Labile assembly of a tardigrade protein induces biostasis

Tardigrades are microscopic animals that survive desiccation by inducing biostasis. To survive drying tardigrades rely on intrinsically disordered CAHS proteins, which also function to prevent perturbations induced by drying in vitro and in heterologous systems. CAHS proteins have been shown to form gels both in vitro and in vivo, which has been speculated to be linked to their protective capacity. However, the sequence features and mechanisms underlying gel formation and the necessity of gelation for protection have not been demonstrated. Here we report a mechanism of fibrillization and gelation for CAHS D similar to that of intermediate filament assembly. We show that in vitro, gelation restricts molecular motion, immobilizing and protecting labile material from the harmful effects of drying. In vivo, we observe that CAHS D forms fibrillar networks during osmotic stress. Fibrillar networking of CAHS D improves survival of osmotically shocked cells. We observe two emergent properties associated with fibrillization; (i) prevention of cell volume change and (ii) reduction of metabolic activity during osmotic shock. We find that there is no significant correlation between maintenance of cell volume and survival, while there is a significant correlation between reduced metabolism and survival. Importantly, CAHS D's fibrillar network formation is reversible and metabolic rates return to control levels after CAHS fibers are resolved. This work provides insights into how tardigrades induce reversible biostasis through the self-assembly of labile CAHS gels.

Nevus Lipomatosus Cutaneous Superficialis of Hoffmann and Zurhelle: a rare cutaneous hamartoma

Nevus lipomatosus cutaneous superficialis (NLCS) is a rare idiopathic cutaneous hamartoma characterized by ectopic clusters of mature adipose tissues in dermis. It is classified into two types. Classical type presenting as multiple lesions with onset at birth or within third decade of life and solitary type with onset between third to sixth decade of life. Here we present a case of 45 years female with adult onset, asymptomatic, grouped, skin colored, soft sessile growth in zosteriform pattern on left buttock. We here intend to report rare case of classical Nevus Lipomatosus Cutaneous Superficialis.

Efficacy of Eutectic Mixture of Local Anesthetic Cream and Vibrator Device in Pain Reduction during Peripheral Venous Cannulation in a Tertiary Care Center of Central Nepal

Background Venous cannulation is a commonly performed procedure which often leads to patient anxiety. Application of a vibrator device and or prior use of topical anesthetics are proven methods to decrease associated pain. Objective To compare the clinical efficacy of prior use of Eutectic Mixture of Local Anesthetic (EMLA) cream and vibrator device in pain reduction during peripheral venous cannulation. Method A true experimental study was conducted in November 2019 among 78 patients aged 20-60 years receiving peripheral cannulation at operation theatre. They were included using consecutive sampling and sorted to interventional and noninterventional group using simple random sampling lottery method. Participants in the non-interventional group received peripheral cannulation using routine technique whereas participants in the interventional group received topical Eutectic Mixture of Local Anesthetic cream or vibrator device prior to cannulation. Perceived post cannulation pain intensity was measured using numerical pain rating scale. Kruskal-Wallis test was used for data comparison. Result The mean age of the participants was 40.57 ± 12.5 years. The median pain score of Eutectic Mixture of Local Anesthetic cream, vibrator and no intervention was 3, 3 and 6 respectively. The reduction in median pain intensity was significantly greater with topical anesthetic cream and vibrator device when compared to the noninterventional group (p < 0.05). Conclusion Prior interventions with Eutectic Mixture of Local Anesthetic or vibrator device are useful in reducing pain intensity during peripheral venous cannulation. Routine use of these in day to day practice could be a part of standard nursing care practice.

Oral Health Care Practice and Circumstances during Covid-19 among Dental Patients in Tertiary Care Hospital in Nepal

Background Patients are hesitant to enter a dental hospital because of the significant danger of cross infection and illness transmission due to rapid spread of corona virus. Objective To assess knowledge regarding Covid-19, oral health practices and circumstances on dental treatment during a pandemic. Method Cross sectional study was conducted among patients visiting dental department of Dhulikhel hospital from September to October 2020. Questionnaires were interviewed following safety protocols regarding the pandemic and descriptive analysis was performed. Both verbal and written consent as well as ethical approval was taken before the study. Result A total 411 patients aged 14 to 75 years old from 14 different districts across Nepal participated in the study. All of the patient were free of Covid-19 symptoms and had strong knowledge and awareness about disease transmission. During the crisis 96% of the people maintain good oral hygiene while 25.8% acquire new dental problems where majority experienced oral discomfort and swelling, 93.2% of them did not attend a dental clinic or hospital in the interim owing to fear and inaccessibility. Majority of the participants were impressed by the safety precautions and preparations during treatment and 99.3% strongly suggest or pledge to visit dental department if necessary during the pandemic. Conclusion Dental patient visiting Dhulikhel hospital is highly aware of current health crisis, possible transmission and preventive measures. Proper safe hospital setup can encourage them to seek dental treatment during crisis. Dental pain and swelling in Endodontic department recorded most common dental emergency during this pandemic.

