Symmetry Control of Unconventional Spin-Orbit Torques in IrO2

Spin-orbit torques generated by a spin current are key to magnetic switching in spintronic applications. The polarization of the spin current dictates the direction of switching required for energy-efficient devices. Conventionally, the polarizations of these spin currents are restricted to be along a certain direction due to the symmetry of the material allowing only for efficient in-plane magnetic switching. Unconventional spin-orbit torques arising from novel spin current polarizations, however, have the potential to switch other magnetization orientations such as perpendicular magnetic anisotropy, which is desired for higher density spintronic-based memory devices. Here, it is demonstrated that low crystalline symmetry is not required for unconventional spin-orbit torques and can be generated in a nonmagnetic high symmetry material, iridium dioxide (IrO2 ), using epitaxial design. It is shown that by reducing the relative crystalline symmetry with respect to the growth direction large unconventional spin currents can be generated and hence spin-orbit torques. Furthermore, the spin polarizations detected in (001), (110), and (111) oriented IrO2 thin films are compared to show which crystal symmetries restrict unconventional spin transport. Understanding and tuning unconventional spin transport generation in high symmetry materials can provide a new route towards energy-efficient magnetic switching in spintronic devices.

ICARUS at the Fermilab Short-Baseline Neutrino program: initial operation

The ICARUS collaboration employed the 760-ton T600 detector in a successful 3-year physics run at the underground LNGS laboratory, performing a sensitive search for LSND-like anomalous ν e appearance in the CERN Neutrino to Gran Sasso beam, which contributed to the constraints on the allowed neutrino oscillation parameters to a narrow region around 1 eV2 . After a significant overhaul at CERN, the T600 detector has been installed at Fermilab. In 2020 the cryogenic commissioning began with detector cool down, liquid argon filling and recirculation. ICARUS then started its operations collecting the first neutrino events from the booster neutrino beam (BNB) and the Neutrinos at the Main Injector (NuMI) beam off-axis, which were used to test the ICARUS event selection, reconstruction and analysis algorithms. ICARUS successfully completed its commissioning phase in June 2022. The first goal of the ICARUS data taking will be a study to either confirm or refute the claim by Neutrino-4 short-baseline reactor experiment. ICARUS will also perform measurement of neutrino cross sections with the NuMI beam and several Beyond Standard Model searches. After the first year of operations, ICARUS will search for evidence of sterile neutrinos jointly with the Short-Baseline Near Detector, within the Short-Baseline Neutrino program. In this paper, the main activities carried out during the overhauling and installation phases are highlighted. Preliminary technical results from the ICARUS commissioning data with the BNB and NuMI beams are presented both in terms of performance of all ICARUS subsystems and of capability to select and reconstruct neutrino events.

Néel Spin Currents in Antiferromagnets

Ferromagnets are known to support spin-polarized currents that control various spin-dependent transport phenomena useful for spintronics. On the contrary, fully compensated antiferromagnets are expected to support only globally spin-neutral currents. Here, we demonstrate that these globally spin-neutral currents can represent the Néel spin currents, i.e., staggered spin currents flowing through different magnetic sublattices. The Néel spin currents emerge in antiferromagnets with strong intrasublattice coupling (hopping) and drive the spin-dependent transport phenomena such as tunneling magnetoresistance (TMR) and spin-transfer torque (STT) in antiferromagnetic tunnel junctions (AFMTJs). Using RuO_{2} and Fe_{4}GeTe_{2} as representative antiferromagnets, we predict that the Néel spin currents with a strong staggered spin polarization produce a sizable fieldlike STT capable of the deterministic switching of the Néel vector in the associated AFMTJs. Our work uncovers the previously unexplored potential of fully compensated antiferromagnets and paves a new route to realize the efficient writing and reading of information for antiferromagnetic spintronics.

Switchable Anomalous Hall Effects in Polar-Stacked 2D Antiferromagnet MnBi2Te4

van der Waals (vdW) assembly of two-dimensional (2D) materials allows polar layer stacking to realize novel properties switchable by the induced electric polarization. Here, based on symmetry analyses and density-functional calculations, we explore the emergence of the anomalous Hall effect (AHE) in antiferromagnetic MnBi₂Te₄ films assembled by polar layer stacking. We demonstrate that breaking P̂T̂ symmetry in an MnBi₂Te₄ bilayer produces a magnetoelectric effect and a spontaneous AHE switchable by electric polarization. We find that reversible polarization at one of the interfaces in a three-layer MnBi₂Te₄ film drives a metal-insulator transition, as well as switching between the AHE and quantum AHE (QAHE). Finally, we predict that engineering interlayer polarization in a three-layer MnBi₂Te₄ film allows converting MnBi₂Te₄ from a trivial insulator to a Chern insulator. Overall, our work emphasizes the topological properties in 2D vdW antiferromagnets induced by polar layer stacking, which do not exist in a bulk material.

