Discovering and exploring the hidden diversity of human gut viruses using highly enriched virome samples

Viruses are an abundant and crucial component of the human microbiome, but accurately discovering them via metagenomics is still challenging. Currently, the available viral reference genomes poorly represent the diversity in microbiome samples, and expanding such a set of viral references is difficult. As a result, many viruses are still undetectable through metagenomics even when considering the power of de novo metagenomic assembly and binning, as viruses lack universal markers. Here, we describe a novel approach to catalog new viral members of the human gut microbiome and show how the resulting resource improves metagenomic analyses. We retrieved >3,000 viral-like particles (VLP) enriched metagenomic samples (viromes), evaluated the efficiency of the enrichment in each sample to leverage the viromes of highest purity, and applied multiple analysis steps involving assembly and comparison with hundreds of thousands of metagenome-assembled genomes to discover new viral genomes. We reported over 162,000 viral sequences passing quality control from thousands of gut metagenomes and viromes. The great majority of the retrieved viral sequences (~94.4%) were of unknown origin, most had a CRISPR spacer matching host bacteria, and four of them could be detected in >50% of a set of 18,756 gut metagenomes we surveyed. We included the obtained collection of sequences in a new MetaPhlAn 4.1 release, which can quantify reads within a metagenome matching the known and newly uncovered viral diversity. Additionally, we released the viral database for further virome and metagenomic studies of the human microbiome.

Comparison of the Mean Cross-sectional Area of the Median Nerve between Pregnant and Non-Pregnant Women Using Ultrasonography in a Tertiary Level Hospital, Nepal

Background The median nerve is subjected to compression in the carpal tunnel giving rise to a constellation of symptoms known as carpal tunnel syndrome. It is the most frequent form of peripheral entrapment neuropathies and is most prevalent in the middle age females. The most common cause of this syndrome is idiopathic. One of the known secondary causes is pregnancy. Objective To compare the mean cross sectional area of median nerve using ultrasound in pregnant and non-pregnant females at carpal tunnel inlet and its variations with different trimesters. Method The study was conducted during a period of one year (October 2014 to September 2015). A total of 204 participants were evaluated among which 102 were nonpregnant and 102 were pregnant. Among the 102 pregnant participants, 34 females each were in the first, second, and third trimesters. A convenience sampling technique was used for the selection of the participants. The mean cross-sectional area of the median nerve was calculated in both of these groups in both hands by using the direct method. The mean cross-sectional area of non-pregnant female was used as the reference value to which that of pregnant female were compared. Data obtained were compiled and analyzed using Statistical Package for Social Sciences Version 16. Result The overall mean cross-sectional area of the median nerve in non-pregnant females was 6.76 ± 1.05 mm2 and in pregnant females was 6.84 ± 1.09 mm. No statistically significant difference was noted in the mean cross-sectional area of the median nerve in either hand in both pregnant and non-pregnant females. No statistically significant difference was noted in the overall mean cross-sectional area between the non-pregnant and pregnant females. There was no significant difference in the mean cross-sectional area within the different trimesters in both hands on intergroup comparisons. Conclusion Ultrasound examination of the median nerve and measurement of its crosssectional area is a useful diagnostic tool in the evaluation of carpal tunnel syndrome. Ultrasound has the advantage of easy availability, low cost, quick scan time, able to scan a long segment of nerve and examine the structures in both static and dynamic states. Besides, it also helps in the identification of various anatomic variants and pathologies within or adjacent to carpal tunnel.

Arthroscopic Debridement for Mucoid Degeneration of Anterior Cruciate Ligament - A Single Institution Experience from Nepal