Perspectives of community-dwelling older adults with dementia and their carers regarding their oral health practices and care: rapid review

AIM

To review evidence on oral health practices, beliefs/views and experiences of community-dwelling older adults living with dementia, including their carers.

MATERIALS AND METHODS

A search of key terms across six databases including Pubmed, Web of Science and OVID (Embase, MEDLINE [R] and PsycINFO) and Google Scholar was conducted, supplemented by reference screening. The Mixed Methods Appraisal Tool (MMAT) 2018 was used to assess the methodological quality.

RESULTS

Eighteen studies reported across 19 papers were included in the review. Papers largely focused on normative needs (n = 13), whilst also reporting oral health-related experiences (n = 2), practices (n = 7), and beliefs/views (n = 9), of community dwellers with dementia. Generally, people living with dementia presented with poor oral and dental health, the exception being one study where dental care was integrated with memory clinic services. Maintenance of oral health focused only on toothbrushing. Overall, people living with dementia have reduced capacity for self-performed oral hygiene and high reliance on caregivers. There was a paucity of evidence on their perceptions of oral health and quality of life, the findings of which were equivocal, with weak evidence suggesting possible difficulty in identifying and communicating their needs. Experiences of accessing dental care, when explored, appear to be system dependent.

CONCLUSION

There was limited research evidence on oral health-related practices, beliefs/views and experiences of people with dementia. Recommendations for future research are presented.

A systematic review of droplet and aerosol generation in dentistry

OBJECTIVES

This review aimed to identify which dental procedures generate droplets and aerosols with subsequent contamination, and for these, characterise their pattern, spread and settle.

DATA RESOURCES

Medline(OVID), Embase(OVID), Cochrane Central Register of Controlled Trials, Scopus, Web of Science and LILACS databases were searched for eligible studies from each database's inception to May 2020 (search updated 11/08/20). Studies investigating clinical dental activities that generate aerosol using duplicate independent screening. Data extraction by one reviewer and verified by another. Risk of bias assessed through contamination measurement tool sensitivity assessment.

STUDY SELECTION

A total eighty-three studies met the inclusion criteria and covered: ultrasonic scaling (USS, n = 44), highspeed air-rotor (HSAR, n = 31); oral surgery (n = 11), slow-speed handpiece (n = 4); air-water (triple) syringe (n = 4), air-polishing (n = 4), prophylaxis (n = 2) and hand-scaling (n = 2). Although no studies investigated respiratory viruses, those on bacteria, blood-splatter and aerosol showed activities using powered devices produced greatest contamination. Contamination was found for all activities, and at the furthest points studied. The operator's torso, operator's arm and patient's body were especially affected. Heterogeneity precluded inter-study comparisons but intra-study comparisons allowed construction of a proposed hierarchy of procedure contamination risk: higher (USS, HSAR, air-water syringe, air polishing, extractions using motorised handpieces); moderate (slow-speed handpieces, prophylaxis, extractions) and lower (air-water syringe [water only] and hand scaling).

CONCLUSION

Gaps in evidence, low sensitivity of measures and variable quality limit conclusions around contamination for procedures. A hierarchy of contamination from procedures is proposed for challenge/verification by future research which should consider standardised methodologies to facilitate research synthesis.

CLINICAL SIGNIFICANCE

This manuscript addresses uncertainty around aerosol generating procedures (AGPs) in dentistry. Findings indicate a continuum of procedure-related aerosol generation rather than the common binary AGP or non-AGP perspective. The findings inform discussion around AGPs and direct future research to support knowledge and decision making around COVID-19 and dental procedures.

Translation with Cross-cultural Adaptation of Cerebral Palsy Quality of Life Questionnaire for Children into Nepali and its Psychometric Properties

Background Cerebral Palsy Quality of Life questionnaire for children primary caregiver version is the widely used condition specific outcome measure which assesses the wellbeing of the child. It has been translated to many languages and shows excellent psychometric properties. Availability in Nepali would facilitate the use in clinical practice and research in Nepali population. Objective The objective of this study was translation with cross-culturally adaption of Cerebral Palsy Quality of Life questionnaire for children primary caregiver version into Nepali and assess its psychometric properties. Method Cross-cultural adaptation was performed using forward and backward translation protocol. Pretesting was done on six participants to confirm that the original concept was preserved. The Nepali version of questionnaire was administered twice for data collection. The feasibility, sensitivity, internal consistency and test-retest reliability was determined. Result Culturally adapted Nepali version showed good feasibility only the domain "Access to service" had a highest missing score related to use of the special equipment, attending kindergarten and applying for respite care. Floor and ceiling effect were < 15% in all the domains except in few items of "Pain and impact of disability" and "Social well being and acceptance". Test retest reliability (0.82 - 0.91) and internal consistency (0.68 - 0.84) was good. There were weak association of domains with the gross motor functional classification system level. Conclusion Cross-culturally adapted Nepali Cerebral Palsy Quality of Life questionnaire for children primary caregiver was developed. It demonstrates good psychometric properties confirming to assess quality of life of children with Cerebral palsy in Nepal.

