Safety and immunogenicity of conjugate vaccine for typhoid (Vi-DT): Finding from an observer-blind, active-controlled, randomized, non-inferiority, phase III clinical trial among healthy volunteers

Typhoid fever is a significant public health concern with most of the sufferers between 15 and 25 y of age in Nepal. We undertook this study to demonstrate Vi polysaccharide conjugated with diphtheria toxoid (Vi-DT) conjugate vaccine which is non-inferior to Typbar typhoid conjugate vaccine, a Vi polysaccharide vaccine conjugated with tetanus toxoid (Vi-TT) with a focus on the adult population from Dhulikhel Hospital which was one of the total four sites in Nepal. In this study, we assigned the eligible participants in 1:1:1:1 ratio by block randomization, and stratified into three age groups (6 months to less than 2 y, 2 y to less than 18 y, and 18 y to 45 y), allotted to Group A, B, C, and D. Group A, B, and C received 25 μg (0.5 mL) of Vi-DT study vaccine and participants in Group D received 25 μg (0.5 mL) Vi-TT vaccine. We descriptively analyzed safety in all the participants receiving one dose of the investigational vaccine. The anti-Vi-IgG seroconversion rate in Vi-DT recipients was 99.71% (97.5% CI 98.04-99.96; 344 of 345 participants) and 99.13% (94.27-99.87; 114 of 115) in Vi-TT recipients which indicates that Vi-DT vaccine is non-inferior to Vi-TT vaccine. In safety aspect, 16.81% of total subject had at least one solicited adverse reaction and 22.61% of the Vi-TT participants experienced at least one solicited adverse reaction with most of them being local adverse reactions. None of the enrolled participants reported serious adverse events. Our study shows that a single dose of the Vi-DT vaccine is immunogenic, safe to administer and non-inferior to the Vi-TT vaccine four weeks after vaccination.

Discrepancies between Glycated Hemoglobin and Fasting Plasma Glucose in New-onset Diabetes Mellitus

Background Fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c) are commonly used for diagnosing diabetes mellitus in Nepal. Though HbA1c criteria are convenient for diagnosis there is a discrepancy between the fasting plasma glucose and HbA1c for diagnosis. Objective To assess the comparability between fasting plasma glucose and glycated hemoglobin levels in the new-onset diabetes mellitus. Method This is a hospital-based descriptive cross-sectional study including 128 newly diagnosed diabetes mellitus conducted at Dhulikhel Hospital, Kathmandu University Hospital. New onset diabetes patients above 18 years of age who met inclusion criteria were included. The clinical characteristics and biochemical parameters were analyzed. Statistical analysis was done using student's t-test and correlation coefficient. Result There were 128 newly diagnosed diabetes mellitus patients included in the study among which 57.0% were males with a mean age of 49.48±11.40 years. The mean fasting plasma glucose, postprandial sugar (PPBS), and glycated hemoglobin were 205.54±88.93 mg/dL, 331.08±146.61 mg/dL, and 9.59±2.70% respectively. Diabetes was diagnosed using fasting plasma glucose, and glycated hemoglobin criteria in 84.4% and 90.6% of patients. In new-onset diabetic patients, 76.56% of patients had both elevated levels of fasting plasma glucose and glycated hemoglobin. Of the diabetic patients who had fasting plasma glucose ≥126 mg/dL, 90.7% of patients had HbA1c ≥ 6.5% whereas 1.6% of new-onset diabetes had < 126 mg/dL and glycated hemoglobin < 6.5%. There was a strong correlation between fasting plasma glucose and glycated hemoglobin (r=0.723; p<0.01). Conclusion Both fasting plasma glucose and glycated hemoglobin tests have to be used together for diagnosing diabetes mellitus.

Mean Atd Angle among Type 2 Diabetes Mellitus Patients Visiting a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction: An atd angle is one of the dermatoglyphic patterns which is an indication of the degree of distal displacement of the axial triradius on the palm. This is one of the markers of diabetes mellitus that is used as a screening tool in order to reduce the risk of onset and initiate early treatment. The aim of this study is to find the mean atd angle among type 2 diabetes mellitus patients visiting a tertiary care centre. Methods: This descriptive cross-sectional study was done among diabetic patients in a tertiary centre from 9 June 2021 to 5 May 2022. Ethical approval was taken from Institutional Review Committee (Reference number: KUSMS/IRC 40/2021). Both palm prints of study subjects were taken and the atd angle was measured. Convenience sampling was done. Point estimate and 95% confidence interval were calculated. Results: Among 133 palm prints of diabetic patients, the mean atd angle was 42.13±4.73° (male: 41.90±4.75° and female: 42.35±4.70°). The right palms showed mean atd angle of 42.31±4.42° and that of left palms was 41.94±5.04°. Conclusions: The mean atd angle among type 2 diabetes mellitus patients is similar to other studies done in similar settings.

