factory produced beer. The alcohol strength varies across their types, ingredients used, residence and regions.

Knowledge of diabetes mellitus among pregnant women in three districts of Nepal

BACKGROUND

Diabetes mellitus is an emerging health problem in developing world with the consumption of energy dense diet and inactive lifestyle. The problem of diabetes is further expanded due to ignorance and lack of knowledge. The aim of the study was to assess the knowledge of diabetes among pregnant women in three districts of Nepal.

METHODS

A community based cross-sectional study was conducted in three districts in mountain, hilly and plain areas of Nepal. A total of 590 pregnant women were interviewed during the period of July 2009 to June 2010. A knowledge score system was applied. Poor score was <40%, average (40-60%) and good (>60%) of the total score. Statistical software SPSS 11.5 was used for data entry, data management and analysis.

RESULTS

Out of 590 pregnant women, only 41% had heard about diabetes mellitus. Majority of the participants (75%) from age group >30 years had not heard about diabetes. Among the 241 with some knowledge, the knowledge score median percent(range) on the meaning, symptoms, risk factors, treatment, prevention, complications and overall knowledge were 50%(0-100), 25% (0-75), 20% (0-60), 20% (0-100), 25% (0-100), 20% (0-60) and 26% (0- 58) respectively. According to defined category, majority of those who ever heard about diabetes had poor knowledge (95%). Knowledge among literate women (p=.001), women residing in Kailali district (plain region) (p=.003) and those with positive family history of diabetes (p=.003) was found to be significant.

CONCLUSIONS

As large proportions of Nepalese pregnant women do not have any knowledge or have poor knowledge regarding diabetes, extensive health education and health promotion programs are urgently recommended to prevent diabetes in Nepal.

Factors associated with the motivation and de-motivation of health workforce in Nepal

BACKGROUND

Health workforce plays an important role in improving the health of people but its shortage is a major problem facing Nepal. This is further compounded by prolonged absence, low motivation, and improper distribution. The objective of the study is to find out the factors determining motivation of health workforce in the public sector.

METHODS

A cross sectional study was conducted during September, 2012 to February, 2013. The health facilities were selected proportionately representing all the Illakas and then a simple random sampling was done to select individual facilities. Data was collected using questionnaire. The collected data was entered and analyzed in SPSS. Ethical approval was taken from the Nepal Health Research Council.

RESULTS

More than a half (55%) of the health workers were satisfied with their current jobs and the financial benefits they acquired. The results revealed that higher age, higher education (OR:2.6; CI:1.414-4.660) and lower service duration (OR:2.567; CI:1.193-3.306) were significant factors for the motivation of health workers along with financial rewards (OR:4.706; CI:2.961-7.478), working environment (OR:2.344; CI:1.507-3.648) and opportunity for capacity development (OR:5.437; CI:3.344-8.840). The major de-motivational factors were: low remuneration (OR:3.215; CI:2.049-5.045), limited capacity development opportunity (OR:4.269; CI:2.672-6.821), poor working environment (OR:4.062; CI:2.528-6.526), non-recognition of performance (OR: 2.157; CI:1.389-3.350), and political interferences (OR:2.752; CI:1.754-4.320).

CONCLUSIONS

Motivation of health workers is an important factor for smooth functioning of health intuitions and increased access to quality services. The good working environment, salary and other financial benefits matter greatly for enhanced performance of health workers along with additional factors.

Health governance at local level from human resource for health perspectives: the case of Nepal

BACKGROUND

Evidence about effects of good governance in Human Resources for Health (HRH) is scant in Nepal. The study aimed to explore the situation of health governance at the local level and suggest measures to address the HRH challenges.

METHODS

Ninety health facilities from Siraha, Bardiya and Doti districts were included in the study. Focus group discussions (N=36) with different groups and key informants interviews (33 VDC Secretaries, 76 Health Facility Management Committees and 9 central level policy makers and managers) were conducted.

RESULTS

Only 49 (54%) of the health facilities have properly displayed signboard, 42 (47%) citizen charter, 36 (40%) free health services and Information on Aama program in 25 (28%) health facilities. In total 52 (58%) health facilities have not displayed names of women receiving Aama benefits. Seventy two out of 90 health facilities have not displayed social audit reports and 80 (89%) of the health facilities have not maintained complaint box. The initiative of decentralized human resource management, where implemented, has increased ownership at the local level. Staff retention has been reported well though it does not apply in case of the medical doctors. Rule of law in terms of human resource recruitment and transfer, promotion, and training were not fully implemented and were lenient in the upper level. Nepotism and power exercise was frequently reported as a hindrance in implementing the gender and social inclusion policy fully.