Comparative Efficacy of Fexofenadine Versus Levocetrizine Versus Desloratadine via 1% Histamine Wheal Suppression Test

Background Urticaria and allergic dermatoses remains a great challenge to treating dermatologist. Histamine is the major mediator in such disorders. Antihistamines as levocetrizine, fexofenadine and desloratadine are often used to treat such conditions. Ability of antihistamines to suppress the allergic response helps to evaluate the efficacy of the medicine. Objective To compare the efficacy of levocetrizine versus fexofenadine versus desloratadine in suppressing histamine induced wheals in adults. Method One hundred and two healthy adult volunteers completed the study. Subjects were randomized into 3 groups using an envelope method. First group received fexofenadine (N=36), second group received levocetrizine (N =37), and third group received desloratadine (N=29). Pretesting was performed by skin prick test with histamine 1% (positive control) and normal saline (negative control). Wheal size was recorded before and after the treatment (at 0.5, 1, 2, 4 and 24 hours). Result At 30 minutes and 1 hour fexofenadine showed statistically significant wheal suppression than levocetrizine and desloratadine (p=0.0016). However by 2 and 4 hours all three antihistamines; fexofenadine, levocetirizine and desloratadine showed significant suppression of wheal. Whereas at 24 hours desloratadine showed greater wheal suppression than levocetrizine and fexofenadine (p= 0.014). Conclusion The results of the present study showed that fexofenadine presented early onset of action but longer suppression of wheal size was seen with desloratadine as compared to other antihistamines. These potentials could be employed in clinical aspects; depending upon the response needed.

Modulation of the Wnt pathway through inhibition of CLK2 and DYRK1A by lorecivivint as a novel, potentially disease-modifying approach for knee osteoarthritis treatment

OBJECTIVES

Wnt pathway upregulation contributes to knee osteoarthritis (OA) through osteoblast differentiation, increased catabolic enzymes, and inflammation. The small-molecule Wnt pathway inhibitor, lorecivivint (SM04690), which previously demonstrated chondrogenesis and cartilage protection in an animal OA model, was evaluated to elucidate its mechanism of action.

DESIGN

Biochemical assays measured kinase activity. Western blots measured protein phosphorylation in human mesenchymal stem cells (hMSCs), chondrocytes, and synovial fibroblasts. siRNA knockdown effects in hMSCs and BEAS-2B cells on Wnt pathway, chondrogenic genes, and LPS-induced inflammatory cytokines was measured by qPCR. In vivo anti-inflammation, pain, and function were evaluated following single intra-articular (IA) lorecivivint or vehicle injection in the monosodium iodoacetate (MIA)-induced rat OA model.

RESULTS

Lorecivivint inhibited intranuclear kinases CDC-like kinase 2 (CLK2) and dual-specificity tyrosine phosphorylation-regulated kinase 1A (DYRK1A). Lorecivivint inhibited CLK2-mediated phosphorylation of serine/arginine-rich (SR) splicing factors and DYRK1A-mediated phosphorylation of SIRT1 and FOXO1. siRNA knockdowns identified a role for CLK2 and DYRK1A in Wnt pathway modulation without affecting β-catenin with CLK2 inhibition inducing early chondrogenesis and DYRK1A inhibition enhancing mature chondrocyte function. NF-κB and STAT3 inhibition by lorecivivint reduced inflammation. DYRK1A knockdown was sufficient for anti-inflammatory effects, while combined DYRK1A/CLK2 knockdown enhanced this effect. In the MIA model, lorecivivint inhibited production of inflammatory cytokines and cartilage degradative enzymes, resulting in increased joint cartilage, decreased pain, and improved weight-bearing function.

CONCLUSIONS

Lorecivivint inhibition of CLK2 and DYRK1A suggested a novel mechanism for Wnt pathway inhibition, enhancing chondrogenesis, chondrocyte function, and anti-inflammation. Lorecivivint shows potential to modify structure and improve symptoms of knee OA.

A small-molecule inhibitor of the Wnt pathway (SM04690) as a potential disease modifying agent for the treatment of osteoarthritis of the knee

OBJECTIVES

Osteoarthritis (OA) is a degenerative disease characterized by loss of cartilage and increased subchondral bone within synovial joints. Wnt signaling affects the pathogenesis of OA as this pathway modulates both the differentiation of osteoblasts and chondrocytes, and production of catabolic proteases. A novel small-molecule Wnt pathway inhibitor, SM04690, was evaluated in a series of in vitro and in vivo animal studies to determine its effects on chondrogenesis, cartilage protection and synovial-lined joint pathology.

