[18F]FDG PET/CT for identifying the causes of fever of unknown origin (FUO)

Fever of unknown origin (FUO) continues to be a challenging diagnosis in clinical medicine. It has more than 200 known causes, including infections, autoimmune diseases, neoplasia, and other miscellaneous disorders. Despite the development of a wide range of diagnostic tools, a specific diagnostic algorithm for FUO is not yet available. However, [18F]FDG PET/CT, which yields information on cellular metabolism, in addition to details of organ anatomy, has been shown to be successful in the FUO investigation. This study highlights the uses of [18F]FDG PET/CT in diagnosing various causes of FUO. [18F]FDG PET/CT has been increasingly used to detect septic infections, sterile inflammatory processes, and malignancies, occupying a significant portion of the known causes of FUO. It has led to a more definitive identification of the etiology of FUO and accurate clinical management. However, more in-depth studies are crucial to understanding if [18F]FDG PET/CT can be used in the work-up of FUO.

Cecal volvulus following appendectomy in a teenage patient: A case report

Patients mimicking appendicitis symptoms in a rural setting or those post-appendectomy, indicating cecal volvulus, should always be considered. Swift action can prevent catastrophic consequences.

Abstract

We present a case of a 14-year-old female who initially underwent open appendectomy for acute appendicitis and subsequently experienced symptoms of abdominal distention, vomiting, and fever. Her condition deteriorated following the appendectomy, despite a prior appendectomy for similar symptoms at a different facility. A computed tomography (CT) scan identified cecal volvulus as the underlying issue. This led to the performance of a laparotomy, cecopexy, and decompressive ileostomy. After six weeks, ileostomy closure was successfully carried out, and the patient currently enjoys good health. This case highlights the significance of considering uncommon factors as potential contributors to postoperative complications in young patients.

Effects of COVID-19 Virus Infection on Pregnancy Outcomes: a Systematic Review and Meta-analysis

BACKGROUND

Pregnant mothers are more susceptible to Corona Virus Diseases 2019 (COVID-19) during pandemic. Our aim was to find out the effects of the COVID-19 infection on pregnancy outcomes compared to mothers without COVID-19 diseases.

METHODS

The review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) and obtained number of the Centre for review and Dissemination (CRD42021272321). The observational studies from September 1st to October 31, 2021 were searched with Medical Subject Heading (MeSH) term in the databases. A Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline was followed. Certainty of the evidence were assessed using Grading of Recommendations Assessment Development and Evaluation (GRADEpro) approach.

RESULTS

Pregnant women with Polymerase Chain Reaction (PCR) positive group for COVID-19 were likely to have preeclampsia/eclampsia of Relative Risk (RR) and Confidence Interval (CI) (RR, 1.52; 95% CI, 1.14-2.02) respectively. Likewise, foetal distress (RR, 1.56; 95% CI, 1.31- 1.85, caesarean section (RR, 1.25; 95% CI, 1.10-1.42), postpartum haemorrhage (RR, 1.37; 95%CI, 1.00-1.88), moderate certainty of the evidence in ICU/high-dependency unit admission (RR, 4.92; 95% CI, 3.28- 7.38), preterm births (RR, 2.12; 95% CI, 1.10-4.08) and perinatal death (RR, 2.55; 95% CI, 1.64-3.95). Very wide CI on maternal death rate (RR 9.87; 95% CI, 3.10- 31.45) was observed compared to COVID-19 negative group.

CONCLUSIONS

Pregnant mothers with COVID-19 positive diseases have a moderate certainty of the effect of admission to ICU/high-dependency unit, Preterm birth and perinatal death.

Prevalence and Associated Factors of Adolescent Obesity among Rural School Adolescents in Nepal: A Cross-Sectional Study

Background

Overweight and obesity are major risk factors for chronic diseases and are the leading cause of mortality worldwide. Obesity during adolescence is strongly associated with adulthood obesity leading to increased morbidities and mortality. As a developing country undergoing rapid urbanization, Nepal is in a transitional phase where undernutrition coexists with obesity; however, there is a dearth of literature on the status of adolescent obesity in the rural section of Nepal. The aim of this study was to determine the prevalence of adolescent obesity in a rural district of Nepal and find out its associated factors.

Methods

An institution-based cross-sectional study was conducted among the adolescent students studying in classes 8, 9, and 10 in four secondary schools of Gosaikunda rural municipality of Rasuwa district, Nepal. Total enumerative sampling was used, and Global School-based Health Survey (GSHS) standard questionnaires were used in collecting the information. Height and weight measurements were taken, and the body mass index was classified according to Asia-Pacific criteria. The collected data were analyzed using "SPSS" version 22. Logistic regression analysis was used to evaluate the associated factors, and a p value of ≤0.05 was considered statistically significant.

Results

Out of 267 adolescents, 14.6% were obese and 14.6% were overweight. Of the female participants, 39.6% were either obese or overweight, while 12.6% of the male adolescents were overweight/obese. Among the total participants, 16.5% were underweight, including 14.0% females and 20.4% males. Female adolescents were about five times (AOR: 5.2, 95% CI (2.5-10.9), p < 0.01) more likely of being overweight/obese than male adolescents.

Conclusions

More than one-quarter of the adolescents were found to be obese/overweight, and the prevalence was significantly more among female adolescents. It emphasizes the necessity of school-based programs promoting a healthy lifestyle among students to maintain healthy weight status.

Menstruation hygiene management among secondary school students of Chitwan, Nepal:a cross-sectional study

BACKGROUND

Despite significant progress in reproductive health, many societies still treat menstruation as disgraceful and shameful process and relate it with negative consequences. This belief and attitude may increase the incidence of reproductive tract infection, leading to significant negative impact on women's health. To manage menstruation hygienically and with dignity, it is essential that women and adolescent girls have sufficient knowledge on menstruation hygiene management. Thus, this study aims to identify the knowledge, associated factors related to menstrual hygiene management (MHM) and effectiveness of health education on MHM.

METHODS

A school-based study was conducted between August 2021 to April 2022 among 400 secondary school girls. The sampling unit was selected by using systematic random sampling method. Health education was given in the interval between the pretest and posttest of knowledge assessment on MHM. Logistic regression analysis and Wilcoxon rank test were applied to identify predictors and to evaluate the effectiveness of health education.

RESULTS

Overall, 57.7% of the girls had unsatisfactory level of knowledge. Around two third (61.4%) missed school days during the menstrual period. Almost 99.5% had experienced some form of cultural restrictions during the menstrual period. After imparting health education, the level of knowledge on menstruation hygiene had significantly improved (z = 17.129, p = < 0.001) to satisfactory compared to the baseline knowledge level (42.3% vs. 92.5%). During multivariate analysis, factors such as having studied in public schools (AoR = 1.7, p = 0.026), having no or one close female friend (AoR = 2.2, p = 0.011), caste other than Brahmin/Chhetri (AoR = 1.4, p = 0.05) and factors such as living in joint family (AoR = 1.6, p = 0.048) were significantly associated with unsatisfactory level of knowledge on MHM.

CONCLUSIONS

A substantial number of respondents had unsatisfactory level of knowledge on MHM. Factors such as ethnicity status, types of family, number of close female friends, types of schools and mothers' education were associated with unsatisfactory level of knowledge. School absenteeism and cultural restriction were found to be common/frequent. Imparting of health education was found to be an effective measure to enhance knowledge on MHM.