CONCLUSIONS

Transparency, gender and social inclusion is yet to be implemented fully at the district and health facility level.

Community participation and mobilization in community-based maternal, newborn and child health programmes in Nepal

A number of studies on community mobilization for maternal and newborn health have demonstrated that community participation is of profound importance in the delivery of community based survival interventions for mother, newborn and children and a cost effective way to reduce mortality. However, the lessons learnt from the efficacy trials have not been tested within the health systems. Nepal is well known for its public health programmes and wide successes in campaign based interventions as a result of active involvement of volunteers and organizations based in the community. This paper analyzes the degree of community participation and mobilization in community-based maternal, newborn and child health programmes and its potential implication in acceleration towards achieving Millennium Development Goals 4 and 5. The study is based on analysis of the existing national community based maternal, neonatal and child health programmes in terms of degree of community mobilization and participation for ownership and sustainability of programmes. Furthermore, a qualitative assessment was carried out to assess the level of engagement of community structures in community based maternal, newborn and child health programme. None of the national community based maternal, newborn and child health programmes used the community action cycle approach and there was minimal level of involvement of community networks. The mother's groups had been least engaged in identifying and solving the maternal, newborn and child health problems and Female community health volunteer were engaged in delivering messages at household level and not through the mother's groups. Though the Community Action Cycle was studied in Nepal and it was found effective to achieve the objectives, getting its lessons into practice to design community health programs were lacking. The mother's groups need to be revitalized to ensure their active participation in identifying, analyzing and agreeing on steps to solve the problems related to maternal, neonatal and child health so that care seeking and utilization of health services will be further enhanced. The national strategies need to explore the possibilities of incorporating the community action cycle frame into its programmes, test the frame and ensure its implementation in the National community based programs in order to improve health outcomes of mother, newborn and children.

Postoperative complications of septal quilting and BIPP packing following septoplasty

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Juvenile angiofibroma and its management

This prospective longitudinal study was done to determine extent of tumor and to highlight the importance of lateral rhinotomy approach for nasopharyngeal angiofibroma. Patients with a diagnosis of nasopharyngeal angiofibroma who underwent surgery in Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu from April, 2004 to Jan 2009 were included in the study. Extent of tumour and surgical approaches were noted in a special form prepared for the study. Fisch Staging system was followed for the extent of tumor. A total number of patients were 23 and all of them were male. Age ranged from 15-30 years with mean age of 18.25 years. All the patients underwent contrast enhanced CTScan. Two patients had stage I tumor, 9 patients had stage II disease, other 12 patients had stage III tumor. Twenty patients were operated by lateral rhinotomy approach. In one patient with the tumour hanging in the oropharynx with a pedical attached to the lateral wall of nasopharynx was removed by peroral route and in another patient with tumour confined to nasopharynx and posterior part of nose was removed by transpalatal approach. One patient who had tumour extention into infratemporal fossa were operated by lateral rhinotomy with inferior sublabial extetention approach. Eleven patients underwent preoperative embolization with gelfoam 48 hours prior to surgery. Most of them had stage III disease and were managed surgically by lateral rhinotomy approach. Lateral rhinotomy approach with or without extention of incision can be used to remove tumours in majority of patients.

Functional Endoscopic Sinus Surgery (FESS)

Functional Endoscopic sinus surgery (FESS) is a minimally invasive surgical procedure that opens up the sinus air cells and the sinus ostia with an endoscope. The use of FESS as a sinus surgical method has now become widely accepted and the term functional is meant to distinguish this type of endoscopic surgery from the nonendoscopic more conventional sinus procedure. Functional Endoscopic sninus surgery is being done regularly at TU Teaching Hospital from 2003. Total number of cases done from March 2003 till December 2005 were 94. Maximum number of FESS was done for nasal polyps, which was carried out in 80 patients, out of which, FESS for ethmoidal polyp was done in 47 patients and for antrochoanal polyps in 33 patients. Other conditions where FESS was carried out were chronic maxillary sinusitis in 8 patients, fungal sinusitis in 5 patients, and endoscopic medial maxillectomy for inverted papilloma in 1 patient.

Lipoblastoma in head and neck--a rare childhood tumour

Lipoblastoma is an uncommon benign mesenchymal tumour that occurs primarily in children younger than 3 yrs of age. Despite the lesions being benign, great difficulty can be encountered in its management because of its tendency to invade the different fascial planes. A rare case of huge lipoblastoma diagnosed in a 22 months old child, involving various spaces of face and skull base has been reported. This huge tumour was completely and successfully removed through cheek incision without any postoperative complications.