DESIGN

A high-throughput screen was performed using a cell-based reporter assay for Wnt pathway activity to develop a small molecule designated SM04690. Its properties were evaluated in bone-marrow-derived human mesenchymal stem cells (hMSCs) to assess chondrocyte differentiation and effects on cartilage catabolism by immunocytochemistry and gene expression, and glycosaminoglycan breakdown. In vivo effects of SM04690 on Wnt signaling, cartilage regeneration and protection were measured using biochemical and histopathological techniques in a rodent acute cruciate ligament tear and partial medial meniscectomy (ACLT + pMMx) OA model.

RESULTS

SM04690 induced hMSC differentiation into mature, functional chondrocytes and decreased cartilage catabolic marker levels compared to vehicle. A single SM04690 intra-articular (IA) injection was efficacious in a rodent OA model, with increased cartilage thickness, evidence for cartilage regeneration, and protection from cartilage catabolism observed, resulting in significantly improved Osteoarthritis Research Society International (OARSI) histology scores and biomarkers, compared to vehicle.

CONCLUSIONS

SM04690 induced chondrogenesis and appeared to inhibit joint destruction in a rat OA model, and is a candidate for a potential disease modifying therapy for OA.

Knowledge and Practice of Health Care Workers regarding Needle Stick Injuries in a Tertiary Care Center of Nepal

Background Needle stick injuries are common health hazards among health care workers. Considering the increasing prevalence of body fluid borne infectious diseases; knowledge regarding the common errors and universal precautions are vital for the prevention of such accidents. Objective This study aimed to assess for knowledge and practice approaches among health care workers regarding needle stick injuries. Method This is a cross sectional survey was conducted using an anonymous, self-reporting 25-item structured questionnaire at a tertiary care center of central Nepal. A total of 165 health care personnel of working experience of more than 6 months were included in the study. Questionnaire included aspects of prevalence and knowledge on needle stick injury, hepatitis B immunization status and post exposure prophylaxis for HIV. Result Prevalence of needle stick injury was found to be 703 per 1000 health care worker (70.3%) during their working tenure and majority of the injury happened among nurses (p<0.05) besides other professions. Seventy nine (47.9%) participants experienced the injury more than one time in their career and the mean number of injury was 2.06±1.16. The practice of needle recapping is still prevalent and 80% participants often use single handed technique. Vaccination against hepatitis B virus was not completed by 31% health workers. Inadequate knowledge about post exposure prophylaxis for HIV was reported by 46% participants. Conclusion High prevalence of needle stick injury with a high rate of ignorance was noted. These issues need to be addressed, through appropriate education and interventional strategies.

Risks of Adverse Perinatal Outcomes after Repeat Terminations of Pregnancy by their Methods: a Nationwide Register-based Cohort Study in Finland 1996-2013

BACKGROUND

Repeat terminations of pregnancy (TOPs) are associated with an increased risk of adverse outcomes in the subsequent birth. The perinatal outcomes after repeat TOPs by their methods have not yet been properly studied. This study aimed to examine perinatal outcomes in subsequent pregnancy among the women with a singleton birth and a history of TOPs.

METHODS

All the first-time mothers (n = 419 879) with a singleton birth during 1996-2013 in Finland were identified from the Medical Birth Register and linked to the Abortion Register. Adjusted multivariable logistic regression analysis was used to estimate risks of adverse perinatal outcomes.

RESULTS

The increased incidence of adverse perinatal outcomes was found with increasing number of surgical TOPs. After adjusting for confounders, the women with one surgical TOP had slightly increased but significant odds of 1.07 (95% CI 1.02, 1.13) for being small for gestational age compared with the women having no TOP. A significantly high risk for extremely preterm birth (OR 1.51, 95% CI 1.03, 2.23) was found among the women having had repeat surgical TOPs when compared to the women with no TOP. Non-significant risks were found for adverse perinatal outcomes after women's repeat surgical TOPs than repeat medical TOPs.

CONCLUSION

Information regarding the consequences of repeat induced TOPs will be significant in sexual health education as well as counselling women after first termination.

Acute Upper Gastrointestinal Bleeding in a Tertiary Care Centre of Nepal

INTRODUCTION

AUGIB is characterized by hematemesis or melena or both. Peptic ulcers and variceal bleed account for majority of cases. Use of proton pump inhibitors in current era is associated with a gradual reduction in burden of peptic ulcer disease. We conducted this study to look into the cause of AUGIB in our community.

METHODS

We studied 100 patients in one year period who presented to us with hematemesis or melena. The study was conducted in department of Gastroenterology, Bir hospital, Kathmandu. We identified the culprit lesions by upper gastrointestinal endoscopy.