Tunneling Magnetoresistance in Noncollinear Antiferromagnetic Tunnel Junctions

Antiferromagnetic (AFM) spintronics has emerged as a subfield of spintronics driven by the advantages of antiferromagnets producing no stray fields and exhibiting ultrafast magnetization dynamics. The efficient method to detect an AFM order parameter, known as the Néel vector, by electric means is critical to realize concepts of AFM spintronics. Here, we demonstrate that noncollinear AFM metals, such as Mn_{3}Sn, exhibit a momentum dependent spin polarization which can be exploited in AFM tunnel junctions to detect the Néel vector. Using first-principles calculations, we predict a tunneling magnetoresistance (TMR) effect as high as 300% in AFM tunnel junctions with Mn_{3}Sn electrodes, where the junction resistance depends on the relative orientation of their Néel vectors and exhibits four nonvolatile resistance states. We argue that the spin-split band structure and the related TMR effect can also be realized in other noncollinear AFM metals like Mn_{3}Ge, Mn_{3}Ga, Mn_{3}Pt, and Mn_{3}GaN. Our work provides a robust method for detecting the Néel vector in noncollinear antiferromagnets via the TMR effect, which may be useful for their application in AFM spintronic devices.

321 Surgery Induction Guidebook – an Aid to a Successful Transition

Aim

There is a 4–12% increase in mortality following the August change over in the National Health Service (NHS) UK. A well-structured induction programme is mandatory to improve both the competency and confidence of new junior doctors. This activity was designed to evaluate and improve the induction process in Pilgrim Hospital by introducing an induction guidebook. It aimed to provide a sustainable and reliable source of information to junior doctors.

Method

An initial survey in the department assessed the needs and identified the information required for the guidebook. An induction guidebook was designed and circulated during the changeover. A feedback survey was conducted after the six months of the initial Induction guidebook release, to know the usefulness of components of the induction guidebook and identify any gaps to improve the guidebook.

Results

A total of 15 participants completed the feedback survey. 47% (7) found the induction guidebook beneficial and 53.3 % (8) found it ‘slightly beneficial'. Similarly, only 1 participant (6.7%) rated the guidebook to be “of minor importance”, while 53% (8) rating it “very important” part of induction. The feedback for the contents of the book was also encouraging with suggestions.

Conclusions

The guidebook proved to be a valuable source in helping new doctors during times of transition to adjust to the local system and improve the induction process. It provided information about local guidelines, job overview, team structure, IT, useful contacts, and other relevant information. We recommend the departmental guidebook as a vital part of local departmental induction during the changeover.

287 COVID-19 and Surgical Specialties – Lessons Learnt: A Rural DGH Perspective

Introduction

The COVID-19 pandemic has seen the restructuring of surgical services worldwide. We aimed to evaluate pre-operative planning and post-operative outcomes in expedited colorectal surgery (ECRS), emergency general surgery (EGS), and emergency orthopaedic surgery (EOS) during the COVID-19 era at our rural hospital.

Method

This was a prospective observational cohort study. Electronic hospital systems identified adult patients who underwent ECRS, major EGS or EOS at our site, from the start of the UK lockdown.

Results

Following exclusion criteria, 98 patients were included in data analysis. Post-operative respiratory complications were seen in 27.8% of ECRS patients, 13.3% of EGS patients and 4% of EOS patients. 2 patients were diagnosed with COVID-19, with 1 COVID-19 associated mortality. Length of hospital stay was reduced for EOS in the COVID-19 setting and this was found to be statistically significant (p value <0.001).

Conclusions

When compared to the literature, COVID-19 related complications in surgical patients were found to be lower at our rural hospital. This could be due to regional variation in the prevalence of COVID-19. If there were to be a second surge, we suggest NHS Trusts should be given the autonomy to make local decisions on modifying their elective caseload, rather than following a national ‘one-size-fits-all’ guideline.

Comparison of Outcome of Borderline and Normal Amniotic Fluid Index in Term Pregnancy

Background Determination of Amniotic Fluid Index (AFI) is an important component of antepartum assessment of all normal pregnancies. Objective To compare the obstetric interventions and neonatal outcomes in term pregnancies with borderline Amniotic Fluid Index versus normal Amniotic Fluid Index. Method This hospital based prospective study was conducted at Tribhuwan University Teaching Hospital over 1 year between 2017 and 2018 in 128 women having uncomplicated term pregnancy admitted in labor ward. Of the 128 women, 64 women had borderline Amniotic Fluid Index (5.1-8 cm) and 64 normal AFI (8.1 - 24 cm). Parameters studied were induction of labor, cesarean section, instrumental delivery, intrapartum abnormal fetal heart rate, meconium staining of liquor, APGAR score at 5 and 7 minutes, birth weight, neonatal intensive care unit (NICU) admission and neonatal death. Data was analyzed using software OpenEpi. Result Statistically significant difference in result was obtained in the two groups in terms of rate of induction of labor (73.4% vs 35.9%, p = 0.0001, OR = 4.9), rate of cesarean section (42.1% vs 28 .1%, p = 0.04, OR = 1.8), tachypnea (50% vs 11.1%, p = 0.01) and low birth weight (9.1% vs 4.5%, p = 0.04). No statistical significance was found in meconium staining of liquor (33% vs 38.3%, p = 0.3) and APGAR score of <7 at 5 minutes (3.1% vs 1.5%, p = 0.06). There were no neonatal intensive care unit admissions and neonatal mortality in any of the babies. Conclusion Detection of amniotic fluid volume at term is important for timely maternal interventions to improve the overall fetal outcome.