Background Mucoid degeneration of anterior cruciate ligament is characterized by infiltration of mucoid-like material scattered throughout the anterior cruciate ligament substance. It is an uncommon condition, but previously, underdiagnosed or often misdiagnosed as an anterior cruciate ligament tear. Objective To present our early experiences with mucoid degeneration of anterior cruciate ligament in last five years in terms of clinical presentation and the outcomes of arthroscopic management. Method This was a retrospective descriptive cross-sectional study on patient who received arthroscopic debridement for mucoid degeneration of anterior cruciate ligament in Dhulikhel Hospital over five years period (2017 May to 2022 April). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale that has been translated and validated to be used in local (Nepali) language and context was used for evaluation of outcome evaluation. Result Twenty-one patients of mean age 44.21 years, predominantly females (18), were managed in five years period. The mean Western Ontario and McMaster Universities Osteoarthritis Index score was 16.33±10.47 with a range of 0 to 36 (11.57 to 21.09 at 95% confidence interval). The mean Western Ontario and McMaster Universities Osteoarthritis Index score converted on a scale of 0 to 100 was 17. Thirteen patients had isolated Mucoid degeneration of anterior cruciate ligament whereas nine others had associated either meniscal tear or chondral lesions. Conclusion Mucoid degeneration of anterior cruciate ligament could be a cause of knee pain in middle-aged patients and arthroscopic debridement can improve the patient's symptoms and provide a good functional outcome.

Sellar Tuberculosis Mimicking Pituitary Adenoma

Tuberculosis of central nervous system accounts for only 1% of tuberculosis cases worldwide, of which pituitary is an extremely unusual site. We report a case of pituitary tuberculosis in a 29-year-old female presenting with complains of headache and diminished vision on right eye. It was misdiagnosed as pituitary adenoma on radiology. Biopsy showed epithelioid granulomas, langhans giant cells and caseous necrosis. Ziehl nelseen stain showed presence of acid fast bacilli confirming the tubercular etiology. Therefore, histology remains the mainstay for diagnosis of these lesions. Early diagnosis and prompt use of antitubercular drugs results in good outcome.

A statistical model for describing and simulating microbial community profiles

Many methods have been developed for statistical analysis of microbial community profiles, but due to the complex nature of typical microbiome measurements (e.g. sparsity, zero-inflation, non-independence, and compositionality) and of the associated underlying biology, it is difficult to compare or evaluate such methods within a single systematic framework. To address this challenge, we developed SparseDOSSA (Sparse Data Observations for the Simulation of Synthetic Abundances): a statistical model of microbial ecological population structure, which can be used to parameterize real-world microbial community profiles and to simulate new, realistic profiles of known structure for methods evaluation. Specifically, SparseDOSSA's model captures marginal microbial feature abundances as a zero-inflated log-normal distribution, with additional model components for absolute cell counts and the sequence read generation process, microbe-microbe, and microbe-environment interactions. Together, these allow fully known covariance structure between synthetic features (i.e. "taxa") or between features and "phenotypes" to be simulated for method benchmarking. Here, we demonstrate SparseDOSSA's performance for 1) accurately modeling human-associated microbial population profiles; 2) generating synthetic communities with controlled population and ecological structures; 3) spiking-in true positive synthetic associations to benchmark analysis methods; and 4) recapitulating an end-to-end mouse microbiome feeding experiment. Together, these represent the most common analysis types in assessment of real microbial community environmental and epidemiological statistics, thus demonstrating SparseDOSSA's utility as a general-purpose aid for modeling communities and evaluating quantitative methods. An open-source implementation is available at http://huttenhower.sph.harvard.edu/sparsedossa2.

Vaginal Atresia with Cervical Agenesis, a Rare Congenital Malformation

Congenital vaginal atresia and cervical agenesis is a rare congenital abnormality of the female genital tract. Here we report a case of 15-year old girl with primary amenorrhea with hematometra, presented with lower abdominal mass. She was symptomatic since 5 months and visited local hospital after 4 months of onset of her symptoms when it became severe, where diagnostic laparotomy was performed for suspected Adnexal mass. Intraoperatively adnexal mass was adhered with and extended up to the uterus with 16 weeks size of uterus. Abdomen was closed without any further intervention and was referred to higher center for needful. When she presented to Kathmandu Model Hospital, she was asymptomatic on her 5th post-operative day of laparotomy. We planned for surgical intervention after examination and investigation. Drainage with vaginoplasty with amnion graft with placement of mould was done.