COVID 19 Vaccine Breakthrough Infection among Health Care Workers

Background Mass vaccination is considered the primary strategy for reducing the impact of COVID-19, and it has been implemented globally. Objective To study the extent of SARS-CoV-2 infection and breakthrough infection among the HCWs who were fully vaccinated for at least 14 days and investigated the relation between neutralizing antibody response and breakthrough infection. Method This study was a retrospective cohort study among health care workers at Dhulikhel Hospital Kathmandu University Hospital from December 2021 to October 2022. The interviews with semi structured questionnaire were conducted in person or over phone. Out of 1450 participants 137 fully vaccinated HCWs without breakthrough infection were randomly selected for the prospective serological cohort. Result Out of 1079 participants' majority (51.8%) were of age 25-34 years. Two thirds (66.7%) were females. More than half of participant (54.7%) had infection with SARS-CoV-2 at least once whereas more than one third people (35%) had reported SARS-CoV-2 infection 14 days after receiving full vaccination. Infection after vaccination had less moderate and sever/critical illness and less need for hospitalization as compared to infection before vaccination. Staffs who were directly involved in patient care had higher chance of breakthrough infection compared to those not involved directly in patient care. Those who had prior infection or booster dose had relatively higher antibody level and participants with low level of antibody had higher chance for breakthrough infection (35.3%) than participants with moderate to high level of antibody (11.9%). Conclusion Vaccinations significantly decreased severe diseases and the need for hospitalizations. Breakthrough infection was higher among the health care workers involved in direct patient care and with low level of antibody.

Cross-cultural Adaptation and Psychometric Properties of Nepali Version of Developmental Coordination Disorder Questionnaire

Background Revised developmental coordination disorder questionnaire (DCDQ'07) is the best available population-based screening tool to identify developmental coordination disorder and being a parent reported tool, it needs to be available in Nepali language for its application in Nepali population. Objective The objective of this study was to cross-culturally adapt developmental coordination disorder questionnaire into Nepali (DCDQ-NP). The psychometric properties of Nepali version of Developmental coordination disorder questionnaire were established. Method The adaptation was done following Beaton's guideline and the psychometric properties was studied in the community sample of 165 parents of school going children of 5-15 years. Fifty parents were asked to refill the questionnaire after the two weeks period. The study determines internal consistency, test retest reliability, floor and ceiling effect and construct validity. Result Significant cultural adaptation was required to obtain relevant Nepali version. The Nepali version of Developmental coordination disorder questionnaire demonstrates high internal consistency (α = 0.912), excellent test-retest reliability (IC = 0.901) and the floor and ceiling effect were acceptable. Principal component analysis showed three factor structure accounting 62% of variance. Conclusion The developmental coordination disorder questionnaire into Nepali were successfully translated and culturally adapted preserving its original concept. It showed good psychometric properties in a Nepali population. The adapted questionnaire shall be of significance in carry out further research in developmental coordination disorder in Nepal.

Post-tonsillectomy Hemorrhage in Patients Receiving Ketorolac Analgesic

Background Ketorolac, the non-steroidal anti-inflammatory drug, is thought to have less sedation as well as postoperative nausea and vomiting in comparison to opioids, but with higher risk of post-tonsillectomy hemorrhage as reported in some of the literatures. There is no consensus till date in the use of ketorolac in the management of pain following tonsil and adenoid related surgeries. Objective To find out the incidence of hemorrhage following tonsil and adenoid related surgeries in patients receiving ketorolac in postoperative period. Method This is a retrospective chart review of patients undergoing tonsil and adenoid related surgeries who had received ketorolac during April, 2013 to May, 2019 at department of ENT-HNS, Patan Academy of Health Sciences (PAHS), Lalitpur, Nepal. Post-tonsillectomy hemorrhage rate was calculated in pediatric and adult patients. Result During the study period, 103 patients (male - 50 and female - 53) received ketorolac in postoperative period. Tonsillectomy and adenotonsillectomy were performed in 71and 32 patients respectively. Forty-five patients were < 18 years whereas 58 were ≥ 18 years. Most common indication for surgery was recurrent tonsillitis (66/103) followed by adenotonsillar hypertrophy (31/103). Post-tonsillectomy hemorrhage was observed in 15 patients; among them, four out 45 were < 18 years and 11 out of 58 ≥ 18 years. All five patients out of 15, who required surgical intervention for post-tonsillectomy hemorrhage, were ≥ 18 years and were operated for recurrent tonsillitis. Rest of the patients (10/15) were managed conservatively. None of the patients required blood transfusion. Conclusion Ketorolac is not associated with increased risk of post-tonsillectomy hemorrhage in children and can safely be administered. Whereas in adults, recurrent tonsillitis being the most common indication for tonsillectomy, it should be used cautiously.

Knowledge, Attitude and Practice of Medical Ethics among Doctors and Nurses in Pokhara Valley, Nepal

Background Medical ethics is defined as the ethical obligations of medical professionals towards their patients, colleagues, and society. The inadequacy and non-uniformity of this topic has been associated with rising cases of professional misconduct and medical negligence all over the world. Objective To assess and compare the status of knowledge, attitude and practice of medical ethics among medical doctors and nurses in three major hospitals of Pokhara valley. Method This was a cross-sectional study conducted from 15th Mar 2018 to 13th Apr 2018; in which 124 doctors and 103 nurses were asked to fill up medical ethics related questionnaire. The data was entered in SPSS file and the association of variables was determined by Chi-square and statistical significance was considered if the p-value < 0.05. Result The study showed that 56.5%, 8.1%, and 13.7% of doctors were aware of the Hippocratic oath, Nuremberg Code, and Helsinki declaration respectively compared to only 1% of nurses. There was a significant difference in opinions on various questions related to medical ethics with p-value < 0.05 in 12 out of 22 questions. Only a few (12.1% doctors vs. 25.2% nurses) stood in support of the physicianassisted dying. Conclusion The study showed that there was inadequate as well as a non-uniform level of knowledge of three major codes of medical ethics and principles related to it which resulted in significant disparity in the attitude and practice of medical ethics among doctors and nurses in Pokhara valley.

Knowledge, attitude and practice regarding diabetes and hypertension among school students of Nepal: A rural vs. urban study

Background

The burden of non-communicable diseases like diabetes and hypertension is increasing worldwide including low-and middle-income countries. Good knowledge of such diseases among young people will make them adopt a healthy lifestyle from an early age, which will, in turn, prevent them from developing such non-communicable diseases. This study aimed to assess the knowledge, attitude, and practice of rural and urban school students regarding diabetes and hypertension. We also aimed to see the differences in the knowledge, attitude, and practice of students from rural vs. urban communities.

Methods

A school-based cross-sectional study was conducted from May 1 2021 to June 30, 2021, in four schools in Nepal (1 from a metropolitan city, 2 from an urban municipality, and 1 from a rural municipality). The study was conducted among the secondary-level students of classes 9 and 10 in each school. The data were collected from the participants via pre-tested questionnaires and analyzed in the Statistical Packages for Social Sciences (SPSS) version 20.0. Logistic regression analysis was carried out to determine the determinants of knowledge and attitude regarding diabetes and hypertension.

