Use of Magnetic Resonance Imaging in the Evaluation ofAcute Cholecystitis in Emergency Setting

Background Acute cholecystitis is one of the commonest surgical disease. The rapid diagnosis at its early stage is one of the crucial factor in patient care and management. Objective To evaluate the role of magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) in the diagnosis or exclusion of acute cholecystitis, coexisting choledocholithiasis, and acute pancreatitis in emergency setting. Method This study was conducted in the department of radiodiagnosis B and C teaching hospital, Birtamod, Nepal from July 2016 to November 2019. Patients, clinically diagnosed as acute cholecystitis or biliary condition with positive Murphy's sign with or without jaundice and deranged Liver Function Test, raised Leucocyte counts were evaluated by Magnetic Resonance imaging. The sensitivity, specificity, Positive Productive Value (PPV), Negative Productive Value (NPV) were calculated for the diagnosis of acute cholecystitis. Data was entered and analysed by using SPSS version 20. Result There were 40 patients included in our study. Among them 27 (67.5%) were females and 13 (32.5%) male. The age of the patients ranged from 16 years to 79 years, mean age 49.4 years. Majority of the patients were in the age group of 40-60 years (57.5%). The overall sensitivity, specificity, Positive Productive Value and Negative Productive Value of Magnetic Resonance imaging diagnosis of acute cholecystitis were 100%, 66.6%, 94.4% and 100% respectively. Acute cholecystitis associated with gall stone disease were common and found in 72.5% cases, with sensitivity 96.5%, specificity 27.7%, Positive Productive Value 77.7% and Negative Productive Value 75.0%. Conclusion Magnetic resonance imaging (MRI)/Magnetic resonance cholangiopancreatography (MRCP) is an excellent tool for the evaluation of biliary pathology and can be used for the preoperative evaluation of acute cholecystitis at the emergency setting.

Pathways to mental health care in Nepal: a 14-center nationwide study

BACKGROUND

Pathways to care studies are feasible and tested means of finding the actual routes taken by patients before reaching proper care. In view of the predominance of nonprofessional service providers and the lack of previous large studies on pathways in Nepal, this multicenter study is needed. The aim of the study was to trace the various pathways and carers involved in mental health care; assess clinical variables such as the duration of untreated illness, clinical presentation and treatment; and compare geographically and culturally diverse landscapes.

METHODS

This was a cross-sectional, convenience sampling study performed at 14 centers where new cases were being taken. The World Health Organization Study of the Pathways-to-Care Schedule was applied. The Nepali version of the encounter form was used. The data were collected between 17 September and 16 October 2020 and were analyzed using the Statistical Package for the Social Sciences (SPSS). Additionally, perspectives from local investigators were collected and discussed.

RESULTS

Most of the first carers were native/religious faith healers (28.2%), followed by psychiatrists (26%). The median duration for the first psychiatric consultation was 3 weeks. The duration of untreated illness was 30.72 ± 80.34 (median: 4) weeks, and the time taken for this journey was 94.99 ± 274.58 (median: 30) min. The longest delay from the onset of illness to psychiatric care was for epilepsy {90.0 ± 199.0 (median: 25.5)} weeks, followed by neurotic illness {22.89 ± 73.45 (median: 2)} and psychotic illness {10.54 ± 18.28 (median: 2)} weeks. Overall, most patients with severe mental illnesses (SMIs) had their first contact with faithhealers (49%), then met with medical doctors (13%) or psychiatrists (28%). Marked differences in clinical presentation surfaced when hilly centers were compared with the Terai belt.

CONCLUSIONS

Faith healers, general practitioners and hospital doctors are major carers, and the means of educating them for proper referral can be considered. The investigators see several hindrances and opportunities in the studied pathways. The employment of more mental health professionals and better mental health advocacy, public awareness programs and school education are suggested strategies to improve proper mental health care.

Pathways to care and supernatural beliefs among patients with psychotic disorders in Nepal

Background

Longer pathways to care worsen the course of psychotic illness as well. The study aimed to assess the pathways to care, supernatural beliefs, and impact on the duration of untreated psychosis in patients with schizophrenia. It was a cross-sectional, observational study that involved 133 patients and their caregivers. Supernatural Attitude Questionnaire and World Health Organization Encounter form for Pathways to care were used to evaluate the pathways to care, supernatural beliefs in caregivers, and duration of untreated psychosis. SPSS descriptive and non-parametric tests were used for analysis.