Integrating taxonomic, functional, and strain-level profiling of diverse microbial communities with bioBakery 3

Culture-independent analyses of microbial communities have progressed dramatically in the last decade, particularly due to advances in methods for biological profiling via shotgun metagenomics. Opportunities for improvement continue to accelerate, with greater access to multi-omics, microbial reference genomes, and strain-level diversity. To leverage these, we present bioBakery 3, a set of integrated, improved methods for taxonomic, strain-level, functional, and phylogenetic profiling of metagenomes newly developed to build on the largest set of reference sequences now available. Compared to current alternatives, MetaPhlAn 3 increases the accuracy of taxonomic profiling, and HUMAnN 3 improves that of functional potential and activity. These methods detected novel disease-microbiome links in applications to CRC (1262 metagenomes) and IBD (1635 metagenomes and 817 metatranscriptomes). Strain-level profiling of an additional 4077 metagenomes with StrainPhlAn 3 and PanPhlAn 3 unraveled the phylogenetic and functional structure of the common gut microbe Ruminococcus bromii, previously described by only 15 isolate genomes. With open-source implementations and cloud-deployable reproducible workflows, the bioBakery 3 platform can help researchers deepen the resolution, scale, and accuracy of multi-omic profiling for microbial community studies.

COVID-19 Pandemic: An Experience of OBGYN Residents at Kathmandu Model Hospital

COVID-19, a novel corona virus has affected the life of each and every individual worldwide. Nepal being the neighborhood country of china, though, we had a late case detection. But, since the month of July this virus has spread in an alarming manner in Nepal. Nepal being one of the developing countries, we lack in equipments, manpower resources and also in treatment centers. Looking into the devastating scenario of Covid 19 in China, Italy, New York, Brazil and our neighboring countries like India, Pakistan and Bangladesh is scary. We wondered how we were going to handle this pandemic if similar circumstances happened in our country too. At the same time being OBGYN residents, we all know pregnancy is very crucial and our patients have faced much difficulties to receive the maternal health services. In this manuscript, we have shared our experience regarding preparedness for COVID-19, management of positive cases and its effect in OBGYN trainee.

Awareness Regarding Diabetes Mellitus among General Population of Banepa Municipality

Background Diabetes is a silent disease and many people with diabetes may become aware of it only after life-threatening complications. The presence of knowledge of diabetes could contribute in early diagnosis and minimize the occurrence of complications. Hence, healthcare and public policy makers are putting extensive efforts to aware them on diabetes. Objective To assess the level of diabetes knowledge and its risk among the general public of Banepa municipality. Method A Cross sectional study was conducted to assess the awareness about diabetes among the general public of Banepa municipality. During the period of November 2019 to January 2020, 273 respondents of Banepa municipality were included with informed consent. Data was collected using a pre-tested structured questionnaire through one-to-one interviews. Indian Diabetes risk score (IDRS) was used to identify the risk of diabetes among them that consists of four elements i.e. age, abdominal obesity, physical activity, and family history. Data entry and analysis was done using SPSS version 20. Result It was found that 61.9% had a higher level of knowledge of diabetes. IDRS score shows more than half percent (53.5%) of respondents were in high risk, 39.2% were in medium risk and 7.3% were in low risk. Conclusion This study implies that there was good knowledge about diabetes among people. However, the majority of them are at risk for developing diabetes in future which may be due to lack of practical implication of knowledge. It reflects the necessity to educate and reinforce the public regarding prevention of diabetes which further postpones its complications.

Misleading Diagnosis of Dysgerminoma in a Young Asymptomatic Patient

Dysgerminomas account for approximately one third of all malignant ovarian germ cell tumors (tumors arising from ovarian germinal elements) and are the most common ovarian malignancy detected during pregnancy. They are the only germ cell malignancy with a significant rate of bilateral ovarian involvement that is 15-20 percent. They have a variable gross appearance, but in general are solid, pink to tan to cream colored lobulated masses. They have the best prognosis of all malignant ovarian germ cell tumor variants. Two thirds are stage I at diagnosis, and prognosis is excellent even for those with advanced disease due to exquisite tumor chemosensitivity. The 5 year disease specific survival rate approximates 99 percent. This is a case report of a huge ovarian dysgerminoma in a young unmarried lady that was quite asymptomatic. She underwent laparotomy with right ovarian cystectomy.