Results

Of 380 respondents, 35.5% were residents of metropolitan city, 37.4% were from the urban municipality and 27.1% were from the rural municipality. The mean age of respondents was 15.61±0.99 years and 51.1% were male. Respondents having a family history of diabetes and hypertension were 21.1% and 37.9% respectively. Respondents from the metropolitan city had significantly higher mean knowledge scores than the respondents from the urban and rural municipality (p<0.001) while there was no significant difference in mean attitude scores. There was significantly higher daily consumption of fruits and vegetables among the participants from rural municipality (p<0.01) while no significant difference was seen in salt consumption and time spent on physical activity. In univariate regression analysis, place of residence, family occupation, parental education, and family history of diabetes and hypertension were significantly associated with good knowledge level. In multivariate analysis, only a higher grade of study (grade 10 in comparison to grade 9) was an independent predictor of a student’s good attitude level.

Conclusion

In general, there was a good attitude towards diabetes and hypertension despite poor knowledge. The mean knowledge scores were lower in urban municipality and rural municipality compared to metropolitan city. Low knowledge scores on diabetes and hypertension among the students show an urgent need for school-based interventional programs focusing on non-communicable diseases and lifestyle modification with more emphasis on rural communities.

Prevalence and Contributing Factors of Gender-based Violence in SAARC Territories from 2010 to 2020: A Systematic Review and Meta-analysis

BACKGROUND

Gender-based violence is a key global concern due to the high prevalence and increased socio-economic burden for survivors. However, estimation of the prevalence of gender-based violence is difficult due to differences in study design and underreporting of abuse, especially in developing nations. Therefore, we conducted this study to estimate the prevalence of Gender-based violence among women living in the SAARC region.

METHODS

The review protocol was registered in PROSPERO (CRD42020219577). Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed throughout the review. A thorough database search was conducted to identify studies done in the SAARC region. Title and abstract screening were done in Covidence, followed by a full-text review. Data were extracted and pooled for analysis using the inclusion and exclusion criteria. Subgroup analysis was done where possible.

RESULTS

A total of 76 studies were included in the systematic review and metaanalysis. The community prevalence of domestic violence (DV) was 43.8% (95% CI, 35.1% - 52.9%), GBV prevalence was 34.9% (95% CI, 30.2% - 39.9%) and IPV prevalence was 39.8% (95% CI, 30.7% - 49.6%). GBV prevalence was highest in illiterate women [54.2% (95% CI, 46.8% - 61.5%)] and lowest among women with higher than secondary level education [23.1% (95% CI, 16.2% - 32.0%)]. The prevalence of GBV among women in pregnancy or postpartum period was 32.3% (95% CI, 25.1% - 40.4%, I2: 98.64), while among female sexual workers, the prevalence of Gender-based violence was 42.1% (95% CI, 28.1% - 57.5%, I2: 99.25).

CONCLUSIONS

There is a high prevalence of Gender-based violence in the SAARC region. Higher socioeconomic status and educational status are protective factors for Gender-based violence. However, more studies using validated tools are needed to understand the true extent of the problem.

Demographics and Awareness of Diabetic Retinopathy among Diabetic Patients Attending Department of Ophthalmology at Dhulikhel Hospital

Background Diabetes mellitus is considered as a major public health concern globally. Poor management of diabetes may lead to several serious complications including endstage renal disease, diabetic retinopathy, diabetic neuropathy, and cardiovascular complications. Among them diabetic retinopathy is one of the leading causes of visual impairment and blindness in Nepal. Objective To assess the demographics and level of awareness among individuals with diabetes about diabetic retinopathy during their visit to Department of Ophthalmology at Dhulikhel Hospital. Method A descriptive cross-sectional study was conducted involving all consecutive cases of diabetes mellitus who attended eye clinic with the principal investigator and co-investigator from March 2021 to August 2021. Detailed demographics of the participants, their level of awareness regarding diabetic retinopathy and associated complications were documented. This was followed by a detailed ocular examination intending to screen for the presence of features of diabetic retinopathy. Result A total of 260 patients with a mean age of 54 years ± 12.20 (range of 24 - 85 years) were included. The male to female ratio was 2.2:1. Among them, 65.4% of the patients had diabetes mellitus for less than 5 years duration. Diabetic retinopathy was found in 18.46% of the cases. Awareness of diabetic ocular complications was significantly higher among literate population (p = 0.054), among those who have positive family history of diabetes mellitus (p = 0.529) and those who had undergone prior fundus evaluation (p = 0.000). Conclusion From result of this study, we can emphasize that there is a necessity for health education in order to increase the awareness and knowledge about diabetic retinopathy to lower the burden of sight threatening complications related with the issue.

The Role of Vitamins in Non-Alcoholic Fatty Liver Disease: A Systematic Review

Non-Alcoholic Fatty Liver Disease (NAFLD) emerged as the most prevalent liver disorder contributing significantly to disease burden worldwide. It manifests as a broad spectrum of hepatic damage with varying severity ranging from less serious steatosis to a more severe Non-Alcoholic Steatohepatitis (NASH), with or without fibrosis, cirrhosis, and hepatocellular carcinoma. Vitamins, on the other hand, are micronutrients that are vital for healthy well-being. Some studies have linked liver diseases with hypovitaminosis; however, there are still some gaps about the basis of their correlation. Hence, this systematic review aims to discuss the role of vitamins in the pathogenesis of NAFLD and explore their hepatoprotective potential that may benefit clinicians in managing this condition.

This systematic review searched for studies indexed in the PubMed, PubMed Central, Medline, Google Scholar, and ScienceDirect databases. Inclusion and exclusion criteria were applied, duplicates were removed, and meticulous screening of articles was done systematically. Out of 729 unique studies generated using the search strategy, 17 were finally included after thorough review and quality appraisal. 

NAFLD is not simply an outcome of insulin resistance and metabolic derangements; instead, it is a disease with complex underlying pathogenesis. Moreover, vitamin deficiency has been associated with NAFLD development and increased susceptibility to more severe liver damage. Derangement in vitamins correlates to the lipotoxic hepatic environment, altered immune system, unwarranted inflammation, oxidative stress, gene mutations, epigenetic modification, and gut dysbiosis seen in NAFLD. As they influence several pathophysiologic processes in the liver, vitamins A, B3, B6, B9, B12, C, D, and E are promising potential options that can impact NAFLD management. However, more well-designed studies conducted in the human population are still necessary to establish their efficacy and safety as therapeutic agents.

Unraveling the Association Between Schizophrenia and Substance Use Disorder-Predictors, Mechanisms and Treatment Modifications: A Systematic Review

Individuals with schizophrenia are particularly vulnerable to substance abuse problems. Comorbidity with substance use disorders (SUDs) frequently results in early death and increased dysfunction observed in schizophrenia. This dual diagnosis can be explained through multiple general mechanisms. Tobacco, alcohol, cannabis, and cocaine are substances widely used by individuals with schizophrenia. This study highlights the predictors, mechanisms responsible for the relationship between substance use disorder and schizophrenia and how it can help with the treatment of both disorders. The publications were rigorously reviewed after being found in multiple databases. The study's inclusion criteria were research published within the last five years, publications written in English, full-text availability, and human studies. A total of ten papers were selected for examination from a total of 9,106 articles found using the search method across several databases. This study follows the rules listed within the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist 2009. The information gathered from these published studies was used to investigate the elements that contribute to the link between schizophrenia and substance abuse. Here, we evaluate a close relationship between schizophrenia and substance use disorders. The articles studied exhibit a bidirectional association between the two disorders in most individuals. From our analysis, the comorbidity between the two disorders is partially due to shared polygenic liability. Individuals with schizophrenia have dysfunctional Mesocorticolimbic brain reward circuits indicating a history of substance use. An underlying genetic vulnerability to schizophrenia may be triggered by extensive cannabis usage at a young age. A combination of psychological and pharmacological interventions for both disorders can significantly improve the outcome.