Results

Overall, 59.4% of the participants had a non-medical person as the first treatment contact. Duration of untreated psychosis (DUP) for the whole study sample was 6.04 (SD 15.14) months and when it was compared among the first contact with a medical person (mean 4.43; SD 14.39) and non-medical person (mean 7.15; SD 15.63), the later had significantly longer (Mann-Whitney U = 1278; p < 0.001) DUP. More than half of the patients had one or more supernatural beliefs. Having supernatural beliefs and carryout rituals related to these beliefs is associated with a higher number of visits to different professionals before reaching a psychiatrist.

Conclusions

Patients with psychosis and their caregivers seek first help from non-medical persons, especially faith healers. This is associated with a longer duration of untreated psychosis and supernatural beliefs in caregivers. Thus, there is a need to improve mental health literacy and have public awareness programs to address the belief systems and clarify the prevailing myths in society.

Prevalence of Hepatitis B and C among HIV Infected Patients in Nepal over 1990-2020

Background Hepatitis B and C (HBV and HCV) are viral infections caused by corresponding viruses. Here in this study we planned to conduct this meta-analysis to pool data on the prevalence and risk factors of HBV and/or HCV among HIV patients in Nepal. Method We used MOOSE guideline for the systemic review of available literature. We searched online databases using appropriate keywords. We used CMA-3 for data synthesis. Odds ratio, and proportion were used to estimate the outcome with a 95% confidence interval where appropriate. We assessed the heterogeneity using the I-squared (I2 ) test. Result We included nine studies for our synthesis. Pooling of data showed HBV in 4.6% (CI: 3.7-5.6), HCV in 19.7% (CI: 10.8-33.0), both HBV and HCV in 1.3% (CI: 0.5-3.7) in HIV affected individuals. Among HBV co-infected HIV positive patients, 59.5% (CI: 25.5-86.3) were male; 76.1% (CI: 30.1-96.0) were married and 43.6% (CI: 3.8-93.8) had a history of intravenous drug use (IVDU). Among HCV co-infected HIV positive individuals 88.3% (CI: 73.6-95.4) were male; 63.6% (CI: 55.4-71.1) were married; 91.5% (CI: 68.6-98.1) were literate; 59.2% (CI: 49.9-67.9) were on ART; and 92.2% (95%CI: 84.9-96.1) had a history of IVDU. Conclusion The pooled prevalence of co-infection with HBV, HCV, and combined HBV and HCV were 4.6%, 19.7% and 1.3% respectively among HIV positive patients. Thus, it is necessary to appropriately screen for HBV and HCV in individuals diagnosed with HIV and high-risk populations. IVDU remains the most common risk factor found in co-infected individuals.

Mindfulness based interventions for depression and anxiety in Asian Population: A systematic review

Introduction: Mindfulness based interventions (MBIs) have emerged as effective interventions for various psychiatric conditions including depression and anxiety. Asia being home to Buddhist tradition, it will be interesting to explore the trend and efficacy of MBIs in Asian population in Asian settings. The aim of this study is to perform a systematic review of mindfulness based interventions (MBIs) for management of depression and anxiety (disorders or symptoms) in Asian population. Material And Method: Two researchers independently searched for literature published between January 2007 to December 2018 in Medline, Google Scholar, PsychInfo and Cochrane library using the search terms - ‘Mindfulness/Vipassana’ combined with ‘meditation’, ‘intervention’ ‘therapy’, ‘depression', ‘anxiety’ ‘Asia’ etc. Further, publications were also identified from the references recited in the retrieved articles. After screening 185 articles and applying the eligibility criteria, 40 articles were finally selected for the systematic review. Results: Out of 40 selected articles, 33 articles were controlled trials and 7 had a pre-post test design without any control group. Most of the published studies have evaluated MBCT and MBSR for depressive and anxiety symptoms in different settings. Some of the studies have tested traditional Buddhist meditation and modified models. Overall, MBCT and MBSR seem to be efficacious over ‘routine treatment’ or ‘no treatment’ control for reducing depressive and anxiety symptoms at the end of the treatment. Studies which have modified MBIs based on MBCT/MBSR models have also demonstrated their feasibility and short term efficacy in specific populations like medical professionals with evidence for short term efficacy. Conclusion: Overall, there is emerging evidence of MBIs for depression and anxiety across diverse settings in Asia. Future research should address methodological limitations of current research to strengthen the evidence.