An open-source handheld extruder loaded with pore-forming bioink for in situ wound dressing

The increasing demand in rapid wound dressing and healing has promoted the development of intraoperative strategies, such as intraoperative bioprinting, which allows deposition of bioinks directly at the injury sites to conform to their specific shapes and structures. Although successes have been achieved to varying degrees, either the instrumentation remains complex and high-cost or the bioink is insufficient for desired cellular activities. Here, we report the development of a cost-effective, open-source handheld bioprinter featuring an ergonomic design, which was entirely portable powered by a battery pack. We further integrated an aqueous two-phase emulsion bioink based on gelatin methacryloyl with the handheld system, enabling convenient shape-controlled in situ bioprinting. The unique pore-forming property of the emulsion bioink facilitated liquid and oxygen transport as well as cellular proliferation and spreading, with an additional ability of good elasticity to withstand repeated mechanical compressions. These advantages of our pore-forming bioink-loaded handheld bioprinter are believed to pave a new avenue for effective wound dressing potentially in a personalized manner down the future.

Pregnancy Complicated by Acute Pancreatitis with Ascariasis

Ascariasis lumbricoides infections are common in tropical and sub-tropical countries. As it is one of the common causes for common bile duct obstruction. But in pregnancy is a rare entity. It may present with complications like acute pancreatitis. Here we present a case of 24 year female gravida 2 para 1 at 34 weeks of pregnancy presented with chief complain of pain over epigastric region radiating to back and associated with two episodes of vomiting, non bilious, not mixed with blood. Ultrasonography showed long tubular hyperechoic structure in gallbladder lumen most likely ascariasis and then she was diagnosed as a case of acute pancreatitis with alive ascariasis.

Masson's Hemangioma of the Cheek: A Case Report

We report a rare case of intravascular papillary endothelial hyperplasia (IPEH) of the cheek. This neoplasm, known as Masson's tumor, is an unusual vascular lesion of proliferating endothelial cells. It is usually confined to the lumen of preexisting vessels or vascular malformations. The principal significance of IPEH is its resemblance to a variety of benign and malignant diseases and possible misdiagnosis as such. Achieving a correct diagnosis is essential to avoid subjecting a patient to either unnecessarily aggressive or inadequate therapy. For this reason, awareness of this lesion is very important.

Cheiro-Oral Syndrome

Cheiro-Oral Syndrome (COS) is a very rare neurological syndrome associated with varied etiology. We report a 53-year-old man presented with left sided perioral and ipsilateral hand/fingers burning sensation for a one-month duration. On examination, he had hypesthesia over left perioral and distal palmar aspect of all five fingers. MRI revealed subacute infarct in the posterior limb of right internal capsule adjacent to and minimally involving thalamus. He was diagnosed as CheiroOral Syndrome as a result of ischemic stroke and managed.

Intramedullary Nailing System in Unstable Both Bone Diaphyseal Fractures in Children

Background Forearm fractures in pediatric population is usually managed conservatively. Unstable fractures need operative intervention like closed or open intramedullary nailing or open reduction and internal fixation with plates and screws. However, there is no consensus regarding the method of treatment according to age group. Objective To standardize the use of elastic nailing system as effective form of treatment in terms of function, cost and lower complications as compared to widely used titanium nails in developed countries.Method Sixty eight pediatric patients with both bone forearm diaphyseal fractures were managed with closed reduction and intramedullary fixation with rush nail or k-wire and followed at least for 6 months for evaluation of radiological and functional outcome. Result Patients were divided into two age groups, Group A for age of 5 to 9 years (26 patients) and Group B for age of 10-15 years (42 patients). The mean time for union for Group A patient was 7.31 weeks which was significantly lower than that of Group B patients of 9.33 weeks (p-value < 0.05). All the patients in Group A had excellent outcome and 36 (85.7%) patients had excellent outcome and 6 (14.3%) had good outcome in Group B. 5 out of 68 cases (7.35 %) had minor complications (2 in Group A and 3 in Group B). The mean time for implant removal was 17.9 weeks in Group A and 22.9 in Group B. Conclusion Intramedullary fixation for unstable diaphyseal both bone fractures of forearm is safe and cost effective method of treatment with good to excellent functional outcome with union time being significantly lower in younger age group.