New Evidence in the Pathogenesis of Celiac Disease and Type 1 Diabetes Mellitus: A Systematic Review

Celiac disease (CD) and type 1 diabetes mellitus (T1DM) are autoimmune diseases that coexist frequently. These illnesses share a common genetic background. This study aims to review the different pathophysiologic mechanisms that have been studied about the coexistence of CD and T1DM, to contrast them, and to summarize their specific role in these autoimmune diseases. We conducted a systematic review following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist and used the Medical Subject Headings (MeSH) search strategy to obtain relevant articles. We found 585 papers which were reduced to 355 after removing duplicates. Later, the filters and inclusion/exclusion criteria were applied which ended the search with 78 articles. Finally, we reviewed the articles that contained information about the pathogenesis of CD and T1DM, their coexistence, and how the pathogenesis impacts clinical outcomes. The reviewed studies strongly conclude that the presence of human leukocyte antigen (HLA) genes DQ2 and DQ8 are high-risk for developing the coexistence of CD and T1DM. We found that killer immunoglobulin-like receptor (KIR) genes, enterovirus infection in gut cells, and gut microbiota dysbiosis with the predominance of Bacteroides spp. also play a role in the pathogenesis and development of symptoms of CD in patients with the previous diagnosis of T1DM. CD4+ and CD8+ cell levels vary among patients and studies, consequently, more study on this topic is needed.

Type 2 Diabetes and Causes of Sudden Cardiac Death: A Systematic Review

Type 2 diabetes mellitus has been on the rise in recent years. A major cause of death in the United States is myocardial infarction with underlying coronary artery disease. Impairment of tissue insulin sensitivity in type 2 diabetes is a significant factor for sudden cardiac death. The complex pathophysiology stems from coexisting cardiovascular disease and complications of impaired tissue sensitivity to insulin. Long-term diabetics with underlying kidney disease and those requiring dialysis have systemic inflammation that adds to an increased risk of death. During times of pathological stress, myocardial tissue will express substrates and growth factors that cause conduction disequilibrium and predispose to sudden cardiac death. Diabetes is a modifiable risk factor in the prevention of sudden cardiac arrest. Specific prevention measures aimed towards lifestyle modification and medications are important to prevent diabetes and decrease mortality of future cardiac death. In recent times, drugs that compete with glucose in the proximal convoluted tubule of the nephron have clinical significance in lowering the risk of sudden cardiac arrest.

The Role of Allogeneic Stem Cell Transplantation in Multiple Myeloma: A Systematic Review of the Literature

Multiple myeloma (MM) is an indolent B-cell malignancy, where treatment is aimed at preventing organ dysfunction from light chain accumulation (slowing disease progression) and inducing remission. Allogeneic stem cell transplant (allo-SCT), through graft versus myeloma (GVM) effects, has the potential to induce remission to a potentially curative-like state. In this systematic review, we aimed to understand this relationship to the risks and severity of disease in categorized patients and gain an updated comprehension of the future of allo-SCT in MM treatment. We conducted this review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and searched the PubMed database to obtain the specified literature with both the use of keywords and Medical Subject Headings (MeSH). A total of 16 relevant articles were included for discussion after the quality appraisal was completed, as appropriate, by either the Cochrane tool or Newcastle-Ottawa checklist. Our review concludes that while allo-SCT may benefit high-risk patients, successful procedures may incorporate a tandem autologous hematopoietic stem cell transplant approach in combination with novel pharmacologic contributions for which there is an observed synergy in the modulation of the immunologic microenvironment. Furthermore, tailored patient selection by evaluating pre-transplant factors including high-risk cytogenetics, age, and pre-salvage International Staging System (ISS) can predict post-transplantation success including non-relapse mortality. Successive research should continue to revise and update treatment options as the evolving therapeutic drug regimens may change over the course of indolent disease.

“Hybrid” medical leadership emergency medicine training for international medical graduates

Purpose

The purpose of this paper is to outline the “Hybrid” “International” Emergency Medicine (HIEM) programme, which is an ethical pathway for the recruitment, employment and training of Emergency Medicine doctors; with a rotation through the NHS on a two-year medical training initiative with a Tier 5 visa, “earn, learn and return” programme. The HIEM programme offers an advantage to the Tier 2 visa by combining training, education and employment resulting in new learning to help improve the health system in Nepal and provide continued cultural support, clinical and leadership development experience in the UK NHS. Finally, this programme also provides a Return on Investment to the NHS.

Design/methodology/approach

A shortage of doctors in the UK, combined with a need to develop Emergency Medicine doctors in Nepal, led to a UK Emergency Medicine Physician (PS) to facilitate collaboration between UK/Nepal partners. A mapping exercise of the Royal College of Emergency Medicine curriculum with the competencies for the health system and quality improvement leaders and partners with patients produced a “HIEM programme”. The HIEM programme aims to develop first-class doctors to study in Emergency Departments in the UK NHS while also building trainee capability to improve the health system in Nepal with a research thesis.

Findings

The HIEM programme has 12 doctors on its programme across years one and two, with the first six doctors working in the UK NHS and progressing well. There are reports of high levels of satisfaction with the trainees in their transition from Nepal to the UK and the hospital is due to save £720,000 (after costs) over two years. Each trainee will earn £79,200 over two years which is enough to pay back the £16,000 cost for the course fees. Nepal as a country will benefit from the HIEM programme as each trainee will submit a health system improvement Thesis.

Research limitations/implications

The HIEM programme is in its infancy as it is two years through a four-year programme. Further evaluation data are required to assess the full impact of this programme. In addition, the HIEM programme has only focussed on the development of one medical speciality which is Emergency Medicine. Further research is required to evaluate the impact of this model across other medical and surgical specialties.

Practical implications

The HIEM programme has exciting potential to support International Medical Graduates undertake a planned programme of development while they study in the UK with a Tier 5 visa. IMGs require continuous support while in the UK and are required to demonstrate continued learning through continuous professional development (CPD). The HIEM programme offers an opportunity for this CPD learning to be structured, meaningful and progressive to enable new learning. There is also specific support to develop academic and research skills to undertake a thesis in an area that requires health system improvement in Nepal.

Originality/value

This is the first time an integrated clinical, leadership, quality improvement and patient partnership model curriculum has been developed. The integrated nature of the curriculum saves precious time, money and resources. The integrated nature of this “hybrid” curriculum supports the development of an evidence-based approach to generating attitudes of collaboration, partnership and facilitation and team building in medical leadership with patient engagement. This “hybrid” model gives hope for the increased added value of the programme at a time of global austerity and challenges in healthcare.