RESULTS

The average age of patients with AUGIB was 51.6 years with 59 (59%) males. Duodenal ulcers are most common 29 (29%), followed by varices 23 (23%) and gastric ulcers 14 (14%). More than one lesion was identified in 38 (38%) patients. Patients with variceal bleed were more likely to present with hematemesis alone as compared to those with ulcer bleed (P=0.005). Variceal bleed patients presented earlier to the hospital (P=0.005), had lower MAP at presentation (P=0.0002), had lower hemoglobin level (P=0.0001) and higher serum creatinine level at presentation (P=0.001). Patients with variceal bleed were more likely to have consumed alcohol 20 (86.9%) and patients with ulcer bleed were more likely to be smokers 29 (67.4%) or consume tobacco 14 (32.5%) (P=0.006).

CONCLUSIONS

Ulcer related bleeding is still the most common cause of AUGIB. Many patients with AUGIB have more than one lesions identified during upper gastrointestinal endoscopy.

Outcome of Endoscopic Variceal Band Ligation

INTRODUCTION

Bleeding from esophageal varices in cirrhosis is an emergent condition with high mortality. One of the preferred modality of treating esophageal varices is EVL. We aimed to find out the outcome of EVL in controlling acute esophageal variceal bleeding, prophylactic banding to prevent future bleeding and the number of sessions required for complete eradication of varices.

METHODS

This descriptive observational study was carried out in Gastroenterology and Hepatology unit of Bir Hospital, NAMS from June 2016 to May 2017. Consecutive cases who presented in emergency room with acute variceal bleeding due to liver cirrhosis and cases of liver cirrhosis with large varices and red color signs on endoscopic examination were enrolled. They underwent EVL and subsequent re-endoscope at one month interval till the eradication of varices was achieved.

RESULTS

Among 83 patients, 15 (18.1%) were of Child Pugh class A, 29 (34.9%) B and 39 (47%) were of C. In 20 (24.1%) cases varices could be eradicated in one session of EVL while 57 (68.7%) required two sessions and in 6 (7.2%) cases it took three sessions. Total average EVL session required for obliteration of esophageal varices was 1.84±0.53. There was only one (1.2%) of early re-bleeding post EVL.

CONCLUSIONS

EVL is an effective modality of treatment in controlling acute esophageal variceal bleeding, in preventing future variceal bleeding as well as in eradicating esophageal varices with very few complications.

C-reactive Protein in Periodontitis and its Comparison with Body Mass Index and Smoking Behaviour

INTRODUCTION

Chronic periodontitis is an infectious disease resulting in inflammation within the supporting tissues of the teeth, progressive attachment loss, and bone loss. In addition to declining oral health, there is always low grade infection present in periodontitis. Studies show increased levels of systemic biomarkers in periodontal disease such as CRP, which is considered a key-marker of CVD. Research has also shown positive association between BMI and smoking with periodontitis and CRP. The objective of the study was to assess the levels of CRP in patients with and without periodontitis and their relation with BMI and smoking behaviour.

METHODS

Patients visiting the Dental department of Bir Hospital were invited to participate in the study. Total 31 subjects in each group: Case (periodontitis) and Control (without periodontitis) were selected using convenience sampling technique. All subjects underwent periodontal examination by a single examiner. Serum CRP samples were taken before periodontal treatment. Data analysis was done by SPSS 17 software program.

RESULTS

Increase in mean CRP levels in periodontitis (5.8595mg/L) with high statistical significance (P=0.000) in comparison to subjects without periodontitis (1.1214mg/L) was observed. BMI showed positive association with periodontitis (P=0.046) but not with CRP (0.213). Smoking behaviour showed no significant relation with either CRP (P=0.344) or periodontitis (P=0.541).

CONCLUSIONS

We found highly significant association between periodontitis and CRP levels but not always with BMI and smoking. CRP, which is an established marker for CVD was significantly increased in periodontal infections. Hence, a close interaction among Physician, Periodontist and Patient to prevent adverse health situations is recommended.

Clinico-etiological Profile of Melasma among Female Health Workers in a Tertiary Care Center of Central Nepal - A Cross Sectional Study

Background Melasma is an acquired symmetrical dyschromia with profound psychosocial impacts. It is a common pigmentary disorder with less clear etiology and limited management options. There are limited data regarding melasma in our scenario. Objective To evaluate the clinico-etiological profile of melasma, among the female health workers (FHW) in a tertiary health center. Method This is a single center, cross-sectional, descriptive study involving female health workers with or without melasma. A total of 198 female health workers were evaluated at Dhulikhel hospital Kathmandu university hospital for clinic-etiological profile of melasma in January 2017. Video-dermatoscopy was used for the clinical diagnosis of melasma. A structured, self-administered questionnaire was used for assessment. Risk factor assessment of etiological agents as sun exposure, hormonal medication, photo aggravating drugs, stressors as night duty were evaluated. Result The point prevalence of melasma among female health workers 20.7% (n=41). The mean age of respondents was 26.2 ± 3.23 years with duration of disease process 3.6 ± 2.5 years. Centro-facial pattern was the commonest clinical type (53.7%) and video-dermatoscopy revealed mixed pattern as the commonest (56.1%) pigment deposition pattern. Among 132 female health workers doing night duty on regular basis, 23 had melasma while 66 female health workers not doing night duty, 18 had melasma (p = 0.10). Whereas while comparing hours of night duty per week among respondents with melasma (n=23) and without melasma (n=18) were 23.72±10.08 hours and 17.8±4.77 hours respectively (p=0.02). Conclusion The present study reveals higher prevalence of melasma among female health workers having more stressors as night duty.