Controlling spin current polarization through non-collinear antiferromagnetism

The interconversion of charge and spin currents via spin-Hall effect is essential for spintronics. Energy-efficient and deterministic switching of magnetization can be achieved when spin polarizations of these spin currents are collinear with the magnetization. However, symmetry conditions generally restrict spin polarizations to be orthogonal to both the charge and spin flows. Spin polarizations can deviate from such direction in nonmagnetic materials only when the crystalline symmetry is reduced. Here, we show control of the spin polarization direction by using a non-collinear antiferromagnet Mn₃GaN, in which the triangular spin structure creates a low magnetic symmetry while maintaining a high crystalline symmetry. We demonstrate that epitaxial Mn₃GaN/permalloy heterostructures can generate unconventional spin-orbit torques at room temperature corresponding to out-of-plane and Dresselhaus-like spin polarizations which are forbidden in any sample with two-fold rotational symmetry. Our results demonstrate an approach based on spin-structure design for controlling spin-orbit torque, enabling high-efficient antiferromagnetic spintronics.

In the typical spin-hall effect, spin-current, charge current, and spin polarisation are all mutually perpendicular, a feature enforced by symmetry. Here, using an anti-ferromagnet with a triangular spin structure, the authors demonstrate a spin-hall effect without a perpendicular spin alignment.

Nonlinear Anomalous Hall Effect for Néel Vector Detection

Antiferromagnetic (AFM) spintronics exploits the Néel vector as a state variable for novel spintronic devices. Recent studies have shown that the fieldlike and antidamping spin-orbit torques (SOTs) can be used to switch the Néel vector in antiferromagnets with proper symmetries. However, the precise detection of the Néel vector remains a challenging problem. In this Letter, we predict that the nonlinear anomalous Hall effect (AHE) can be used to detect the Néel vector in most compensated antiferromagnets supporting the antidamping SOT. We show that the magnetic crystal group symmetry of these antiferromagnets combined with spin-orbit coupling produce a sizable Berry curvature dipole and hence the nonlinear AHE. As a specific example, we consider the half-Heusler alloy CuMnSb, in which the Néel vector can be switched by the antidamping SOT. Based on density-functional theory calculations, we show that the nonlinear AHE in CuMnSb results in a measurable Hall voltage under conventional experimental conditions. The strong dependence of the Berry curvature dipole on the Néel vector orientation provides a new detection scheme of the Néel vector based on the nonlinear AHE. Our predictions enrich the material platform for studying nontrivial phenomena associated with the Berry curvature and broaden the range of materials useful for AFM spintronics.

Dirac Nodal Line Metal for Topological Antiferromagnetic Spintronics

Topological antiferromagnetic (AFM) spintronics is an emerging field of research, which exploits the Néel vector to control the topological electronic states and the associated spin-dependent transport properties. A recently discovered Néel spin-orbit torque has been proposed to electrically manipulate Dirac band crossings in antiferromagnets; however, a reliable AFM material to realize these properties in practice is missing. In this Letter, we predict that room-temperature AFM metal MnPd_{2} allows the electrical control of the Dirac nodal line by the Néel spin-orbit torque. Based on first-principles density functional theory calculations, we show that reorientation of the Néel vector leads to switching between the symmetry-protected degenerate state and the gapped state associated with the dispersive Dirac nodal line at the Fermi energy. The calculated spin Hall conductivity strongly depends on the Néel vector orientation and can be used to experimentally detect the predicted effect using a proposed spin-orbit torque device. Our results indicate that AFM Dirac nodal line metal MnPd_{2} represents a promising material for topological AFM spintronics.