Virologic Response Following a Switch to Dolutegravir-based Regimen in People Living with HIV/AIDS at a Tertiary Care Center in Nepal

Background The dolutegravir-based antiretroviral regimen is the preferred first-line regimen for the management of people living with human immunodeficiency virus in Nepal recently. It is considered safe to transition to a dolutegravir-based regimen for children and adults on Nevirapine and Efavirenz-based regimens. Objective To determine the virologic response following the transition to a Dolutegravir-based regimen in people living with human immunodeficiency virus previously taking Nevirapine and Efavirenz-based regimen. Method This is a retrospective cohort study including people living with human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS) who were transitioned to Tenofovir/Lamivudine/Dolutegravir previously on other antiretroviral therapy regimens for at least 6 months and who had their viral load test done before transition. The medical records of patients were reviewed from records available at the antiretroviral therapy clinic of Dhulikhel Hospital. The viral load done at least 3 months after switching to the Dolutegravir-based regimen was recorded. Descriptive analysis of socio-demographic and clinical characteristics data was done. Result Fifty-seven people living with human immunodeficiency virus/ acquired immunodeficiency syndrome who transitioned to a Dolutegravir-based regimen previously on other antiretroviral therapy regimens for at least 6 months were included in this study. Tenofovir/Lamivudine/Efavirenz (47.4%), Zidovudine/ Lamivudine/Nevirapine (22.8%) and Zidovudine/Lamivudine/Efavirenz (17.5%) were the most common antiretroviral regimens before transition. The majority of the patients (86%) had suppressed viral load of fewer than 40 copies/mL before the switch. Following the transition, 96.5% of the patients had suppressed viral load of fewer than 40 copies/mL. Conclusion Dolutegravir-based antiretroviral regimen led to untransmittable viral load following a switch from Nevirapine and Efavirenz-based regimen.

Prevalence of Metabolic Syndrome in Newly Diagnosed Type 2 Diabetes Mellitus

Background The clustering of risk factors in metabolic syndrome increases the risk of atherosclerotic cardiovascular disease and all-cause mortality. The prevalence of coronary heart disease is high in diabetic patients with metabolic syndrome than non diabetic patients with metabolic syndrome. Objective To determine the prevalence of metabolic syndrome in new onset Type 2 Diabetes Mellitus (T2DM) and to study the risk components of metabolic syndrome. Method This is a hospital based cross sectional study conducted in 132 newly diagnosed T2DM patients at Dhulikhel Hospital, Kathmandu University Hospital in Nepal in 2018. The socio-demographic profile, clinical characteristics, and biochemical parameters were analyzed to study the prevalence, risk factors, and concordance between various definitions of metabolic syndrome. Statistical analysis was done using Student's t-test, Chi-square test and Kappa statistics. Result One hundred and thirty two newly diagnosed T2DM patients were included in the study. Majority of the patients (58.9%) were in the age group of 40-60 years with the mean age of 49.72±12.44 years. The prevalence of metabolic syndrome was 111 (84.1%), 106 (80.3.%), 94 (71.2%) and 82 (62.1%) using World Health Organization(WHO), Harmonized, National Cholesterol Education Program-Adult Treatment Panel III (NCEP ATP III) and International Diabetes Federation (IDF) definitions respectively. One hundred and six patients (80.3%) had 3 or more individual components of metabolic syndrome. There was substantial agreement between NCEP ATP III-Harmonized (k=0.714, p<0.001) and Harmonized-WHO (k=0.716, p<0.001) definitions for diagnosing metabolic syndrome. The increased prevalence of metabolic syndrome in females than males is due to increased prevalence of abdominal obesity (p<0.05), dyslipidemia (low HDL cholesterol (p<0.05)) and presence of diabetes. Conclusion The prevalence of metabolic syndrome in newly diagnosed T2DM is high in the Nepalese population. The central obesity and low HDL cholesterol were significant risk factors in female diabetic patients predisposing to metabolic syndrome.