Presence of choledocholithiasis in patients undergoing cholecystectomy for mild biliary pancreatitis

Introduction: Standard recommendations for patients recovering from an episode of biliary pancreatitis include cholecystectomy with intra operative cholangiogram or ERCP during the same hospital admission as it is believed that the instigating factor is the passage of stones through the common bile duct. As ERCP is not widely available and expensive, cholecystectomy with IOC is routinely performed to rule out choledocholithiasis. However detection of common bile duct stones is challenging. Whether these patients undergoing cholecystectomy require direct common bile duct evaluation is controversial. Objective of the study was to see the presence of common bile duct stones in patients with resolving acute mild biliary pancreatitis. Methods: Patients admitted in the surgical ward in Patan Hospital and Bir Hospital with the diagnosis of mild acute biliary pancreatitis who underwent cholecystectomy with intra-operative cholangiography from August 2010 to July 2012 were studied. The outcome of cholangiogram was analyzed together with findings of common bile duct exploration. Results: A total of 52 patients with acute mild biliary pancreatitis were operated during this period. The common bile duct stone was found in 1.9%.  Out of four patients with abnormal cholangiogram, only one patient (25%) had stone on exploration, rest of the three cases (75%) had negative exploration.Conclusion: The presence of common bile duct stone in case of mild acute biliary pancreatitis undergoing cholecystectomy is very low (1.96%), and thus policy of selective IOC should be applied for cases with mild biliary pancreatitis.Journal of Society of Surgeons of Nepal Vol.17(1) 2014: 11-15

Trigger factor assisted soluble expression of recombinant spike protein of porcine epidemic diarrhea virus in Escherichia coli

BACKGROUND

Porcine epidemic diarrhea virus (PEDV) is a highly contagious enteric pathogen of swine. The spike glycoprotein (S) of PEDV is the major immunogenic determinant that plays a pivotal role in the induction of neutralizing antibodies against PEDV, which therefore is an ideal target for the development of subunit vaccine. In an attempt to develop a subunit vaccine for PEDV, we cloned two different fragments of S protein and expressed as glutathione S-transferase (GST)-tagged fusion proteins, namely rGST-COE and rGST-S1D, in E.coli. However, the expression of these recombinant protein antigens using a variety of expression vectors, strains, and induction conditions invariably resulted in inclusion bodies. To achieve the soluble expression of recombinant proteins, several chaperone co-expression systems were tested in this study.

RESULTS

We firstly tested various chaperone co-expression systems and found that co-expression of trigger factor (TF) with recombinant proteins at 15 °C was most useful in soluble production of rGST-COE and rGST-S1D compared to GroEL-ES and DnaK-DnaJ-GrpE/GroEL-ES systems. The soluble rGST-COE and rGST-S1D were purified using glutathione Sepharose 4B with a yield of 7.5 mg/l and 5 mg/l, respectively. Purified proteins were detected by western blot using mouse anti-GST mAb and pig anti-PEDV immune sera. In an indirect ELISA, purified proteins showed immune reactivity with pig anti-PEDV immune sera. Finally, immunization of mice with 10 μg of purified proteins elicited highly potent serum IgG and serum neutralizing antibody titers.

CONCLUSIONS

In this study, soluble production of recombinant spike protein of PEDV, rGST-COE and rGST-S1D, were achieved by using TF chaperone co-expression system. Our results suggest that soluble rGST-COE and rGST-S1D produced by co-expressing chaperones may have the potential to be used as subunit vaccine antigens.

Drug-conjugated polymers as gene carriers for synergistic therapeutic effect

The ability to safely and effectively transfer gene into cells is the fundamental goal of gene delivery. In spite of the best efforts of researchers around the world, gene therapy has limited success. This may be because of several limitations of delivering gene which is one of the greatest technical challenges in the modern medicine. To address these issues, many efforts have been made to bind drugs and genes together by polymers for co-delivery to achieve synergistic effect. Usually, binding interaction of drugs with polymers is either physical or chemical. In case of drug-polymer physical interaction, the efficiency of drugs generally decreases because of separation of drugs from polymers in vivo whenever it comes in contact with charged biofluid/s or cells. While chemical interaction of drug-polymer overcomes the aforementioned obstacle, several problems such as steric hindrance, solubility, and biodegradability hinder it to develop as gene carrier. Considering these benefits and pitfalls, the objective of this review is to discuss the possible extent of drug-conjugated polymers as safe and efficient gene delivery carriers for achieving synergistic effect to combat various genetic disorders.