Air Transfer of Obstetric Emergencies to a Tertiary Care Center in Nepal

Aims: This study was performed to review the places, indications, maternal-perinatal outcomes requiring emergency air transfer to a tertiary level referral center.Methods: A hospital based descriptive study of one year duration, conducted in Tribhuvan University Teaching Hospital (TUTH), over a period of twelve months. All the women who were air transferred for pregnancy complications were enrolled.Results: There were total 19 airlifted obstetric emergencies to TUTH over one year period:  majority (68%) from hilly areas and others (32%) from mountain region. Out of them, referred cases were 11 [district hospital (5), healthpost (4); Primary Health Center (PHC) (2)]; and rest were from home (8). Two cases were abortion related; septic abortion (1) and incomplete abortion (1). There were three antepartum cases: pregnancy with meningoencephalitis (1), eclampsia (1) and bleeding placenta previa (1); maximum, eleven intrapartum cases, obstructed labor (6),labor dystocia (3), breech in labor (1) and undelivered second twin (1). Rest three were postpartum cases, one each of eclampsia, puerperal sepsis and retained placenta. Maternal morbidities were one each case of uterine rupture, acute kidney injury, retained placenta with PPH and vesicovaginal fistula that developed in the case of shoulder dystocia. Maternal mortality occurred in 2 cases, first women with antepartum eclampsia who had intracerebral bleed and second was a case of pregnancy with meningoencephalitis who later developed brain death. Regarding perinatal outcome 12/14 (86%) had live birth and 2/14 (14%) had IUFD upon arrival.Conclusion: Air lift on personal expenditure, despite economic constraints has proven beneficial in our country’s context with difficult geographical terrain and inadequate health services, whereas anticipation of any critical condition right in the beginning and timely transfer however could have been more advantageous.

Changing trends in caesarean deliveries at a tertiary care Centra: a ten year appraisal

Introduction: Over the last few decades, the rise in the rates of Caesarean Sections (CS) has become a global phenomenon. The objective of this study was to follow the CS rates over the last 10 years and to compute the various indications of CS in an attempt to analyze the possible reasons for this changing trend in the institute.Methods: All deliveries that took place between April 13, 2004 to April 14, 2014 (Baisakh 2061 BS and Chaitra 2070 BS) in TUTH were retrospectively collected. Annual total number of deliveries, rates of CS, instrumental deliveries and Vaginal Birth after Caesarian Section (VBAC) along with indications for CS were computed and analyzed.Result: A total of 38,770 deliveries were conducted over ten years with 26,791 (69.10%) vaginal deliveries and 11,979 (24.80%) CS. There was a steep rise in the rates of CS from 21.04% in 2004 to 39.23% in 2014. Rates of instrumental deliveries and VBAC remained low at 0.86% to 3.35% and 0.15% to 0.7 % respectively. Fetal distress was the commonest indication of emergency CS while previous CS was the commonest indication for elective CS.Conclusion: Over the last decade, the global trend of rising CS rates was also found to be mirrored at TUTH. The causes for rise in CS  rates were- increased diagnosis of fetal distress and oligohydramnios, delivery of most breech by Caesarean sections, low rates of VBAC and instrumental deliveries, complicated referrals from all over the country and last but not the least,  threat of malpractice litigations.Journal of Society of Surgeons of NepalVol. 17, No. 2, 2014, Page: 7-11

Assessment of Knee Joint Injuries with Low Field Strength Magnetic Resonance Imaging

BACKGROUND

Magnetic Resonance Imaging is an appropriate screening tool before therapeutic arthroscopy, making diagnostic arthroscopy unnecessary in most patients. This study aims to evaluate the MRI findings in knee injuries and diagnostic value of low Strength MRI for assessing Meniscal and cruciate ligament tear.

METHODS

A cross sectional study was conducted on patients undergoing "Magnetic Resonance Imaging of the Knee" for injuries of the knee and excluded patients undergoing MRI for other causes, poor diagnostic quality MRI and post operative MRI. All patients were interviewed for mechanism of injury and followed up for arthroscopic findings. Statistical analysis was doe using IBM SPSS 20.0.

RESULTS

A total of 81 MRIs was included in the study. Arthroscopic finding of only 32 patients could be followed up. Anterior cruciate ligament (ACL) tear was the most common internal ligament tear accounting for 34(42%) of cases followed by medial meniscus tear in 33(40.7%). Twisting 14( 42.4%)was the most common mechanism involved in medial meniscus tear while combined mechanism of injury was most common mechanism for ACL tear 16( 47.05%). The sensitivity of MRI for diagnosis of ACL tear and medial meniscus tear was 96.3% and 94.7% respectively. Specificity for ACL tear was however only 80% and that for medial meniscus tear was 100%.

CONCLUSIONS

The diagnostic value of MRI for diagnosing internal derangement of knee was high even with a low Tesla (0.3 T) MRI thus emphasizing the role of MRI as a non-invasive alternative to diagnostic arthroscopy.

Magnetic Resonance Imaging Findings in Degenerative Disc Disease of Cervical Spine in Symptomatic Patients

BACKGROUND

The pathophysiological findings demonstrated in cervical spine in Magnetic Resonance Imaging (MRI) can explain only partly the occurrence of neck and shoulder pain. This study aims to evaluate the occurrence of cervical degenerative disc pathologies in symptomatic patient with neck pain and radiculopathy.