Clinical Outcome of Autologous Serum Therapy in Chronic Idiopathic Urticaria

BACKGROUND

Quality of life in chronic idiopathic urticaria is hampered as efficacy of H1-antihistamines is limited. Autologous serum containing tolerance-generating anti-idiotype antibodies is a novel and cost-effective therapy. This study was conducted to evaluate the efficacy of autologous serum therapy (AST) among chronic urticaria patients with autologous skin prick test positive and negative status.

METHODS

Untreated 102 patients of chronic urticaria were enrolled in a non-randomized interventional study. Patients were categorized into two groups based on autologous serum skin prick test as test positive (ASST +) and test negative (ASST -). Patients were then treated with intramuscular injection of 0.05ml per kg body weight of autologous serum weekly for 10 weeks. Urticaria activity scoring (UAS) tool was used for quantification of the symptoms. Weekly recording of UAS (range: 0-42) was made before the therapy (baseline) and during the therapy for 10 weeks.

RESULTS

Significant improvement with AST in the mean UAS was noted from baseline to 10 weeks in both the group of patients (14.6 ± 6.3 and 10.2 ± 5.1 for ASST+ group ; 16.9 ± 7.8 and 8.6 ± 4.8 for ASST- group; at baseline and 10 weeks, respectively (p-value for both <0.05)). However no statistical significance was found while comparing the efficacy of the therapy against ASST + and ASST - Groups (p-value > 0.05).

CONCLUSIONS

Irrespective of autologous skin prick test results, autologous serum therapy showed significant improvement in patients with chornic idiopathic urticaria. AST can, thus, be an effective treatment modality for it.

Combination Topical PUVAsol with Methotrexate Versus Methotrexate in the Treatment of Palmoplantar Psoriasis

Background Non-pustular palmoplantar psoriasis (PPP) is chronic and disabling dermatosis. Topical psoralen and solar ultraviolet - A therapy (PUVAsol) is efficacious and safe therapy in psoriasis management. Objective To study the efficacy and adverse clinical effect profile of topical PUVAsol along with methotrexate in PPP. Method This is a prospective, randomized, clinical trial conducted among 54 patients with moderate to severe PPP. Patients were grouped into two categories. Group I was treated with weekly oral methotrexate only while group II had additional soak PUVAsol therapy twice weekly for a total of three months. Modified palmoplantar psoriasis area severity index (mPPPASI) score was used for quantification of severity. Patients were followed up monthly for the efficacy and adverse clinical event profile for 3 months; additionally patients were followed up monthly for next three months for assessment of relapse. Result The mean age of patients with PPP was found to be 38.7 ± 13 years and male: female ratio was 1.1:1. In comparison to group I patients, statistically significant improvement was observed among group II patients in the third month follow up (p= 0.039). Fifteen patients (35%) achieved mPPPASI 75 during the treatment period. No significant difference was noted among the mPPPASI score during relapse assessment. Eleven (29%) patients had evidence of relapse (mPPPASI more than 25% of baseline) during follow up period. No statistically significant adverse clinical events were noted. Conclusion Topical PUVAsol is an efficacious, safe and cost effective modality in moderate to severe PPP. It could be employed in rotational or maintenance therapy of psoriasis.

Diseases in Disaster: Post-Earthquake Dermatoses, Nepal 2015

Nepal experienced a devastating earthquake measuring 7.8 Richter scale on 25th April 2015. Although the heightened effects were secondary to trauma, the indirect effects were also of prime importance. We came across different dermatoses, directly or indirectly secondary to earthquake. We here present an audit of the cutaneous effects following four months of the major shock presenting to a tertiary care center of central Nepal. A total of 7326 patients presented to the dermatology department over a period of four months following the major shock. Among them a total of 3833 patients (52.32%) had direct or indirect dermatoses following earthquake.

