Adnexal arteriovenous malformation presenting with spontaneous massive haemoperitoneum

Arteriovenous malformations (AVMs) are vascular anomalies composed of a tangle of abnormal vessels in which one or more feeding arteries are directly connected to one or more draining veins via a nidus with no intervening capillary bed. The adnexa are particularly rare sites for the formation of such malformations. Here, we present the case of a middle-aged woman who presented with spontaneous massive haemoperitoneum occurring as a result of a ruptured adnexal AVM. The diagnosis was suspected on transabdominal sonography and confirmed on CT angiography. The patient was shifted to the interventional radiology suite for an urgent angioembolisation following which she improved haemodynamically and her symptoms resolved. The case highlights the fact that although exceedingly rare, gonadal AVMs are an important cause of spontaneous intraperitoneal bleeding. Diagnostic and interventional radiology play an important role in the early and accurate diagnosis of this entity, and angioembolisation can be lifesaving in such patients.

Cystic hepatic metastases in treatment naïve neuroendocrine tumor: Cytomorphology clubbed with cell block immunocytochemistry clinches the diagnosis

Cystic hepatic lesions encompass a vast spectrum of infectious, non-neoplastic, and neoplastic entities. Most hepatic cysts are benign and asymptomatic, requiring no active intervention. However, symptomatic and malignant cysts need proper evaluation and specific treatment. An accurate preoperative diagnosis is pivotal for patient management. At times, these lesions may mimic, especially symptomatology and radiology, leading to a diagnostic ordeal. We herein present a case of a patient with cystic liver lesions in a treatment naïve neuroendocrine tumor that was a diagnostic dilemma on radiology. Low cellularity of cytology smears made the diagnosis challenging, and cell block immunocytochemistry finally clinched the diagnosis. A timely diagnosis provided on cytology fuelled further work-up, the discovery of primary tumor, and initiation of appropriate therapy.

Correlation between Sonoelastography and Histopathological Findings in Evaluation of Chronic Renal Allograft Disease

Background Non-invasive evaluation tool for allograft kidney is important to predict chronic allograft dysfunction as it can be alternative to the invasive biopsy which is prone to so many complications. Sonoelastography can assess the stiffness of the allograft renal parenchyma, which is prone to undergo interstitial fibrosis. Objective To correlate sonoelastography with histopathology findings in the renal allografts. Method Sonoelastography was done in 60 renal allograft recipients prior to their biopsy for various indications. Estimated glomerular filtration rate (eGFR) of the patient were also obtained. Histopathology reports were collected to determine Banff score of interstitial fibrosis. Descriptive measurements (Mean ± standard deviation, Frequencies, Proportions) were calculated. Correlations among the variables were measured using Pearson's correlation, independent sample t-test, and ANOVA. Result The mean strain index (SI) was lower in higher grades of fibrosis. There was significant difference in mean SI (F=18.264; df= 2,57; p < 0.001) among the histological grades of fibrosis. Also a significant difference in SI among mild and moderate (S.E. 0.27, p value < 0.001), mild and severe (S.E. 0.213, p value < 0.001) as well as moderate and severe fibrosis (S.E. 0.244, p value < 0.001) was seen. Significant correlation of eGFR with SI (p < 0.001) was also seen. Conclusion Strain index, measured with sonoelastography, significantly correlated with different grades of tissue fibrosis. Thus it can be used as alternative method for evaluation of renal allograft patients to avoid complications of biopsy.

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.

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.