METHODS

The study was a retrospective and institutional record based descriptive study carried out for the duration of 3yrs in a well-equipped imaging center. Only MRI performed for neck pain with or without radiculopathy with complete clinical form was included in the study. MRI findings were entered in SPSS spread sheet and analyzed using SPSS 19.0.

RESULTS

A total of 750 MRI was reviewed among which 571(76.13%) had cervical degenerative disc pathology. Disc degeneration and disc bulge was the most common finding, followed by neural foramina stenosis, disc herniation and myelopathic changes. Disc degeneration and disc bulge was seen more frequently in patients older than 40 years than those less than 40 years. Disc herniation was rare in extremes of age and noted predominantly in productive population between 3 rd and 6 th decade of life.

CONCLUSIONS

Disc degeneration and global disc bulge were predominant findings in symptomatic patients increasing with the age. Disc herniation and neural foraminal stenosis were common changes seen associated with neck pain with or without radiculopathy and were predominant in productive age group.

Magnetic Resonance Imaging Findings in Lumbar Disc Degeneration in Symptomatic Patients

BACKGROUND

The sequel of disc degeneration is one of the leading causes of functional incapacity that leads to chronic disability. The study aims to evaluate the MRI findings of degenerative changes in symptomatic patients.

METHODS

The study was a retrospective study for the duration of 3 years. Symptomatic patients undergoing MRI of LS spine were included in the study. Patients undergoing MRI for neurological symptoms alone and acute trauma or suspected infection or tumor were excluded from the study. MRI of patients was evaluated for degenerative changes and their sequel. Data was entered in a predesigned proforma and analysis was done with SPSS version 19.0.

RESULTS

A total of 2037 MRIs of LS spine of symptomatic patients were included in the study. Degenerative changes were demonstrated in 1906 (93.8 %) patients, which comprised 1039 (54.5 %) males and 867 (45.4 %) females. Disc bulge along with disc desiccation was the most common degenerative findings noted in 1667 (81.8 %). Disc herniation was seen in 1032(50.6%), neural foraminal stenosis in 1220 (59.8 %), central spinal canal in 1136 (55.8%) and nerve root compression in 650 (31.9%). Disc bulge, neural foraminal stenosis, central spinal canal stenosis was significantly more common in patients older than 40 years. Disc herniation was however significantly more frequent in patients younger than 40 years.

CONCLUSIONS

Degenerative changes are common in symptomatic patients and increase in frequency with aging. Disc herniation is however more common in younger patients.

Obstetric Hysterectomy and Maternal Survival

Aims: This study was done to analyze the cases of obstetric hysterectomy and maternal complications and survival after that. Methods: A retrospective study was carried out from the review of records   of the near miss, maternal mortality, cesarean audit and operation theater record of the Department of Obstetrics and Gynaecology, Tribhuvan University Teaching Hospital (TUTH), Kathmandu from 2057-2071 BS. Results: Fourteen maternal survival resulted following total of 19 obstetric hysterectomy, subtotal hysterectomy being the procedure of choice in 11 cases, emergency peripartum hysterectomy (EPH) being performed in abundance (18/19) in comparison to an elective peripartum hysterectomy, which was undertaken in a single case of placenta percreta, and inclusive of latter were four cases of morbid placental adhesion, a placenta increta and two placenta accreta. Eight out of 19 cases had vaginal delivery and rest had cesarean section. Among seven cases of cesarean hysterectomy 3 were done for placenta previa with accreta one case each done for abruptio placentae  and placenta accreta and two cases were done for extra placental causes. Among four cases of emergency peripartum hysterectomy (EPH), which were relaparotomy followed by hysterectomy, three cases were done for complication of cesarean section and one done for uterine atonicity. Four cases of spontaneous vaginal deliveries needed peripartum hysterectomy two of them were complicated by morbid placental adhesion placenta increta (1), placental percreta (1), two cases were vaginal birth after cesarean (VBAC). Seven cases of uterine rupture had undergone peripartum hysterectomy.   Conclusions: Obstetric hysterectomy is a lifesaving surgical procedure for maternal survival whenever necessary and mandates a quick decision making process, however in consideration of younger age and low parity or nulliparity, the best obstetric governance and services must foresee not to let mothers meet such situation necessitating organ removal and to enjoy potential reproductive life cycle.DOI: http://dx.doi.org/10.3126/njog.v9i2.11759    