Study on Corticosteroids use Pattern in Dermatological Practice and Investigating Adverse Effect of Corticosteroids Including its Associated Factors

Background Corticosteroids are highly effective drugs with anti-inflammatory and immunosuppressive properties. Due to this, they have become a mainstay of pharmacotherapy in dermatology. However, improper and long term uses are associated with a number of serious adverse effects. Objective To investigate the corticosteroids use pattern, adverse effects and various factors associated with adverse effects in dermatological practice. Method A cross-sectional study was conducted in a dermatology department of tertiary care hospital. All patients using at least one corticosteroids, either topically or systemically or the combination were included in this study. Informed consent was taken from the patients and interviewed using structured questionnaire. Statistical analysis was performed by using SPSS 20. p-value < 0.05 was considered as statistically significant. Result Among the 60 participants under this study, 81.67% of them were females. The mean (±SD) age of the patients was 31.03 years (±15.0). A majority (58.30%) of the patients was prescribed with topical corticosteroids with low potency (25%). Most of them had used corticosteroids for urticaria. Adverse effects were reported by 33.30% of the patients. The most common adverse effect reported was the shedding of skin. Adverse effects was significantly associated with gender; use of systemic corticosteroids; regular use of corticosteroids; discontinuation of dose abruptly; and missed dose. However, there was no significant association between adverse effects and the duration of use of corticosteroids. Conclusion In conclusion, the present study suggested that the proper counselling and clear instruction regarding the use of corticosteroid should be provided to the patients for avoiding the abrupt discontinuation of the prescribed medication leading to treatment failure.

Lichen Planus Pigmentosus: A study for association of Thyroid Dysfunction

Background Lichen planus pigmentosus (LPP) is considered a chronic and progressive variant of lichen planus. Although pigmentation occurs in the sun exposed areas, the etiology remains unknown and there are no appropriate treatment guidelines. Association with thyroid disorder has been described in various disorders of pigmentation. Objective The objective of this study was to find the association between LPP and thyroid dysfunction. Method A total of 54 clinically diagnosed cases of LPP and 54 age and sex matched healthy control volunteers were included in this case control study. Thyroid function test and thyroid peroxidase antibody were analysed to determine the probable association between thyroid diseases and LPP. Result Seventeen (31.7%) patients had biochemical evidence of hypothyroidism and 3 had hyperthyroidism among the diseased group. Among the control group two persons were tested positive for hypothyroidism (c2 = 0.34; p <0.05). Similarly, the levels of thyroid peroxidase antibody in the LPP patients were found to be significantly higher than those of controls (p <0.05). Conclusion Thyroid disorder was found to be an associated factor in LPP. Hence, we recommend routine thyroid function tests in patients with LPP. Further research is warranted among large number of patients to elucidate the exact association.

Photo-onycholysis Following Two Weeks of Doxycycline

Photo-onycholysis is a form of phototoxic reaction characterized by spontaneous separation of the nail plate from the nail bed. It usually follows drug intake and tetracycline is a well-known culprit. We present a case of 19 years gentleman who developed this rare side effect following two weeks of ingestion of doxycycline.

Breech presentation among nullipara at term: an indication for caesarean section

BACKGROUND

Breech is the commonest malpresentation. Vaginal breech delivery in a nulliparous lady carries higher risk than in multiparous ladies. Poor neonatal outcome following vaginal delivery has made the mode of delivery a matter of controversy.

OBJECTIVE

To evaluate the outcome of planned caesarean section among nullipara ladies with breech presentation.

METHOD

This is a prospective, analytical study conducted in Dhulikhel Hospital Kathmandu University Hospital from January 2008 to June 2012 among 102 nullipara ladies at term gestation with breech presentation. All cases underwent caesarean section either elective or emergency. During section cause of breech presentation was searched for. Neonatal condition was evaluated using APGAR Score, need for resuscitation and admission in NICU. Post partum status was also recorded for evaluation of maternal morbidity and mortality.

RESULTS

These Nullipara ladies often had some reason for breech presentation, the most common being cord around the neck. Perinatal outcome was uneventful in 97(95%) neonates, there were two (2%) still birth and three (3%) needed NICU care. APGAR was good in 92 neonates, average in eight and poor in two. Total 16(15.6%) ladies stayed hospital for more than eight days. Among them 11(10.7%) developed wound infection and five stayed in hospital waiting for baby.

CONCLUSION

Nullipara ladies with breech presentation should have elective caesarean section as a preferred route of delivery.

Concurrent vitiligo and psoriasis

Coexistence of vitiligo and psoriasis in a single patient is a rare occurrence. The exact pathogenesis of this coexistence is obscure. Various autoimmune disorders are reported to occur more frequently in patients with both diseases. A case of this interesting coexistence seen on a 26 year old female patient who presented to the dermatology department of Dhulikhel hospital is presented here. She also had hypothyroidism. The possible pathogenesis and literature review of this rare condition is discussed here.

Organism isolation in corneal ulcer: utility of different techniques

INTRODUCTION

Various techniques are available for isolation of microorganism in cases of microbial keratitis including conventional methods of scraping, re-scraping inoculation in different media and corneal biopsy.