The Correlation Between Parkinson's Disease and Rapid Eye Movement Sleep Behavior Disorder: A Systematic Review

Parkinson's disease (PD) is a neurodegenerative disease caused due to the destruction of dopaminergic neurons and the deposition of α-synuclein proteins, known as Lewy bodies. Generally, the diagnosis of PD is centered around motor symptoms. However, the early recognition of non-motor symptoms such as autonomic dysfunction, sleep disturbances, and cognitive and psychiatric disturbances are gaining increased attention for the early diagnosis of PD. Rapid eye movement (REM) sleep behavior disorder or REM sleep behavior disorder (RBD) is described as parasomnia, which is a condition of loss of normal muscle atonia causing the person to act out vivid dreams and it has been seen to be associated with the misprocessing of intercellular α-synuclein leading to neurodegenerative diseases such as PD. This review's objective is to highlight the significance of RBD as a prodromal premotor marker for the early detection of PD. We used PubMed as our primary database to search for articles on May 2, 2021, and a total of 1849 articles were found in our initial search using keywords and medical subject heading (MeSH) keywords. Thereafter, we removed the duplicates, applied the inclusion/exclusion criteria, and did a quality appraisal to include 10 articles in this study. We concluded that the recognition and diagnosis of RBD are of paramount importance to detect early PD, and further longitudinal studies and clinical trials are of utmost importance to understand their correlation; also, treatment trials are needed to prevent the phenoconversion of RBD into PD.

Revisiting Strategies for Maternal Health Care in the Face of COVID-19 Pandemic

Novel coronavirus (SARS-CoV-2) is a new strain of coronavirus causing COVID-19, first identified in Wuhan City, China towards the end of 2019. At present, there is no evidence that pregnant women are more likely to be severely ill, need ICU care, or die from the illness in comparison to non-pregnant adults. Evidences suggest that vertical transmission, might be possible. We searched and retrieved the published literature from PubMed and Google Scholar using various keywords. We further searched the official webpages of various organizations for the updated information. Pregnant individuals in particular are encouraged to take all available precautions to optimize health and avoid exposure to COVID-19. Adequate Testing should be prioritized in pregnant women admitted with suspected COVID-19. When a pregnancy is complicated by critical illness, the pregnant patient should ideally be cared for at a Level III or IV hospital. In the face of COVID-19, antenatal fetal surveillance and ultrasonography should continue as medically indicated when possible and elective ultrasound examinations should not be performed. Maternal immunizations continue to be an essential component of prenatal care and Obgyns should screen all pregnant individuals for mental health issues. Although the most commonly reported sign in COVID-19 is fever, nevertheless, other causes of intrapartum fever should not be overlooked. Cesarean delivery should be based on obstetric indications and not COVID-19 status alone. Infants born to patients with known COVID-19 should be considered infants with suspected COVID-19. The suspected or confirmed COVID-19 mother and infant can be allowed to remain together with enhanced precautions and suspected or confirmed maternal COVID-19 is not a contraindication to breastfeeding. If both the mother and the infant are healthy, it may be prudent to expedite discharge, so as to limit the risk of inadvertent exposure and infection. The Ob-gyns should commit to providing necessary care, although modifications to health care delivery approaches may be necessary.

Gaming Disorder among Medical College Students during COVID-19 Pandemic Lockdown

Background The frequent lockdown in Nepal during COVID-19 pandemic had brought various kinds of complexities such as stress among college students. This situation had created uncertainty of future academic career of undergraduate students in medical colleges. Some previously published literature showed gaming as a coping mechanism against stress. Objective To assess the gaming behavior of Medical college students during lockdown in COVID-19 pandemic. Method A cross-sectional study was conducted during lockdown period of July to August 2020. A total of 412 college students were enrolled. Online Google forms were shared to all the eligible students through email, viber and messenger with the help of class representative. Collected data were analyzed in SPSS version 20.0. Result The prevalence of gaming disorder was 8.5% among 260 internet gaming users. About 69.2% of the participants reported that their gaming behavior had increased due to stress of COVID-19 pandemic. Gender and spending more time online per day showed significant associations with greater scores on the internet gaming disorder. Conclusion During lockdown period of COVID-19 pandemic, the gaming behavior of medical college students has increased.

Online Learning in the Face of COVID-19 Pandemic: Assessment of Students' Satisfaction at Chitwan Medical College of Nepal

Background Online learning can play a vital role in the process of teaching and learning during Corona Virus Disease 2019 (COVID-19) pandemic. However, learners' satisfaction is extremely important in effective implementation of the online learning, especially at institutions where it is newly adopted. Objective To assess satisfaction towards online learning and its predictors among students at Chitwan Medical College, Bharatpur. Method A web-based cross-sectional survey was undertaken among 434 undergraduate and postgraduate students from various academic programs who had participated in the online classes started during this COVID-19 pandemic. A structured questionnaire consisting of 31 items (5-point Likert scale) covering four major student satisfaction domains (learners' dimensions, technological characteristics, instructors' characteristics and course management and coordination) was distributed to the students using Google Form. Result More than half (53.5%) of the students were satisfied with the online learning, while 29.7% gave neutral views. Bivariate analyses found that all four domains scores were positively correlated with each other as well as with the students' overall satisfaction towards learning. In multivariate analysis, female gender [aOR: 2.72, p = 0.013], WiFi as internet modality for learning [aOR: 3.36, p = 0.001) and learners' dimension score [aOR: 1.27, p<0.001] were the significant predictors of students' satisfaction. Conclusion Although recently adopted, the satisfaction of the students towards online classes appears good, and prioritizing the identified predictors and working on the weak links could assist in enhancing students' satisfaction and better outcomes.

Indoor Air Pollution (IAP) Traceable to Household Fuel Consumption and its Impact on Health

Energy is an essential and obligatory prerequisite of life. Indoor air pollution is one of the biggest environmental problems in the world being specifically concentrated in resource limited settings. Inspite of the availability of cleaner fuel technologies, people in resource limited setting still depend on traditional fuel to meet their basic needs resulting even in premature deaths. In Nepal people in rural areas are the pre-dominant users of biomass fuel, there is limited research focusing on rural areas particularly; women as they spend most of their time in kitchen. Reports were extensively searched for literature using preset keywords in English language peer-reviewed journals databases PubMed and Google Scholar published between the years 2005 to 2020. Citation details were examined, titles and abstracts screened for eligibility and if relevant, full text was also reviewed in greater detail. Findings were then presented primarily under two bold themes: Household fuel consumption: existing theories and evidence; and health impact of indoor air pollution. Several health effects were reported of indoor air pollution including respiratory illnesses, cardiovascular diseases, cancer, endocrine system disruption and pregnancy complications. These exposures almost double the health risks predominantly among children and women of rural communities as they are directly involved in household activities causing air pollution. Based on our review of evidence, women and children of rural households were the major victims. Further, determinants of household fuel consumption and health effects should be considered while formulating policies in regard to promoting accessibility of clean fuels and reducing household air pollutants.