Suicide and self harm in Nepal: A scoping review

BACKGROUND

Suicide and self harm behavior has become a major public health issue in recent years in Nepal. This small south Asian country was ranked 7th by suicide rate globally by the 2014 World Health Organization report with an estimated 6,840 suicides annually, or 24.9 suicides per 100,000 people. We decided to explore the epidemiology of suicidal behaviour and self harm, modes of attempt, associated risk factors and trends in specific population.

METHODOLOGY

Two researchers independently reviewed 47 studies published in the US National Library of Medicine's PubMed electronic Database and Google Scholar till December 2016. Finally, twenty articles meeting the objective were included. This article summarizes findings on epidemiology of suicidal behavior, associated patterns, risk factors and trend in specific population in Nepal.

RESULTS

Most of the data available till date are hospital based and either cross-sectional or retrospective. Some of the studies have relied on mortality statistics whereas few have done community based screening. Some of the key findings include higher rate among women and younger age group, a rising trend among specific groups such as marginalized, migrant workers and disaster affected population. The studies also show role of mental illness, predominantly mood disorders and psycho-social factors such as interpersonal or marital conflicts and socio-economic issues in triggering suicide and self harm behavior.

CONCLUSION

Overall, the studies provide satisfactory information about the burden of suicide in Nepal. Some of the limitations include discrepancy in suicide reporting, lack of longitudinal follow up and qualitative studies and absence of studies on preventive aspects. Further, more research is warranted in this area not only at the assessment level but also at an intervention level. Several challenges such as poor distribution of mental health resources, social attitude towards mental illness and suicide in particular need to be addressed.

Prevalence of Conventional Risk Factors in ST Segment Elevation Myocardial Infarction Patients in Shahid Gangalal National Heart Centre, Nepal

INTRODUCTION

Smoking, diabetes mellitus, hypertension, and dyslipidemia are labelled as conventional risk factors for coronary artery disease. Prevalence of these risk factors varies across populations. This study aimed to assess the prevalence of these conventional risk factors in patients, who were discharged from our hospital, with the diagnosis of ST elevation myocardial infarction.

METHODS

Medical records of 495 ST elevation myocardial infarction patients discharged from our centre in between January 2012 to December 2012 were retrospectively reviewed to evaluate the prevalence of conventional risk factors.

RESULTS

Clear dominance (75%) of male patients was seen. Inferior wall myocardial infarction (29.9%) was the most common diagnosis followed by anterior wall myocardial infarction (25.1%). Hypertension (65%), smoking (57.8%) and dyslipidemia (45.5%) were the most common risk factors. Diabetes (31.1%) was the least common. Prevalence of hypertension, dyslipidemia was similar among male and female. Smoking was statistically common in male (76.8%vs 49.5%),though diabetes was common in female (36.5%vs.29.3%) not statistically significant.

CONCLUSIONS

Conventional risk factors are common among ST elevation myocardial infarction patients. Early detection and treatment of these risk factors play a vital role for the prevention of coronary artery disease. Much more focus should be stressed on preventive programs throughout the country.

Use of insecticide-treated bednets in an urban coastal area of Puducherry, India: a cross-sectional study

Use of Insecticide-Treated Bednets (ITNs) has been shown to reduce the incidence of mosquito-borne diseases. However, the impact of ITNs depends on its community acceptance. We studied the ITN usage and factors influencing it, following the distribution of one ITN to each family in an urban area of Puducherry. Around 93.6% of the 157 respondents surveyed were aware of mosquito-borne diseases. Coils and vaporizers were used in 91.1% of the families. Around two-fifths (41.3%) of the 116 families who received the ITNs used it regularly with another 5.1% using it irregularly. Majority of the users (85%) reported reduced mosquito bites and pleasant sleep after use. Small size of ITNs was the most common reason for non-use (46.3%). Families not using normal bed nets at the time of distribution of ITNs were unlikely to use ITNs at present (odds ratio = 5.22, P < 0.001). Therefore, ITN size should be increased and distribution in urban settings should accompany behavior change communication.