METHODS

This was a cross sectional descriptive study conducted from February 2002 to July 2003. A total of 161 eyes of corneal ulcers were evaluated with scraping inoculation. Re-scraping and corneal biopsy were performed in those cases which did not grow any organism in the first scraping or which did not respond to initial treatment.

RESULTS

Microorganisms were isolated in 116 patients (72.04%) after first scraping. S pneumoniae was seen in 50(42%), Fusarium in 21(18%) and Aspergillus in 16(14%) cases. Re-scraping was done in 22 culture negative and non improving cases of which 14 (63.63%) showed isolation of organisms. After re-scraping, Fusarium and Aspergillus were isolated in four patients each (18% each) followed by S. pneumoniae in 3 (14%), S. aureus in 2 (9%), and Penicillium in 1(5%) case. Corneal biopsy was done in 10 cases with isolation of microbial agents in 7 (70%) with Aspergillus and S. aureus in three each, and S. epidermidis in 1(10%).

CONCLUSIONS

Apart from conventional scraping, other isolation techniques should be considered in the treatment of non-responding and culture negative cases of corneal ulcers. Compared to bacteria, fungi are difficult to isolate in the first scraping and requires more frequent repeat scraping and corneal biopsy.

Effect of acute hepatitis E infection in patients with liver cirrhosis

INTRODUCTION

Hepatitis E virus is a major cause of enterically transmitted hepatitis. Mortality is very high if it is associated with pregnancy, especially during third trimester. This study was carried out to find out the effects of acute HEV hepatitis on Chronic Liver Disease patients of different etiologies.

METHODS

The consecutive patients of liver cirrhosis with definite evidence of recent HEV infection were enrolled in this study. Acute hepatitis was diagnosed by presence of prodromal symptoms and anti-HEV IgM antibody in their serum. The outcomes after superinfection with HEV hepatitis were determined by changes in Child Pugh score, recovery of liver function test, hospital stay and mortality.

RESULTS

After exclusion 25 were studied. The etiology of cirrhosis in patients was: alcohol 13, autoimmune hepatitis 3, hepatitis B 2, Budd Chiari syndrome 2, alcohol plus hepatitis B 1, hepatitis C 1, cardiac cirrhosis 1, Wilson's disease 1 and cryptogenic 1. All patients with no recent decompensation showed signs of decompensation during admission. Seven (28%) patients died. The cause of death was either upper gastrointestinal bleeding or hepatorenal syndrome. Remaining patients had prolonged hospital stay with deterioration of Child-Pugh's score.

CONCLUSIONS

Superinfection of HEV in cirrhotic patient causes rapid decompensation. The morbidity and mortality is higher compared to those non-infected patients. Development of hepatorenal syndrome and upper GI bleeding was commonest cause of death.

Acute liver failure caused by hepatitis E virus and paracetamol

Acute liver failure is characterized by severe and sudden liver cell dysfunction leading to hepatic encephalopathy and hepatic coagulopathy in a person without history of liver disease in the past. This catastrophic illness can rapidly progress to coma and death from cerebral edema and multi organ dysfunction. It carries a high mortality rate if liver transplantation is not carried out. In West, paracetamol is the main cause of hepatotoxicity whereas in the East viral hepatitis tops the list. This report describes a case of acute liver failure in which probably both the agents were involved. The patient recovered with antidote therapy and maximum supportive care.

Hepatitis E virus infection in chronic liver disease causes rapid decompensation

Hepatitis E previously known as enterically transmitted non-A, non-B hepatitis, is a self limiting infectious viral disease of developing countries. Various issues regarding the pathogenesis of liver injury and its natural history remain unanswered after two decades of its discovery. A small proportion of patients develop fulminant hepatic failure. Mortality is very high if it is associated with pregnancy, especially during third trimester. After establishment of hepatitis A virus as a cause of decompensation of chronic liver disease, now there are reports that hepatitis E viruses also does the same. Acute hepatitis E in these patients has a protracted course with high morbidity and mortality. Many patients develop hepatorenal syndrome, hepatic encephalopathy and even liver failure after co-infection with hepatitis E virus. Now time has come to institute hepatitis E virus superinfection as one of the cause of acute on chronic liver failure. Hepatitis E is a problem of developing countries and Nepal is in the endemic zone. Sudden decompensation in chronic liver disease patient, who were otherwise stable and under regular follow up, should be carefully dealt with. Patient statistics at our unit shows that 7 cases of chronic liver diseases with superinfection with hepatitis E virus were dealt from April 2004 to August 2005. Two patients (29%) died and 5 recovered. In patients with recovery, there was deterioration of Child-Pugh grading and the duration of hospital stay was longer. Thus, hepatitis E in diagnosed chronic liver disease case should be taken apprehensively. Similarly patients of chronic liver disease traveling to endemic zone should take precaution. If vaccine against hepatitis E virus is developed, chronic liver disease patient would be the eligible candidate for vaccination beside pregnant ladies.