The effect of metformin in EML4-ALK+ lung cancer alone and in combination with crizotinib in cell and rodent models

Cell based studies have suggested that the diabetes drug metformin may combine with the anaplastic lymphoma kinase receptor (ALK) inhibitor crizotinib to increase ALK positive lung cancer cell killing and overcome crizotinib resistance. We therefore tested metformin alone and in combination with crizotinib in vivo, by employing a xenograft mouse model of ALK positive lung cancer. We found that 14 days of daily oral metformin (100 mg/kg) alone had a moderate but statistically significant effect on tumour growth suppression, but in combination with crizotinib, produced no greater tumour suppression than crizotinib (25 mg/kg) alone. We also reassessed the effect of metformin on EML₄-ALK positive lung cancer (H3122) cell viability. Although metformin alone did have a moderate effect on cell viability (30% suppression) this was only at a clinically irrelevant concentration (5 mM) and there was no additive effect with cytotoxic concentrations of crizotinib. Moreover, metformin did not overcome crizotinib resistance in our resistant cells. Nevertheless, we were able to show that metformin induces a G1-cell cycle arrest and apoptosis alone and in combination with crizotinib. Also, consistent with earlier work, the addition of insulin-like growth factor-1 (IGF-1) to EML₄-ALK positive cancer cells reduced cell killing by crizotinib. We therefore hypothesised that the effect of metformin in vivo was not due to direct cytotoxicity on cancer cells, but by modulation of IGF-1 expression. We therefore measured levels of IGF-1 in plasma taken from mice treated with metformin, but found no difference between the drug treatment and control groups. We further hypothesised that the effect of metformin could be due to modulation of thrombospondin 1 (TSP-1), which metformin has been proposed to regulatein vivo, but again we found no difference between the experimental groups. Finally, we investigated the potential for liver and kidney toxicity, as well as CYP3A based interactions, from the combination of metformin with crizotinib.

Meta-analysis of computed tomography and magnetic resonance imaging for diagnosing mycotic aneurysms

Background

Mycotic aneurysms are a serious complication of infective endocarditis and bloodstream infection with high mortality and morbidity. Computed tomography (CT) and magnetic resonance (MRI) play major roles in detecting mycotic aneurysms, but their accuracy is not well established warranting this meta-analysis.

Purpose

We aimed to assess the diagnostic performance of CT and MRI for mycotic aneurysms in this meta-analysis.

Methods

Pubmed, Cochrane and Embase were searched from 1 January 1980–30 June 2019 for diagnostic studies reporting both sensitivity and specificity of CT and/or MRI for detecting mycotic aneurysms, and pooled using random effects models and Meta-DiSc 1.4 software.

Results

Amongst 1507 articles searched, 15 studies with 622 scans for 249 mycotic aneurysms included. CT was performed in 13 studies and MRI in 5 studies, looking at aortic and cerebral mycotic aneurysm in 12 and 3 studies respectively. The pooled sensitivities and specificities for all mycotic aneurysms with 95% confidence intervals were for CT 0.82 (0.77–0.87) and 0.93 (0.89–0.95) respectively, and for MRI 0.79 (0.61–0.91) and 0.89 (0.81–0.95) (Figure). CT or MRI had pooled sensitivities and specificities of 0.84 (0.78–0.89) and 0.92 (0.89–0.95) for aortic and 0.71 (0.54–0.85) and 0.90 (0.83–0.95) for cerebral mycotic aneurysms. Heterogeneity and publication bias was observed in some pooled analysis.

Conclusion

CT and MRI had moderately high diagnostic accuracy for mycotic aneurysms. Sensitivity was numerically higher for detecting aortic than cerebral mycotic aneurysms, with similar specificity. Study heterogeneity, publication bias and modest sample size from the literature were important limitations, warranting larger and higher quality studies.

Forrest plots for CT and MRI pooled data

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): National Heart Foundation of New Zealand - Overseas Clinical and Research Fellowship

Diagnostic utility of ultrasonography and computerized tomography in gall bladder perforation: A case report

Gall bladder (GB) perforation can be misdiagnosed as any other more common cause of acute abdomen. We present a case of a 72-year-female who had presented to the emergency department with an acute abdomen. The clinical presentation and the biochemical markers had pointed towards acute pancreatitis. However, the ultrasonographic examination of the abdomen and the pelvis suggested GB perforation which was confirmed by the multislice computerized tomography scan. Following this the patient underwent open cholecystectomy and was successfully managed. The invaluable contributions from the radiological modalities led to the successful management of the patient.

Knowledge of Health Care Professionals and Medical Students Regarding Covid-19 in a Tertiary Care Hospital in Nepal

INTRODUCTION

The lack of knowledge among health care professionals leads to diagnostic delays, further spread of disease, and poor infection control practices. Health care professionals must be updated knowledge regarding COVID-19. This study aims to assess the knowledge of health care professionals regarding COVID -19 in a medical college in Chitwan.

METHODS

A Knowledge, Attitude and Practice Study was carried out in a tertiary care hospital in Chitwan, Nepal from April 22, 2020, to April 28, 2020. The institutional review committee of Chitwan Medical College provided ethical approval for the research. Data were collected with an online questionnaire using Google forms. The questionnaire was sent out to 724 potential responders who included health care professionals from medical, dental, nursing, and allied health sciences in Chitwan Medical College. A convenient sampling method was used for data collection. Data were analyzed using Statistical Package of Social Sciences.

RESULTS

A total of 181 respondents completed the web survey. Overall, a total of 35 (19.3%) respondents were found to have "Good" knowledge; 105 (58%) respondents had "Fair" knowledge and 41 (22.7%) respondents had "Poor" knowledge regarding various aspects of COVID-19. There was no significant difference among the various health professional groups in their knowledge scores under the four knowledge domains.

CONCLUSIONS

The study of knowledge of health care professionals could act as a reference for the prevention and better management of COVID-19. This study shows that there is a need to implement periodic educational interventions and training programs on infection control practices for COVID-19 across all healthcare professions.

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

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

Contextualizing Critical Care Medicine in the Face of Covid-19 Pandemic

Critical Care Medicine is a specialty dealing with the comprehensive management of patients having, or at risk of developing, acute, life threatening organ dysfunction. The glaring need of critical care services and human resources for critical care have become more evident in the face of the current COVID-19 Pandemic. At this juncture, when the world is facing threat to humanity with an increasing number of deaths due to COVID 19 pandemic, the discussion about the need for ICU beds and human resources for critical care management has re-surfaced and is being increasingly realized. In Nepal, as of 15th April, 2020, there are 194 hospitals with ICU facilities. The total ICU bed strength is 1595 in 194 hospitals (which is approximately 6% of all hospital beds) and only around 50% of them are equipped with ventilators (840). These figures indicate that Nepal has approximately 2.8 ICU beds per 100,000 population. As Nepal braces to contain a major COVID-19 outbreak, the hospital capacities of the country have already come under huge pressure. If the number of confirmed cases of COVID-19 continue to rise at the current pace, the shortage of critical care facilities will become more glaring than ever before. The current pandemic is a tremendous opportunity for health planners to accelerate action and ensure that the country is well-equipped to contain the COVID-19 pandemic. We need to be working towards infrastructure and human resource strengthening and expansion in critical care, in order to efficiently contain the pandemic.

Knowledge of menstrual hygiene management among adolescent girls: what does evidence show?