Virological and Immunological Status of the People Living with HIV Undertaking Highly Active Antiretroviral Therapy

Background The major goal of antiretroviral therapy (ART) is immunological recovery and virological suppression. Immunological and virological response in People Living with HIV (PLHIV) undertaking ART has to be monitored to assess the treatment response, diagnosing treatment failure and switching antiretroviral therapy. Objective To assess the immunological and virological response to antiretroviral therapy among Human Immunodeficiency Virus (HIV) infected individuals. Method This is a cross-sectional study including people living with HIV (PLHIV) taking antiretroviral therapy for at least 6 months and was conducted in Dhulikhel Hospital in 2017. The socio-demographic profile, clinical characteristics, CD4 count and viral load were analyzed. Descriptive analysis of socio-demographic and other characteristics was done. Result Fifty-two patients undertaking antiretroviral therapy were included in the study with the mean age of 29.69±9.59 years at diagnosis. The majority of the patients were male (51.9%). Sexual transmission was the dominant mode of transmission (78.9%). The mean CD4 count at baseline was 244.08±214.32 cells/µL. Four patients (7.7%) had a virological failure. There was a discordance between immunological and virological response in patients taking antiretroviral therapy for more than 2 years' duration with four patients with a recent CD4 count of ≤250 cells/µL had virological suppression. The mean CD4 count at treatment increased from 229.65 cells/µL to 453.33 cells/µL after 1 year of commencement of antiretroviral therapy (p<0.001). Conclusion There are optimal CD4 recovery and virological suppression as expected with antiretroviral therapy use.

The epidemiology of typhoid fever in the Dhulikhel area, Nepal: A prospective cohort study

Introduction

Typhoid fever (TF) continues to cause considerable morbidity and mortality in Nepal, but only limited epidemiologic data is available about TF outside Kathmandu.

Methods

As part of an interventional trial, we performed a prospective cohort study of bacteremic TF patients in Dhulikhel Hospital between October 2012 and October 2014. Demographic, epidemiological, clinical, and microbiologic data were recorded.

Results

116 bacteremic typhoid patients were included in the study. Most were young, healthy, adults (mean age 27.9±12 years), 41.4% of whom were female. More than 70% of patients were employed in non-manual services or were university students. Salmonella Typhi accounted for 64/115 (55.7%) of all isolates, while Salmonella Paratyphi accounted for 51/115 (44.3%), of which 42 were Paratyphi A and 9 Paratyphi B. A significant proportion of TF cases occurred also during the dry season (48/116, 41.6%). The clinical presentation of Salmonella Typhi and Paratyphi infections was similar, except for a greater proportion of arthralgia in patients with Salmonella Typhi. Most Salmonella Typhi and Paratyphi isolates were resistant to nalidixic acid and susceptible to older antibiotics. One Salmonella Paratyphi isolate was resistant to ceftriaxone.

Conclusions

TF remains common in the Dhulikhel area, even among those with a high level of education. Public health measures aimed at reducing the incidence of TF in the Dhulikhel area are warranted. The relative burden of TF caused by Salmonella Paratyphi is rising; a vaccine with activity against Salmonella Paratyphi is needed. Since Salmonella Paratyphi B was more prevalent in this cohort than in large cohorts of patients from Kathmandu, it is likely that there are significant regional variations in the epidemiology of TF outside Kathmandu.

Open label comparative trial of mono versus dual antibiotic therapy for Typhoid Fever in adults

Background

Emerging resistance to antibiotics renders therapy of Typhoid Fever (TF) increasingly challenging. The current single-drug regimens exhibit prolonged fever clearance time (FCT), imposing a great burden on both patients and health systems, and potentially contributing to the development of antibiotic resistance and the chronic carriage of the pathogens. The aim of our study was to assess the efficacy of combining third-generation cephalosporin therapy with azithromycin on the outcomes of TF in patients living in an endemic region.

Methods

An open-label, comparative trial was conducted at Dhulikhel Hospital, Nepal, between October 2012 and October 2014. Only culture-confirmed TF cases were eligible. Patients were alternately allocated to one of four study arms: hospitalized patients received either intravenous ceftriaxone or a combination of ceftriaxone and oral azithromycin, while outpatients received either oral azithromycin or a combination of oral azithromycin and cefexime. The primary outcome evaluated was FCT and the secondary outcomes included duration of bacteremia.