Injection drug use and tricuspid valve endocarditis

Tricuspid valve endocarditis is more common in injection drug users. Pulmonary valve and Eustachian valve endocarditis have been reported but are very rare. Earlier reports of endocarditis in injection drug users emphasized the dominance of right sided involvement. In a series of 105 patients 86 % were right sided and 14 % had left sided involvement. We report a case of isolated tricuspid valve endocarditis in an injection drug user affecting a structurally normal heart and review of the literature on this subject. Key Words: injection drug use, tricuspid valve endocarditis.

The feeding behaviour and Plasmodium infection of Anopheles mosquitoes in southern Ethiopia in relation to use of insecticide-treated livestock for malaria control

Anopheles arabiensis and An. quadriannulatus species B mosquitoes were collected at sites of human and livestock housing and analysed for blood feeding patterns and infection with malaria sporozoites. A low percentage of human blood meals at some sites suggested that zooprophylaxis could be effective in reducing challenge from Plasmodium falciparum.

High-risk childbirth practices in remote Nepal and their determinants

This study describes birth-related practices and their determinants among women in the Jumla district of Nepal. Data were derived from a household survey in 1996. Of 939 married women of reproductive age, 657 who had given birth to their last child during the previous five years were included in the analysis. Qualitative information was further obtained from traditional birth attendants (TBAs), mothers-in-law, community leaders and pregnant women. High-risk practices were common and related to local custom and lack of knowledge on the importance of cleanliness. Husband's level of education greater than fifth grade significantly reduced the high-risk practices in all stages of childbirth, independent of other socio-economic, biological and village variables.

Infant death rates and animal-shed delivery in remote rural areas of Nepal

This article outlines a community-based retrospective study in a remote area of Nepal and describes local birth practices and their impact on infant mortality. Data collection was carried out in two steps, a household survey from September to October 1996 and a qualitative research phase. Data collected include socio-economic background, reproductive history, birth practices and child survival. Among 3007 live-born children, 660 (22%) died before their first birthday. In keeping with local customs, approximately half of the children were delivered in an animal shed and the other half in the home. Children born in an animal shed were at significantly higher risk of dying than were those born in the home even after adjusting for socio-economic status and biological variables. The association was stronger in the neonatal period (OR = 2.8, 95% CI 1.9-4.1) than during the post-neonatal period (OR= 1.3, 95% CI 1.02-1.6). The preparation of the delivery place was inadequate and thereby facilitated infection of both the newborn and the mother. Traditional norms and animal-shed delivery practices are common in the Jumla community. The reasons addressed for giving birth in the animal shed included (1) Household Deity's anger if delivery takes place in the home and (2) easy to clean the shed following the birth.

Inherited and environmentally induced differences in mutation frequencies between wild strains of Sordaria fimicola from "Evolution Canyon"

We have studied whether there is natural genetic variation for mutation frequencies, and whether any such variation is environment-related. Mutation frequencies differed significantly between wild strains of the fungus Sordaria fimicola isolated from a harsher or a milder microscale environment in "Evolution Canyon," Israel. Strains from the harsher, drier, south-facing slope had higher frequencies of new spontaneous mutations and of accumulated mutations than strains from the milder, lusher, north-facing slope. Collective total mutation frequencies over many loci for ascospore pigmentation were 2.3, 3.5 and 4.4% for three strains from the south-facing slope, and 0.9, 1.1, 1.2, 1.3 and 1.3% for five strains from the north-facing slope. Some of this between-slope difference was inherited through two generations of selfing, with average spontaneous mutation frequencies of 1.9% for south-facing slope strains and 0.8% for north-facing slope strains. The remainder was caused by different frequencies of mutations arising in the original environments. There was also significant heritable genetic variation in mutation frequencies within slopes. Similar between-slope differences were found for ascospore germination-resistance to acriflavine, with much higher frequencies in strains from the south-facing slope. Such inherited variation provides a basis for natural selection for optimum mutation rates in each environment.

Fungal multisinusitis with intracranial extension

Aspergillosis is the commonest fungal infection of nose and paranasal sinuses. Itsinvasive form is rare in a healthy patient. A case of fungal multisinusitis with intracranialextension with characteristic computerized tomographic finding is reported.Key Words: Aspergillosis, intracranial extension, CT scan,external frontoethmoidectomy.