A clinicopathological study of dysfunctional uterine bleeding

Background: Dysfunctional uterine bleeding is a form of abnormal uterine bleeding when there is absence of organic disease of the genital tract. The objective of this study was to find out the clinical and pathological aspect of women presenting with dysfunctional uterine bleeding.Materials and Methods: A descriptive study was conducted over a period of one year from April 14th 2010 to April 13th 2011 in the Department of Obstetrics and Gynaecology and Department of Pathology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal. A complete history, clinical examination, pelvic scan, hormonal status if required and endometrial biopsy were done to diagnose dysfunctional uterine bleeding.Results: A total of 120 cases were included. The age of the patients diagnosed dysfunctional uterine bleeding were ranging from 24 -63 years. Dysfunctional uterine bleeding was most common in the age group 40-44 yrs (30%) followed by 45-49 yrs (27.5%). Menorrhagia (41.7%) was the most common presenting sign. Majority histopathology of endometrium revealed anovulatory pattern (61.7%) followed by ovulatory (38.3%). Of the cases with an anovulatory pattern 48.6% was proliferative endometrium, 33.8% disordered proliferative endometrium, 6.8%atrophic, 5.4% weakly proliferative and 2.7% each of simple hyperplasia without atypia and complex hyperplasia with atypia. All cases with ovulatory pattern showed secretory endometrium.Conclusion: Dysfunctional uterine bleeding was the most common in the perimenopausal age group and chiefly in the form of an anovulatory endometrium. . Histopathological evaluation of endometrium helps exclude the local causes and establishes the diagnosis of dysfunctional uterine bleeding, its types, and clinical correlation to histopathological findings and finally helps to determine the mode of management.DOI: http://dx.doi.org/10.3126/jpn.v4i8.11500 Journal of Pathology of Nepal; Vol.4,No. 8 (2014) 635-638

Use of Misoprostol in the Management of Early Pregnancy Loss

Aims: To evaluate the effectiveness of Misoprostol administered vaginally to assist complete evacuation in early pregnancy losses (incomplete abortion, missed abortion and blighted ovum). Methods: It is a descriptive study conducted in the Department of Ob/Gyn and Emergency Department Tribhuvan University Teaching hospital. All women with clinical/USG diagnosis of incomplete abortion, missed abortion and blighted ovum ≤12 weeks POG either from last menstrual period (LMP) or USG were inserted tab. misoprostol 800 mcg in the posterior fornix. Same dose was repeated when the evacuation was incomplete on day 3 of follow-up. Manual vacuum aspiration (MVA) was offered on day 14 if evacuation was incomplete or any complications like excessive bleeding/severe pain occurred during this period. Results: A hundred and thirty three women with incomplete/missed/blighted ovum were reported, of which 112 (84.3%) were analyzed as 21(15.7%) lost to follow up. Among the 112, 51 (45.5%) were incomplete abortion, 34(30.3%) blighted and 27 (24.1%) missed abortion. Complete evacuation was achieved in 98/112 (87.5%) cases [73 (65%) cases with single dose & 25(22.3%) with double doses]. Evacuation was failed in 14(12.5%) cases [incomplete abortion 6 (42%), blighted 7 (50%) & missed abortion 1 (7.1%)]. Failure for complete evacuation (n=14) related to gestational age: 10-12 weeks 9/14(64%), 7-9 weeks 5 (35%) and none in the ≤6 weeks. Although the plan was to evacuate on day 14 of follow-up for incomplete evacuation which was applicable only in 11(78.5%) cases, 3(21.5%) cases were surgically (MVA) treated beforehand (2 for excessive bleeding, 1 for severe pain). No severe complications and side effects requiring treatment were observed. Conclusions: Vaginal Misoprostol is proved to be effective and safe in cases of incomplete abortion, missed abortion and blighted ovum. In the cases that failed to achieve complete evacuation by medical means using misoprostol were subjected to surgical manual vacuum aspiration (MVA) on day 14 of follow-up. DOI: http://www.dx.doi.org/10.3126/njog.v7i2.11133   Nepal Journal of Obstetrics and Gynaecology / Vol 7 / No. 2 / Issue 14 / July-Dec, 2012 / 9-13

Crossed Testicular Ectopia

Crossed testicular ectopia also known as transverse testicular ectopia is a rare anomaly of the testis which is ectopically located in contralateral hemiscrotum with absent testis in the ipsilateral hemiscrotum. Most case are incidentally discovered intraopeartively during operation of inguinal hernia and few case reports are available which have reported preoperative diagnosis of crossed testicular ectopia. We report a case of crossed testicular ectopia in 12 year old boy who presented with right undescended testis diagnosed preoperative on Ultrasound and Magnetic Resonance Imaging as crossed testicular ectopia.

Fostering good governance at peripheral public health facilities: an experience from Nepal

CONTEXT

The Nepalese primary healthcare system at sub-district level consists of three different levels of health facility to serve the mostly rural population. The Ministry of Health and Population decentralised health services by handing over 1433 health facilities in 28 districts to Health Facility Operation and Management Committees (HFOMCs), which were formed following a public meeting, and consist of 9 to 13 members, representing the health facility in-charge, elected members of the village development committee, dalit (disadvantaged caste) and women members. The purpose was to make this local committee responsible for managing all affairs of the health facility. However, the handing over of the health facilities to HFOMCs was not matched by an equivalent increase in the managerial capacity of the members, which potentially makes this initiative ineffective.