Results

105 blood culture-confirmed patients, of whom 51 were treated as outpatients, were eligible for the study. Of the 88 patients who met the inclusion criteria for FCT analysis 41 patients received a single-agent regimen, while 47 patients received a combined regimen. Results showed that FCT was significantly shorter for the latter (95 versus 88 hours, respectively, p = 0·004), and this effect was exhibited in both the hospitalized and the outpatient sub-groups. Repeat blood cultures, drawn on day 3, were positive for 8/47 (17%) patients after monotherapy, versus 2/51 (4%) after combination therapy (p = 0·045). No severe complications or fatalities occurred in any of the groups.

Conclusions

Combined therapy of third-generation cephalosporins and azithromycin for TF may surpass monotherapy in terms of FCT and time to elimination of bacteremia.

Trial registration

Trial registration number: NCT02224040.

Typhoid fever (TF) is a serious disease and the most common etiology of bloodstream infections in febrile patients in the Indian subcontinent. Before the advent of antibiotics its mortality rate reached up to 40%, and dropped dramatically upon their introduction. However, over the last decades multidrug-resistant strains have emerged, further posing a challenge to the treatment of TF. Here, we propose a novel treatment approach, combining azithromycin and a third-generation cephalosporin, two antibiotic agents, which act synergistically on the two niches occupied by the bacteria, the intra- and the extra-cellular compartments respectively. In our study of a rural Nepalese population with culture-confirmed TF, we have shown that dual therapy was superior to monotherapy in terms of time to defervescence and bacteremia elimination, both in outpatient and inpatient settings. We hence advocate the combination of these two antibiotics as a more effective therapeutic strategy than the current standard of care, and suggest that such approach may shorten patients’ hospital stay, and reduce both pathogen carriage rates and the development of antibiotic resistance.

Utility of mangled extremity severity score in severely injured lower limbs

Introduction: Massive lower extremity trauma,in particular open tibial fractures with associated vascular injuries, present an immediate and complex decision-making challenge between a limb salvage attempt and primary amputation. Medical and surgical advances of the past two decades have improved the ability to reconstruct severely injured limb. Limbs that once would have been amputated are now routinely managed with complex reconstruction protocol. Mangled extremity severity score is one of the scoring systems to predict the fate of limbs after severe limb injuries.Methods: Patients fulfilling the inclusion criteria were evaluated with MESS, at the same time treatment protocol for management of injuries of lower limb were followed independently by attending orthopedic surgeon. Mean MESS for salvaged and amputated limbs were calculated and its reliability for prediction of fate of injured limb was assessed using software SPSS v16.Result: The age of patient ranges from 10 to 65 yrs with mean age 35.83. The most common mechanism of injury was Road Traffic Accident followed by fall from height. The mean MESS score for salvaged limbs was 4.18 and for amputated limbs was 8.12 suggesting significant difference in mean scores. The sensitivity (the probability that limbs requiring amputation will have MESS at or above 7) was found to be 75%. The specificity of MESS (the probability that salvage limbs will have MESS < 7) was 95.45%.Conclusion: MESS is a reliable indicator in decision making process whether a limb can be salvaged or needs amputation. The mangled lower extremity with the score of less than 7 may be salvaged and 7 or more may need amputation.JSSN 2015; 18 (1), Page: 23-25

Outcome of minimally invasive plate osteosynthesis in distal tibial fractures

Introduction: Distal tibial fractures present as a major challenge for the orthopedic trauma surgeons. Most non-operative treatments result in non-union or malunion and needs prolonged immobilization of the knee and ankle joints, with resulting stiffness. Open reduction and internal fixation as well as external fixation has high rate of infection and non-union. Minimally Invasive Plate Osteosynthesis has been shown to have a better outcome and has been the procedure of choice in most distal tibial fractures since the introduction of the locking compression plate. The objective of the study is to review the outcome of Minimally Invasive Percutaneous Osteosynthesis (MIPO) in unstable distal tibial fractures.Methods: Charts of patients who underwent MIPO from the year 2008 to 2013 for unstable distal tibial fractures over five years at Patan Hospital and Om Hospital were reviewed. All displaced closed fractures and Gustillo Anderson Type I and II fractures were included in the study. Plates consisted of the anatomically contoured 4.5 mm LCP and 3.5 mm LCP-Pilon form plate. A simple uniplanar external fixator was used to retain the reduction till the plate was inserted and secured with locking screws. The outcome of MIPO in distal tibial fractures were followed up and evaluated.  Clinical and radiological assessments were performed at 6 weeks, and at 3, 6, 9, 12 and 24 months.Results: Of the 75 patients (45 male, 30 female) age ranging from 19 to 70 years (mean 47 years), 5 patients were lost to follow-up. 28 patients at 3 months, 32 at 6 months, and 8 at 9 months met the criteria for a healed fracture. Two patients required autologous bone grafting at 9 months for non-union ultimately resulting in the fracture union at 16 months. There was one malunion attributable to the loss of reduction during plate fixation. There were no deep infections, no soft tissue complications and no failures of fixation. The cause of fracture were RTA (n=35), fall from height (n=9), twisting of ankle as a result of fall from standing height (n=22), and others (n=11). The mean time for surgery from the time of injury was 5 (range, 2 to 14) days; the mean hospital stay was 10 (range, 7 to 21) days.Conclusion: MIPO is an effective treatment for closed, unstable fractures of the distal tibia, avoiding the complications associated with more traditional methods of internal fixation and/or external fixation.Journal of Society of Surgeons of NepalVol. 17, No. 2, 2014, Page: 7-11