Aims: To explore the knowledge of menstrual hygiene management among adolescent girls in different domains like culture, social learning and belief. Methods: This review paper explored the knowledge of menstrual hygiene management under several domains. Literature published in Pub Med, Medline, Google Scholar and HINARI from 2010 to 2020 was reviewed to prepare this paper. Results: The studies revealed that there is a general silence about menstruation. Adequate and accurate information about menstruation and the need for good menstrual hygiene management is limited. It further revealed that girls are not provided with comprehensive information before menarche while growing up, and therefore the first experience of menstruation is without any preparation and usually comes as a shock. Menstruation is widely regarded as a curse from God or as a disease or as being impure or as a taboo. Schools are doing very little to impart education on Menstrual Hygiene Management to adolescents. A majority of the teachers themselves are least or unprepared to address this issue with the girls, even when it is part of the school curriculum. The studies provide a wealth of information for designing interventions to improve menstrual hygiene management. Conclusions: Young girls are not well aware of the menstrual event and the hygienic measures. They are neither well informed nor properly taught by elders and teachers. Effective interventions must be contextualized, designed, and implemented to generate awareness and change the mindset of people surrounding menstruation. Keywords: adolescents, knowledge, menstrual hygiene management, reproductive health

COVID 19 and Nepal: Identification of Critical Public Health Measures

The COVID-19 pandemic is unfolding at an unprecedented pace. The unprecedented threat provides an opportunity to emerge with robust health systems. Nepal has implemented several containment measures such as Rapid Response Team formulation; testing; isolation; quarantine; contact tracing; surveillance, establishment of COVID-19 Crisis Management Centre and designation of dedicated hospitals to gear up for the pandemic. The national public health emergency management mechanisms need further strengthening with the proactive engagement of relevant ministries; we need a strong, real-time national surveillance system and capacity building of a critical mass of health care workers; there is a need to further assess infection prevention and control capacity; expand the network of virus diagnostic laboratories in the private sector with adequate surge capacity; implement participatory community engagement interventions and plan for a phased lockdown exit strategy enabling sustainable suppression of transmission at low-level and enabling in resuming some parts of economic and social life.

Emergency Medicine Education at a Medical Institute in Nepal: Breaking the Frontiers

Emergency medicine, globally, is a developing specialty. The President of International Federation for Emergency Medicine penned down in a 2007 editorial that emergency medicine is rapidly becoming a global specialty. There are an increasing number of countries which are exploring ways to further build emergency medicine. The Hybrid International Emergency Medicine Training Program is the first collaborative international Emergency Medicine training developed in the UK. A Memorandum of Understanding has been signed among Doncaster and Bassetlaw Teaching Hospital, UK, International Centre for Emergency Medicine UK, International Academy of Medical Leadership, UK and Chitwan Medical College, Nepal.The HIEM program has been executed by CMC from November 15, 2018. As per the MOU, the International Training Registrars of HIEM Program will undergo 1st and 4rth Year of training at CMC, Nepal and the 2nd year and 3rd year of training at DBTH, UK. The HIEM Training Program is the first of its kind in the country; HIEM is the first post graduate emergency medicine program in Nepal which also has an international recognition and is unique in the sense that the programme is integrated with training in leadership and management.The HIEM Training Program is recognized by Royal College of Emergency Medicine, UK. CMC has committed to improving emergency care in Nepal by pioneering the HIEM Training Program. We are committed to fulfilling our moral and social responsibility to improve emergency care systems in the country through building up of a cadre of adequately trained Emergency Physicians. Keywords: Emergencies; emergency care; emergency medicine; Nepal.

Inhibition of Mitogen-Activated Protein Kinase Kinase Alone and in Combination with Anaplastic Lymphoma Kinase (ALK) Inhibition Suppresses Tumor Growth in a Mouse Model of ALK-Positive Lung Cancer

Anaplastic lymphoma kinase (ALK)-positive non-small-cell lung cancer most commonly arises through EML4 (Echinoderm Microtuble Like 4)-ALK chromosomal fusion. We have previously demonstrated that combination of the ALK inhibitor crizotinib with the MEK inhibitor selumetinib was highly effective at reducing cell viability of ALK-positive non-small-cell lung cancer (H3122) cells. In this study, we further investigated the efficacy of crizotinib and selumetinib combination therapy in an in vivo xenograft model of ALK-positive lung cancer. Crizotinib decreased tumor volume by 52% compared with control, and the drug combination reduced tumor growth compared with crizotinib. In addition, MEK inhibition alone reduced tumor growth by 59% compared with control. Crizotinib and selumetinib alone and in combination were nontoxic at the dose of 25 mg/kg, with values for ALT (<80 U/l) and creatinine (<2 mg/dl) within the normal range. Our results support the combined use of crizotinib with selumetinib in ALK-positive lung cancer but raise the possibility that a sufficient dose of an MEK inhibitor alone may be as effective as adding an MEK inhibitor to an ALK inhibitor. SIGNIFICANCE STATEMENT: This study contains in vivo evidence supporting the use of combination MEK inhibitors in ALK+ lung cancer research, both singularly and in combination with ALK inhibitors. Contrary to previously published reports, our results suggest that it is possible to gain much of the benefit from combination treatment with an MEK inhibitor alone, at a tolerable dose.

Permcath - A Vascular Access for Hemodialysis, Our Experience in Last Two Years

Background The double lumen tunneled catheter (Permcath) is mostly used as an alternative access, not as a temporary access in End Stage Renal Disease patients requiring hemodialysis. If there is no possibility of other access modalities, failed or unable to create native arteriovenous fistula (AVF), Permcath can be a very good alternative. Objective To find the indications, complications and results of Permcath insertion. Method We reviewed the results of 92 Permcath inserted under ultrasound guidance in two different hospitals, 45 in Sahid Dharma Bhakta National Transplant Center (SDNTC), Bhaktapur and 47 in Nidan Hospital Pvt. Ltd., Lalitpur from April 2016 to April 2018 retrospectively. Result We had inserted 55 Permcath (59.78%) in right internal jugular vein (IJV), 25 (27.17%) in left internal jugular vein and 12(13.04%) in femoral vein. In terms of major complications, two (2.17%) patients had profound hypotension, bradycardia and cardiac arrest due to left internal jugular vein tear. Three patients (3.26%) died within a week due to septicemia and 23 patients (25%) died with multiple causes within one year. Of the cases, till now in 39 cases (42.39%) Permcath has been removed. Major reasons of removal of Permcath are post renal transplant in 18 cases (19.57%), Arterio Venous Fistula maturation in 13 cases (14.13%), Infection in six patients (6.52%) and non functioning Permcath in two patients (2.17%). Conclusion Permcath remains a reliable method for short term vascular access, hence can be used as a bridge to renal transplant or arteriovenous fistula maturation.