Morphological Changes in Degenerative Disc Disease on Magnetic Resonance Imaging: Comparison Between Young and Elderly

BACKGROUND

Morphological changes implicated in low back are complicated by additional age related degenerative changes in spine, which increases with aging. This study aims to compare the morphological MRI findings in young and elderly patients with low back pain and also correlate them with the clinical symptoms.

METHODS

The study was a retrospective hospital record based comparative study carried out in a Teaching Hospital. MRI performed for patients with low back pain during May 2012 to October 2012 were reviewed. The MRI findings were compared between below 60 years and at and above 60 years and were also correlated with symptoms.

RESULTS

A total of 301 MRI met the inclusion criteria out of which 228(75.74%) were young adults and 73(24.25%) were elderly adults. Degenerative changes and disc bulge was more common in elderly. Disc herniations including disc prolapse was more common in young adults. Disc protrusion involving L4-L5 was most common in the elderly while L5-S1 was most common in young adults. Nerve root compression was noted more commonly in the young adults. Radiculopathy was associated with grade III nerve root compression and paramedian disc protrusion in young adults while no such association was noted in elderly. No association of radiculopathy with presence of degenerative changes, spinal stenosis was noted in both groups.

CONCLUSIONS

Degenerative changes are more common in elderly while disc herniations are more common in young adults. Morphologic changes do correlate with symptoms in young adults to some extent while they do not correlate in elderly.

Role of Eosinophils in Acute Appendicitis

INTRODUCTION

High negative appendectomy rate still prevails on conventional histologic examination. Increased mural eosinophilic infiltrate had been observed in acute appendicitis. Present study aimed to evaluate the role of mural eosinophils in clinically suspected acute appendicitis but histological normal appendix, as an indicator of acute inflammation, alone or in association with edema and to estimate the cut off value for high eosinophil count for the diagnosis of acute appendicitis.

METHODS

A prospective cross sectional study was conducted on appendectomy specimens which were categorized into three groups of classical acute appendicitis, negative appendectomy and control. HandE and Giemsa stained section were studied for the presence of mural eosinophilic infiltrate, mast cells and edema.

RESULTS

Of total 170 cases, group 1 comprised of 68 cases, group 2 consisted of 78 cases and group 3 consisted of 24 cases. Mean eosinophil and mast cell counts in the muscularis propria were significantly higher in CAA and NA categories when compared to control group. Positive association was found between high eosinophil count and edema in CAA and NA categories. Cut off value of ≥6/ mm2 for mural eosinophil count was not significantly different in between NA and control categories.

CONCLUSIONS

Increased mural eosinophils were significantly present in acute appendicitis and clinically suspected acute appendicitis but histological normal appendix when compared with control group. Sole presence of increased mural eosinophils might represent acute inflammation. However, cut off value for high eosinophil count could not be established to suggest acute appendicitis.

Survival for 38 years with Animal-type malignant melanoma

Animal-type melanoma is a low-grade malignant tumor with a good prognosis. Although it is common in old grey horses, the tumor is exceedingly rare in humans. Only 173 cases have been reported till 2011. We report a case in a 38-year-old woman who had the neoplasm in the left labium majus since birth. The tumor was composed of heavily melanized polygonal tumor cells with mildly atypical nuclei proliferating diffusely and in nests in the dermis and subcutis with invasion of hair follicles and nerve bundles. Mitotic figures were not seen. Regional lymph nodes were not enlarged. Present case describes a patient with animal-type melanoma who has had the lesion since birth and who is still living despite having the tumor for 38 years. It attests to the fact that this tumor has indolent biologic behaviour despite being malignant. Mistaking this case for other highly pigmented melanocytic tumors, benign or malignant, is a potential diagnostic pitfall.DOI: http://dx.doi.org/10.3126/jpn.v4i8.11599 Journal of Pathology of Nepal; Vol.4,No. 8 (2014) 685-687