Peptidergic and nitrergic inhibitory neurotransmissions in the hamster jejunum: regulation of vasoactive intestinal peptide release by nitric oxide

Regulation of vasoactive intestinal peptide (VIP) release by nitric oxide (NO) was investigated in the hamster jejunum. Electrical field stimulation and applied NO (3-100 microM) evoked biphasic hyperpolarizations consisting of an initial transient hyperpolarizing component followed by a second more slowly developing component (late component). The NO synthase inhibitor N(G)-nitro-L-arginine methyl ester (200 microM) abolished the biphasic inhibitory junction potential evoked by electrical field stimulation. The NO scavenger oxyhemoglobin (50 microM) and the guanylate cyclase inhibitor 1H-[1,2,4]oxadiazolo-[4,3-a]quinoxalin-1-one (ODQ; 10 microM) abolished both components of the inhibitory junction potentials and the NO-induced hyperpolarizations. VIP(6-28) (1 microM), which abolished VIP (3 microM)-induced hyperpolarizations, also inhibited the late components of the inhibitory junction potentials and the NO-induced hyperpolarizations. ODQ inhibited VIP release and cAMP production by electrical field stimulation and NO application. N(6)-2,0-Dibutyryladenosine 3',5'-cyclic monophosphate (0.1-3 mM) caused a membrane hyperpolarization. These results suggest that NO may stimulate VIP release from enteric nerves in the hamster jejunum. In addition, we propose that NO and NO-stimulated VIP contribute to the early and late components of the inhibitory junction potentials, respectively, in the circular smooth muscle cells of the hamster jejunum.

Enhancement of ATP release in hindlimb sympathetic perivascular nerve of the golden hamster during hibernation

The present study investigated the effects of hibernation and hibernating body temperature (10 degrees C) on the relative changes that may occur in adrenergic and purinergic perivascular neurotransmission of the golden hamster. The hindlimb resistance vessels and the tibial artery of age-matched controls, cold exposed controls and hibernated hamsters were examined by pharmacological and electrophysiological techniques. At 34 degrees C, electrical field stimulation (EFS; supramaximal voltage, 0.5 ms; for 10 s) in all three groups evoked only twitch responses at 1-5 Hz, which were inhibited by piridoxal phosphate-6-azophenyl-2',4'-disulphonic acid (PPADS), a 2PX receptor antagonist. At 10-50 Hz the twitch responses were followed by sustained contractile responses, which were inhibited by prazosin, an alpha1-adrenoceptor antagonist. These responses were markedly enhanced at higher frequencies in hibernated tissues. At 10 degrees C, EFS evoked only the PPADS-sensitive transient responses in all the three groups, and this was markedly enhanced in hibernated tissues. At 34 degrees C, a single stimulus evoked a PPADS-sensitive excitatory junction potential (EJP) in all three groups but a train of pulses (e.g. approximately 0.5) evoked EJPs and prazosin-sensitive sustained depolarizations. These responses were markedly enhanced in hibernated cells. At 10 degrees C, either a single stimulus or a train of stimuli evoked only transient PPADS-sensitive EJPs, which were markedly enhanced in hibernated cells. The contractile responses and electrical membrane responses to exogenous ATP (1-1000 microM) and noradrenaline (0.1-100 microM) were unchanged in the three groups at 34 and at 10 degrees C. These results suggest that during hibernation enhancement of ATP release from the sympathetic perivascular nerves may occur, leading to an efficient means for maintenance of vascular tone and peripheral resistance.

Bradykinin causes endothelium-independent hyperpolarisation and neuromodulation by prostanoid synthesis in hamster mesenteric artery

The mechanism of bradykinin-induced hyperpolarisation and purinergic neuromodulation was examined in the hamster superior mesenteric artery using intracellular microelectrode techniques. Bradykinin induced a concentration-dependent hyperpolarisation both in endothelium-intact and -denuded preparations. Indomethacin blocked this hyperpolarisation. Prostacyclin and iloprost also hyperpolarised the membrane of mesenteric artery, while prostaglandin E(2) did not evoke any membrane hyperpolarisation. The bradykinin-, prostacyclin- and iloprost-induced hyperpolarisation were inhibited by glibenclamide. Bradykinin also inhibited the amplitude of the purinergic excitatory junction potentials (e.j.p.s), both in endothelium-intact and -denuded preparations. Indomethacin blocked this inhibitory effect. Prostaglandin E(2) inhibited the e.j. p. in a concentration-dependent manner. Focally applied ATP-induced depolarisation was not modified by bradykinin or prostaglandin E(2.) These findings suggest that bradykinin via prostanoids production pre-synaptically, inhibit the amplitude of purinergic e.j.p., resulting inhibitory purinergic neuromodulation. In addition, bradykinin-released prostanoids elicits membrane hyperpolarisation of smooth muscle cells through opening of K(ATP) channels.