ISSUE

The Health Facility Management Strengthening Program was implemented in 13 districts to foster good governance in the health facilities by increasing the capacity of HFOMCs. This effort focuses on capacity building of HFOMCs as a continuous process rather than a one-off event. Training, follow-up and promotional activities were conducted. This article focuses on how good governance at the peripheral public health facilities in Nepal can be fostered through the active engagement and capacity building of HFOMCs. This article used baseline and monitoring data collected during technical support visits to HFOMCs and their members between July 2008 and October 2011.

LESSONS LEARNED

The results show that the Health Facility Management Strengthening Program was quite successful in strengthening local health governance in the health facilities. The level of community engagement in governance improved, that is, the number of effective HFOMC meetings increased, the inclusion of dalit/women members in the decision-making process expanded, resource mobilization was facilitated, and community accountability, as measured by health facility opening days, increased. Furthermore, availability of technical staff, supervision and monitoring, and display of the citizen charter increased, and health services became more inclusive. Several lessons emerged. Functioning of HFOMCs is largely dependent on the process of selecting members, the staff and community's support of the HFOMC, and a sense of volunteerism and team spirit among the members. Similarly, to ensure the effective participation of dalit/woman members, the educational and livelihood empowerment of the members is deemed necessary. Furthermore, capacity building of and giving authority to HFOMCs should go hand-in-hand.

CONCLUSION

Local governance of health facilities was fostered through the local people's active engagement in HFOMCs and capacity building of the HFOMC members.

Post Caesarean Caecal Perforation with Fecal Peritonitis

NJOG 2011 Nov-Dec; 6 (2): 58-59 DOI: http://dx.doi.org/10.3126/njog.v6i2.6762

Strengthening national health systems for improving efficiency of health service delivery in Nepal

The success of Nepal's community-based health programmes in promoting maternal and child health has been achieved due to an overall improvement in service delivery facilities and health support systems. This article assesses the progress made by the Government of Nepal in improving health service delivery by introducing three key components: an improved health logistics management, facility-based maternal and neonatal health services, and decentralized health facility management.

Nepal health sector decentralization in limbo: what are the bottlenecks?

Nepal's efforts to decentralize its governance date back to over half a century. These efforts remained incomplete due to different reasons including administrative responses and political development affecting its implementation. The Local Self Governance Act (LSGA), 1999 envisaged, for the first time, to decentralize governance in the health sector through devolution of responsibilities, authority and resources to the local bodies. However, the pace of health sector decentralization in Nepal even after the LSGA was enacted has not progressed satisfactorily due to different reasons. The purpose of this paper is to discuss why health sector decentralization in Nepal has not advanced as expected. This paper identifies many issues--policy related, political, functional, and institutional--as stumbling blocks for health sector decentralization of Nepal. More specifically, the major bottlenecks for progress are lack of a clear cut policy, poor coordination among different sectors, improper handover process, lack of elected bodies, poor selection process of management committees, lack of coherence in the capacity building process of local bodies, ongoing debate about state restructuring including federalism and different political ideologies on decentralization.

Capacity building is not an event but a process: lesson from health sector decentralization of Nepal

Health Facility Operation and Management Committee are supposed to govern all the affairs of local health facilities under decentralization policy. The capacity building of the committee was deemed necessary and thus different stakeholders involved in the capacity building process. All agreed up on the need of capacity building of the committee but there were different school of thoughts on the contents and process of capacity building. Major capacity building inputs included orientations and training to the committee. However the follow up part was not uniform; some organizations conducted periodic reflection meeting, where as many ended up with the training. There were some tangible changes observed by the capacity building inputs. Their priority however was on infrastructure and drug purchase. The changes observed were very short lived and not sustainable. The capacity building was equated with training and an event with low priority on follow up, monitoring and coaching. It was not thought as a process. A concept of complete package of capacity building should have been developed where training component would be only an element of overall capacity building.

Live birth following treatment of post molar choriocarcinoma

A G3P(1+1) who underwent dilatation and curettage (D and C) for persistent vaginal bleeding after a month of molar evacuation, underwent successful treatment of choriocarcinoma with methotrexate and was able to have normal baby weighing 2800 gms with good Apgar score and normal placenta. This shows that a normal menstruation and uncomplicated term delivery can be expected after complete chemotherapy for gestational trophoblastic neoplasia (GTN).

Simultaneous occurrence of hematometrocolpos and consecutive pregnancies in uterine didelphys : a case report

Hematometrocolpos drained abdominally at laparotomy done, with suspicion of an ovarian torsion in an adolescent with ipsilateral renal agenesis, was eventually rediscovered to have in coexistent uterine didelphys in a 25 year P3+0 at the time repeat caesrean for breech in the event of third parturition, complicated by partum hemorrhage as in all her previous delivery (first vaginal delivery and retained placenta, second caesarean for obstructed labor by non pregnant half of didelphic uterus). This illustrates how simultaneous occurrence of hematometrocolpos can go unnoticed although there was every reason for this condition not to go unrecognized for the simple fact ofhemivaginal obstruction and hematometra with ipsilateral renal agenesis (on the left side) unaffecting the consecutive pregnancy in the other uterus.