Epistaxis and its Relation with Temperature and Humidity

Nepalese Journal of ENT Head and Neck Surgery Vol.2 No.2 Issue 2 (July-Dec 2011) 4-5 DOI: http://dx.doi.org/10.3126/njenthns.v2i2.6792

Klebsiella pneumoniae producing KPC carbapenemase in a district general hospital in the UK

We report two patients with multidrug-resistant KPC-carbapenemase-producing Klebsiella pneumoniae urinary tract infections. A bla(KPC-2) gene was detected in both of the isolates by polymerase chain reaction and sequencing. The isolates had identical pulsed-field gel electrophoresis patterns and belonged to sequence type ST11. The index patient probably acquired the KPC-producing strain while in hospital in Curaçao, with subsequent nosocomial transmission to the second patient occurring in our hospital. We describe the interventions that were taken to prevent its further spread within the acute Trust and the community.

Impact of a clonal outbreak of extended-spectrum β-lactamase-producing Klebsiella pneumoniae in the development and evolution of bloodstream infections by K. pneumoniae and Escherichia coli: an 11 year experience in Oxfordshire, UK

OBJECTIVES

The objectives of this study were: (i) to describe an outbreak of multidrug-resistant Klebsiella pneumoniae in our population; (ii) to identify the potential source of this outbreak by examining antibiotic resistance trends in urocultures; (iii) to evaluate the contribution of this outbreak to resistance patterns over time in the two commonest Gram-negative blood culture isolates, namely K. pneumoniae and Escherichia coli; and (iv) to assess risk factors for multidrug resistance and the impact of this resistance on mortality and length of stay.

METHODS

We searched Microbiology and Patient Administration Service databases retrospectively and describe resistance trends in E. coli and K. pneumoniae bloodstream infections (BSIs) in Oxfordshire, UK, over an 11 year period.

RESULTS

An outbreak of a multidrug-resistant, CTX-M-15 extended-spectrum β-lactamase (ESBL)-producing K. pneumoniae clone was identified and shown by multilocus sequence typing to belong to a novel sequence type designated ST490. This was associated with a sporadic change in resistance rates in K. pneumoniae BSIs with rates of multidrug resistance (defined as resistance to three or more antibiotic classes) reaching 40%. A case-control study showed prior antibiotic exposure as a risk factor for infection with this organism. During the same time period, rates of ESBL-producing Klebsiella spp. isolated from urocultures increased from 0.5% to almost 6%. By contrast, the rate of multidrug resistance in E. coli rose more steadily from 0% in 2000 to 10% in 2010.

CONCLUSIONS

Changes in resistance rates may be associated with outbreaks of resistant clones in K. pneumoniae. Changing resistance patterns may affect important health economic issues such as length of stay.

Surgery for recurrent lower lip carcinoma

A 38 year old gentleman presented with recurrent squamous cell carcinoma of lower lip. He had earlier undergone previous surgeries and radiotherapy. At the time that he presented in KMCTH his lower lip area was much scarred and the tongue was shrunk and unavailable for vermilion reconstruction. This case report is an account of the various treatment carried out to reconstruct the lip. It was done with co-operation of the ENT department.

Entry knowledge and situational feedback of MBBS students

INTRODUCTION

A need has been felt to acquire knowledge of students at Kathmandu Medical College (KMC) who have decided to take up a medical career and have enrolled at KMC after completing two years of basic sciences.

OBJECTIVE

The intent was to (i) find out the entering status with regard to general knowledge, (ii) get feedback from the students about the facilities provided by the management both at basic sciences complex at Duwakot and clinical sciences at Sinamangal and (iii) get feedback regarding the teaching learning activities provided by various departments in KMC. This attempt at getting their point of view was for trying to improve upon the facilities by taking up their suggestions and doing away with the weaknesses. Preference was given to hostel students as they would be able to comment on living conditions.

METHODOLOGY

A total of 150 students from three consecutive batches from basic and clinical sciences were included in the study. Survey questionnaires were distributed and all the forms were returned. The obtained data was analyzed using SPSS 11.5 version for Windows.