ATP released from perivascular nerves hyperpolarizes smooth muscle cells by releasing an endothelium-derived factor in hamster mesenteric arteries

1. The interaction between perivascular nerves and endothelium was investigated by measuring the changes in smooth muscle membrane potentials using intracellular microelectrode techniques in hamster mesenteric thin (100-150 microm) and thick (300-350 microm) arteries. 2. In both arteries, nerve stimulation evoked excitatory junction potentials (EJPs) which were strongly inhibited by pyridoxalphosphate-6-azophenyl-2',4'-disulphonic acid (PPADS) (0.5-5 microM). This result indicated that the EJPs were induced by the activation of P2X receptors. 3. Transient hyperpolarizations were evoked by trains of pulses at 20 Hz in PPADS (5 microM)-pre-treated thin arteries, but not in the thick arteries. ATP (100 microM) applied to adventitial surfaces mimicked the hyperpolarizations. Both the ATP- and nerve stimulation-induced hyperpolarizations were blocked by cibacron blue F3GA (2-100 microM) and were also abolished after endothelium removal, indicating that the neurally released ATP evoked transient hyperpolarization through the activation of P2Y receptors located on the endothelium. 4. In endothelium-intact preparations, intimal application of uridine 5'-triphosphate (UTP 100 microM), a P2Y2-like receptor agonist, but not 2-methylthio ATP (7 microM), hyperpolarized the smooth muscle. The UTP-induced hyperpolarization was significantly inhibited by cibacron blue F3GA and was abolished after endothelium removal. 5. These results suggest that ATP released from the perivascular nerves may reach the endothelium and activate P2Y2-like receptors to induce the release of an endothelium-derived hyperpolarizing factor in thin arteries.

Cyclic GMP-associated apamin-sensitive nitrergic slow inhibitory junction potential in the hamster ileum

1. The mediators of non-adrenergic, non-cholinergic (NANC) inhibitory junction potentials (i.j.ps) in the circular smooth muscle cells of the hamster ileum were studied. 2. Electrical field stimulation (EFS; 0.5 ms duration, 15 V) of the intramural nerves with a train of five pulses at 20 Hz evoked a rapidly developing hyperpolarization (fast i.j.p.) followed by a sustained hyperpolarization (slow i.j.p.). 3. NG-nitro-L-arginine methyl ester (L-NAME; 50 - 200 microM) and NG-nitro-L-arginine (L-NNA; 50 - 200 microM), NO synthase inhibitors, inhibited or abolished the EFS-induced fast and slow NANC i.j.ps. The effects of these NO synthase inhibitors were reversed by L-arginine (5 mM) but not by D-arginine (5 mM). 4. Exogenously applied nitric oxide (NO; 1 - 100 microM) induced concentration-dependent hyperpolarizations. 5. Oxyhaemoglobin (5 - 50 microM), NO scavenger, inhibited only the slow i.j.p., and the NO-induced hyperpolarization. 6. 1H-[1,2,4]oxadiazolo[4, 3-a]quinoxaline-1-one (ODQ; 10 microM) and cystamine (10 mM), guanylate cyclase inhibitors, inhibited only the slow i.j.p. Zaprinast (100 microM), a phosphodiesterase type V inhibitor, enhanced the amplitude and duration of the slow i.j.p. 7. Apamin (100 nM), a small conductance Ca2+-activated K+ channel blocker, inhibited only the slow i.j.p., and NO-induced hyperpolarization. A high concentration of 8-bromoguanosine 3':5'-cyclic monophosphate (8-bromo-cGMP; 1 mM)-induced membrane hyperpolarization which was blocked by apamin. 8. These results suggest that NO, or a related compound, may be the inhibitory transmitter underlying the apamin-sensitive NANC slow i.j.p. and cyclic GMP mediates the slow i. j.p. in the hamster ileum. It is also likely that NO, without involvement of guanylate cyclase is associated with the fast i.j.p.