Antimicrobial susceptibility patterns of Salmonella typhi and Salmonella paratyphi A in a tertiary care hospital

BACKGROUND

Enteric fever is still an important public health problem in developing countries including Nepal. A changing antibiotic susceptibility pattern of Salmonella typhi and Salmonella paratyphi A and emergence of multi drug resistance has increased to a great concern. Aim of the study was to investigate the antibiotic susceptibility pattern of Salmonella typhi and Salmonella paratyphi A.

METHODS

Study was carried out at the department of microbiology in Kathmandu Medical College. Blood culture samples were collected from suspected enteric fever patient and tested microbiologically by standard procedure. Antibiotic susceptibility test was performed by Kirby-Bauer disc diffusion method and results were interpreted by National Committee for Clinical Laboratory (NCCLS) guideline.

RESULTS

Of total 78 (2.0%) Salmonella serotype isolated from 3,980 blood culture samples, in which 47 (60.3%) were S. typhi and 31 (39.7%) were S. paratyphi A. Isolates were from all age group median age being the 25 years. Among the tested antibiotics S. typhi was susceptible towards Ciprofloxacin (100%) followed by Gentamicin (97.9%), Ofloxacine (95.7%), Ceftriaxone (95.7%) and Chloramphenicol (93.6%). In case of S. paratyphi A most of the tested antibiotics showed high percentage of susceptibility and least susceptible antibiotic for S. paratyphi A was Ampicillin (25.8%). Three isolates of S. typhi showed multidrug resistance.

CONCLUSIONS

A considerable variation was observed in the antimicrobial susceptibility pattern of S.typhi and S. paratyphi A. Hence antibiotic susceptibility test must be sought before instituting appropriate therapy to prevent from further emergence of drug resistance.

Clinical profile of patients with pleural effusion admitted to KMCTH

BACKGROUND

Pleural effusion is the common findings in patients presenting with cardiopulmonary symptoms but specific studies are lacking in Nepal.

OBJECTIVE

The main objective of this study is to fi nd out the various causes of pleural effusion, their mode of clinical presentation and laboratory analysis of blood and pleural fluid to aid diagnosis of patients with pleural effusion.

MATERIALS AND METHODS

Retrospective data from July 2009 to July 2007 from all the cases diagnosed with pleural effusion were taken. Altogether 100 cases diagnosed with pleural effusion by chest X-ray (Posterior- Anterior and Lateral view) and Ultrasonogram of the chest were studied. The following parameters were analysed: Patients demographic profile, causes, location (Unilateral, Bilateral), Blood haemoglobin and count, sputum profile, Monteux test, chest X-ray and USG findings and pleural fluid analysis[Biochemical, Haematological, Microbiological (culture and stain) and cytological]. This study was analysed by using SPSS 16.

RESULTS

The mean age of the patient was 44.89 +/- 21.59 and must patients with pleural effusion belong to age group 21-30. Most common cause of pleural effusion was found to be tubercular effusion followed by parapneumonic effusion. Right sided effusion was seen in most cases of tubercular parapneumonic and malignant effusion whereas bilateral effusion was seen in 87.5% of the patient (7 out of 8) having congestive heart failure and all cases of renal disease (4 out of 4). Shortness of breath (83%), cough (67%) and fever (66%) are the most common mode of clinical presentation.

CONCLUSION

Our study concluded that the most common cause of unilateral pleural effusion is tuberculosis followed by parapneumonic effusion and most cases of those belong to younger age group (21-30 yrs) and most common cause of bilateral pleural effusion is congestive cardiac failure.