Practices on immediate care of newborn in the communities of Kailali district

Immediate proper care of newborn is vitally important for survival, growth and development of a baby. Despite several studies conducted in Nepal about maternal and child health care practices, little is known about factors that determine behaviors related to immediate care of newborn. Identification of behavioral determinants for immediate care of newborn in Kailali district was objective of the study. This formative research was conducted in 6 purposely selected Village Development Committees (VDCs) of Kailali. Altogether 17 Focused Group Discussions (FGDs) were conducted with 106 parents. To triangulate the findings, 58 in-depth interviews were conducted with various individuals. Most people are unaware of importance of immediate care of newborn and many unsafe behavior do exist such as common use of untrained attendants, unsafe cord care, immediate bathing of baby. Most of the existing practices are based on deep-seated traditional beliefs. Some used Clean Home Delivery Kit (CHDK) and a few had used knife to cut the cord. All had tied stump with thread and applied mustard oil to prevent infection. The use of CHDK was high in the Tharu group with surprisingly low among Brahmin/Chetri. Yet! This research showed willingness on the part of the community to learn and change harmful practices. Almost all had similar opinion that survival of a baby is with in their control. As child is the center of love of all and targeting a child many behaviors and practices could be changed. The next step would be to prioritize the behaviors that need to be targeted for change and spread key messages for behavior change.

A simple new technique of performing myomectomy for a predominantly subserosal myoma quickly within few minutes

Removing a degenerated myoma located around the uterine cornu by an innovative technique shelling the myoma a little away from the base by choice of a low placed incision, advantageous in terms of no requirement of blood transfusion because of the reduction in the surgical time is described in a 24 years old lady demanding a fertility conserving surgery.

PLACENTA PREVIA ACCRETA

Placenta accreta is defined as any placental implantation in which the placenta isabnormally and firmly adherent to the underlying uterine wall in part or in total. Theprobable cause is defective decidual formation as shown by its occurence in area wherethe endometrium is deficient or damaged.The commonest condition associated with it are placenta previa and previous caesareansection. A case of placenta previa accreta is described herewith in a 2nd gravida whoeventually needed emergency caesarean hysterectomy (total) due to profuse bleeding.Key Words: Placenta accreta, placenta, caesarean hysterectomy.

Analysis of Septic Abortion During Six Year Period(April 1992-1998) in Teaching hospital, Nepal

Abstract

CERVICAL CERCLAGE

ABSTRACT

Closed Mitral Valvotomy During Pregnancy

Abstract

Toxoplasma antibody prevalence in Nepalese pregnant women and women with bad obstetric history

Sera from randomly selected 345 pregnant Nepalese women aged 16-36 years and 13 women with bad obstetric history (BOH) were tested for the presence of Toxoplasma antibodies using microlatex agglutination (MLA) and ELISA methods. The overall prevalence was 55.4% (191/345). Prevalence was slightly higher (59.0%) in older age-group (27-36 years) compared with younger age-group (16-26 years) (52.2%). No significant difference in antibody prevalence in women belonging to two different ethnic-groups (Tibeto-Burmans 57.8%, Indo-Aryans 52.7%) was observed (p>0.05). MLA antibody titer ranged from 1:16 to 1:2,048. Over three-fourth of the women showed either high (1:510 or over) or low (1:16 or 1:32) antibody titer. Three percent (6/191) of MLA antibody positive subjects had Toxoplasma IgM antibodies by IgM-ELISA. All six IgM antibody positive pregnant women had MLA antibody titer of over 1:510. Of the total 13 women with BOH, 5 (38.5%) had Toxoplasma antibodies of which 2 (40.0%) were positive for Toxoplasma-IgM antibodies.

Some fetal and pregnancy parameters in Nepal

In Patan Hospital, Kathmandu, 4600 single live births were analysed concerning birth weight in relation to gestational age. At term, the median birth weight of females was 2900 g and of males 3010 g. Compared with Norwegian newborns, the birthweights of Nepali babies were lower for all corresponding gestational lengths. The differences increased with gestational age. Fundal height was lower in Nepali than in Norwegian pregnant women for all periods of pregnancy. An increase in the differences between Norwegian and Nepali women was also noted. Hematocrit values of Nepali women who did not take supplementary iron, correspond well to findings in Norwegian women without iron supplementation. Only a slight degree of hemoconcentration was noted towards term. For Norwegian women with iron supplementation the hematocrit values were much higher, with a tendency towards hemoconcentration near term. In Nepal the average woman probably has small iron stores, and without iron supplementation the hematocrit values will remain low throughout the pregnancy. The high altitude does not seem to cause hemoconcentration in pregnancy to a greater extent than at lower altitude. Hemoconcentration is therefore not a major causative factor of the lower birth weights.