Fellowship Training in Nepal: Current Prospects

The need of subspecialty training has been acutely felt in Nepal now with the rapid advancement in the field of medical sciences, the changing burden of diseases, the acute shortage of highly specialized health professionals, the evolving concept of learning and medical education and the ever-increasing focus on right and safety of patients.Fellowship Training is obtained in a specific specialty or subspecialty. Fully academic 3-year Fellowship programsin Pulmonary and Critical Care Medicine, Hepatopancreatobiliary Surgery and Cardiologyhavebeen initiated for certification of the training for the first time in Nepal at Chitwan Medical College (CMC) and all three are recognized by the Nepal Medical Council.The three Fellowship training programs, run in affiliation with Lincoln University, at the CMC have all the training criteria of DM/MCh included along with extra requirement of one more paper publication and the trainees are paid adequate stipend without any tuition fee or bond. The high volume of cases and procedures in CMC, exposes the FCMC Fellows to an increased chance of appropriate skill development along with appropriate postings in various other institutions for adequate experience of hands on training.Fellowship programs are the cornerstone of providing super specialized patient care.The need today is to focus on the basic training concepts and criteria, rather than on various names like diploma, MD, MS, DM/MCh of training.Nepal should focus onthe prerequisites, infrastructure and human resource for expanding the quality Fellowship trainingprograms in the country and thereby enhancing the standard of patient care. Keywords: Cardiology; DM; FCMC; fellowship; hepatopancreatobiliary surgery; MCh; PCCM.

Tobacco Use among Health Professional Students in Chitwan, Nepal

BACKGROUND

Health professional students play a critical role in tobacco control by providing services, advocating for policies and serving as role models for social change. This study aimed to estimate the prevalence of tobacco use and determine the attitude and behavior regarding tobacco use among health professional students.

METHODS

A cross-sectional study was conducted among third-year medical, dental, nursing and pharmacy undergraduates using GHPSS questionnaire.

RESULTS

A total of 16.3% students were current cigarette smokers. 33.2% students had ever smoked cigarettes, and 57.0% had smoked first cigarettes during adolescence life. Cigarette smoking consumption was higher than the use of other tobacco products like chewing tobacco, snuff, bidis, hookah, cigar or pipes and. 10.0%students were current users of other tobacco products.22.1%students had ever used other tobacco products.31.6% were exposed to second-hand smoke at home and 48.9% were exposed to second-hand smoke at public places.

CONCLUSIONS

The prevalence of smoking and exposure to second-hand was high among medical students. Medical educators should consider revising the medical curricula to focus on tobacco cessation training/counseling in medical schools.

Next generation sequencing reveals packaging of host RNAs by brome mosaic virus

Although RNA viruses evolved the mechanisms of specific encapsidation, miss-packaging of cellular RNAs has been reported in such RNA virus systems as flock house virus or cucumber necrosis virus. To find out if brome mosaic virus (BMV), a tripartite RNA virus, can package cellular RNAs, BMV was propagated in barley and in Nicotiana benthamiana hosts, purified by cesium chloride (CsCl) gradient ultracentrifugation followed by nuclease treatment to remove any contaminating cellular (host) RNAs. The extracted virion RNA was then sequenced by using next-generation sequencing (NGS RNA-Seq) with the Illumina protocol. Bioinformatic analysis revealed the content of host RNAs ranging from 0.07% for BMV extracted from barley to 0.10% for the virus extracted from N. benthamiana. The viruses from two sources appeared to co-encapsidate different patterns of host-RNAs, including ribosomal RNAs (rRNAs), messenger RNAs (mRNAs) but also mitochondrial and plastid RNAs and, interestingly, transposable elements, both transposons and retrotransposons. Our data reveal that BMV virions can carry host RNAs, having a potential to mediate horizontal gene transfer (HGT) in plants.

Prevalence of Malnutrition in a Rural Residential Sanskrit School in Baglung, Nepal

INTRODUCTION

Under-nutrition is a condition in which there is inadequate consumption, poor absorption or excessive loss of nutrients. Nepal still faces high chronic as well as acute under-nutrition in children. The following study was conducted a Sanskrit school in rural Baglung to find the prevalence of malnutrition among the children which could reflect the nutritional status of the community.

METHODS

Out of 60 students admitted to the school, only 43 were present at the time when we collected our data. Weight was measured with a standard weighing scale and standing height with a measuring tape attached to the wall. Data were filled up in proforma, entered in Microsoft Excel 2013 and were analyzed and indicators calculated with SPSS version 20 using WHO Child Growth Reference data for 5-19 years and macros.

RESULTS

Stunting (Z score < -2) was found in 53.5% of the study group and severe stunting (Z score < -3) was found in 25.6%. 12.5% of the 8 children under 10 years in our study had weight-for-age < -2 Z score which indicates underweight. No one was severely underweight. In our study, 2.3% had severe thinness (Z-score < -3), 14% had thinness (Z-score < -2). No one was overweight or obese.

CONCLUSIONS

The prevalence of malnutrition was high among the students of the rural Sanskrit school where the study was conducted.

In vivo dual-delivery of glucagon like peptide-1 (GLP-1) and dipeptidyl peptidase-4 (DPP4) inhibitor through composites prepared by microfluidics for diabetes therapy

Oral delivery of proteins is still a challenge in the pharmaceutical field. Nanoparticles are among the most promising carrier systems for the oral delivery of proteins by increasing their oral bioavailability. However, most of the existent data regarding nanosystems for oral protein delivery is from in vitro studies, lacking in vivo experiments to evaluate the efficacy of these systems. Herein, a multifunctional composite system, tailored by droplet microfluidics, was used for dual delivery of glucagon like peptide-1 (GLP-1) and dipeptidyl peptidase-4 inhibitor (iDPP4) in vivo. Oral delivery of GLP-1 with nano- or micro-systems has been studied before, but the simultaneous nanodelivery of GLP-1 with iDPP4 is a novel strategy presented here. The type 2 diabetes mellitus (T2DM) rat model, induced through the combined administration of streptozotocin and nicotinamide, a non-obese model of T2DM, was used. The combination of both drugs resulted in an increase in the hypoglycemic effects in a sustained, but prolonged manner, where the iDPP4 improved the therapeutic efficacy of GLP-1. Four hours after the oral administration of the system, blood glucose levels were decreased by 44%, and were constant for another 4 h, representing half of the glucose area under the curve when compared to the control. An enhancement of the plasmatic insulin levels was also observed 6 h after the oral administration of the dual-drug composite system and, although no statistically significant differences existed, the amount of pancreatic insulin was also higher. These are promising results for the oral delivery of GLP-1 to be pursued further in a chronic diabetic model study.

Choices, Shift and Continuation of Temporary Contraceptive Methods among Women of Reproductive age in Western Development Region of Nepal

Aims: Global family planning programs have been in existence in the developing world. Modern techniques of temporary contraceptives have been proved to be useful tool for limiting births. This study is intended to identify the use pattern, associated factors with the choice, shift and continuity of temporary methods of contraception.Methods: This is descriptive cross-sectional study, incorporating qualitative aspects. Out of sixteen districts six were selected proportionately by using simple random methods from each ecological zone of the Western Development Regions, Nepal. Focus group discussion was accomplished among the different level family planning service providers.Results: User of Depo-Provera and pills were seen more in comparison to other temporary contraceptive. There are different reasons behind choosing of temporary contraceptive method such as Pills make regularity in menstruation, Norplant is useful for prolonged period, Depo-Provera is useful for three months and confidently used for a long time without any risk, motivation by friends/relatives. Reasons in changing the contraceptives includes associated side effects, lack of availability, irregularity in menstruation, choosing the another best method, excessive bleeding, difficult to use, pressure from family and husband to give birth, misunderstanding and stress in the family, traditional belief and lack of education.Conclusions: For proper choice of modern contraceptive methods promotion, education and knowledge about associated factors related to use of these method is needed. Continuous information on contraceptives focusing particularly on the side effects and trained health care providers are essential.