RESULTS

It was found that the entry knowledge on general issue was better in 6th batch of students (87.08+/-17.41) than 5th batch (82.19+/-17.43) and 7th batch (78.93+/-20.60), but not significant (p=0.164>0.05). The students in different batches differed in their rating of various facilities provided by KMCTH. The most liked departments in terms of teaching learning activities were departments of Anatomy and Pathology.

DISCUSSION

Entry knowledge of the students of three batches was found to differ but not significant, correlating with the amount of teaching and learning received at KMC. The facilities provided by KMC were perceived as more satisfactory by the students who enrolled at KMC in later years. The earlier students had to cope with more difficulties as KMC was trying to improve on various facilities it provided to its students.

CONCLUSION

Level of entry knowledge got better as the students attained more and more years of teaching and learning activities. It was also seen that the student's perception of the quality of facilities provided by KMC got better overtime.

Estrogen modifies stress response of catecholamine biosynthetic enzyme genes and cardiovascular system in ovariectomized female rats

Estrogen is likely involved in the gender specific differences in coping with stress. Activation of catecholamine (CA) biosynthetic enzyme gene expression in central and peripheral CA systems plays a key role in response to stress and in regulation of the cardiovascular system. Here we examined whether estradiol can modulate response of hypothalamic-pituitary-adrenal axis (HPA), gene expression of enzymes related to CA biosynthesis in several noradrenergic locations, tetrahydrobiopterin (BH4) concentration and blood pressure (BP) in response to immobilization stress (IMO) of ovariectomized female rats. Rats were injected with 25 mug/kg estradiol benzoate (EB) or sesame oil once daily for 16 days and subsequently exposed to two hours of IMO. The IMO triggered elevation in plasma ACTH was lessened in EB-pretreated animals. However, estradiol did not alter the IMO-elicited rise of tyrosine hydroxylase mRNA levels in adrenal medulla (AM) and in the nucleus of solitary track (NTS) compared with controls. The response of GTP cyclohydrolase I (GTPCH) mRNA in AM to IMO was also similar in both groups. Several responses to IMO in EB-treated rats were reversed. Instead of IMO-elicited elevation in dopamine beta-hydroxylase mRNA levels in the locus coeruleus, GTPCH mRNA and BH4 levels in the NTS, they were reduced by IMO. In a parallel experiment, BP was monitored during restraint stress. The elevation of BP in response to single or repeated restraint stress was sustained during 2 h in controls and reduced after 70 min stress in EB treated rats. One month after withdrawal of EB treatment, the BP response to restraint was similar to that of rats which never received EB. The results demonstrate that estrogen can modulate responses to stress affecting HPA axis, CA biosynthesis, in central and peripheral noradrenergic systems, and BP.

MBBS student selection: search for proper criteria

It is accepted that selecting students for the MBBS course is fairly difficult and not totally effective. This article documents the process undertaken at Kathmandu Medical College (KMC) with reference to previous attempts and suggestions for the future.

Review of admission of MBBS students at KMC

This is an account regarding the intake of the 7th batch of MBBS students at Kathmandu Medical College (KMC) for the academic session 2003-2004. A total of 257 admission forms had been issued to Nepali students. Of these, 252 admission forms were filled up and were submitted to KMC together with the completed questionnaire by the Nepali students. Seven students (approximately 2.7%) did not attend interview. After the interview, out of the 245 interviewed students, the names of only 50 were brought out in the 1st list for admission. The paper presents the system for admission of MBBS students and has made recommendations for future action.

Interpleural catheter technique for perioperative pain management

Management of pain in surgical patient is very crucial. It is more so in thoracic and upper abdominal surgery. Lots of technique and drugs have been used to control postoperative pain including thoracic epidural analgesia. We describe a case in whom Intraoperative and Postoperative pain was managed by injecting 0.5% bupivacaine 20 ml in the interpleural space through the catheter, followed by continuous infusion of 0.1% bupivacaine 10 ml/ hour for 24 hours. The whole perioperative and postoperative period was uneventful. The first series of patients in whom this technique was used was described by Murphy in 1983, (1) who used it in patients with multiple fractured ribs and in postoperative patients after gallbladder and kidney surgery. One year later, Reiestad and Kvalheim published their results of continuous intercostal nerve block for postoperative pain relief and presented their modification of the technique, which is now termed interpleural analgesia.