Understanding health system resilience in responding to COVID-19 pandemic: experiences and lessons from an evolving context of federalization in Nepal

INTRODUCTION

The COVID-19 pandemic has tested the resilience capacities of health systems worldwide and highlighted the need to understand the concept, pathways, and elements of resilience in different country contexts. In this study, we assessed the health system response to COVID-19 in Nepal and examined the processes of policy formulation, communication, and implementation at the three tiers of government, including the dynamic interactions between tiers. Nepal was experiencing the early stages of federalization reform when COVID-19 pandemic hit the country, and clarity in roles and capacity to implement functions were the prevailing challenges, especially among the subnational governments.

METHODS

We adopted a cross-sectional exploratory design, using mixed methods. We conducted a desk-based review of all policy documents introduced in response to COVID-19 from January to December 2020, and collected qualitative data through 22 key informant interviews at three tiers of government, during January-March 2021. Two municipalities were purposively selected for data collection in Lumbini province. Our analysis is based on a resilience framework that has been developed by our research project, ReBUILD for Resilience, which helps to understand pathways to health system resilience through absorption, adaptation and transformation.

RESULTS

In the newly established federal structure, the existing emergency response structure and plans were utilized, which were yet to be tested in the decentralized system. The federal government effectively led the policy formulation process, but with minimal engagement of sub-national governments. Local governments could not demonstrate resilience capacities due to the novelty of the federal system and their consequent lack of experience, confusion on roles, insufficient management capacity and governance structures at local level, which was further aggravated by the limited availability of human, technical and financial resources.

CONCLUSIONS

The study findings emphasize the importance of strong and flexible governance structures and strengthened capacity of subnational governments to effectively manage pandemics. The study elaborates on the key areas and pathways that contribute to the resilience capacities of health systems from the experience of Nepal. We draw out lessons that can be applied to other fragile and shock-prone settings.

Contextual factors affecting the implementation of an anemia focused virtual counseling intervention for pregnant women in plains Nepal: a mixed methods process evaluation

BACKGROUND

Anemia is estimated to cause 115,000 maternal deaths each year. In Nepal, 46% of pregnant women have anemia. As part of an integrated anemia-prevention strategy, family engagement and counseling of pregnant women can increase compliance to iron folic acid tablets, but marginalized women often have lower access to these interventions. We implemented the VALID (Virtual antenatal intervention for improved diet and iron intake) randomized controlled trial to test a family-focused virtual counseling mHealth intervention designed to inclusively increase iron folic acid compliance in rural Nepal; here we report findings from our process evaluation research.

METHODS

We conducted semi structured interviews with 20 pregnant women who had received the intervention, eight husbands, seven mothers-in-laws and four health workers. We did four focus groups discussions with intervention implementers, 39 observations of counseling, and used routine monitoring data in our evaluation. We used inductive and deductive analysis of qualitative data, and descriptive statistics of monitoring data.

RESULTS

We were able to implement the intervention largely as planned and all participants liked the dialogical counseling approach and use of story-telling to trigger conversation. However, an unreliable and inaccessible mobile network impeded training families about how to use the mobile device, arrange the counseling time, and conduct the counseling. Women were not equally confident using mobile devices, and the need to frequently visit households to troubleshoot negated the virtual nature of the intervention for some. Women's lack of agency restricted both their ability to speak freely and their mobility, which meant that some women were unable to move to areas with better mobile reception. It was difficult for some women to schedule the counseling, as there were competing demands on their time. Family members were difficult to engage because they were often working outside the home; the small screen made it difficult to interact, and some women were uncomfortable speaking in front of family members.

CONCLUSIONS

It is important to understand gender norms, mobile access, and mobile literacy before implementing an mHealth intervention. The contextual barriers to implementation meant that we were not able to engage family members as much as we had hoped, and we were not able to minimize in-person contact with families. We recommend a flexible approach to mHealth interventions which can be responsive to local context and the situation of participants. Home visits may be more effective for those women who are most marginalized, lack confidence in using a mobile device, and where internet access is poor.

Health worker perspectives on access to antenatal care in rural plains Nepal during the COVID-19 pandemic

The COVID-19 pandemic affected access to antenatal care in low and middle-income countries where anaemia in pregnancy is prevalent. We analyse how health workers provided antenatal care and the factors affecting access to antenatal care during the COVID-19 pandemic in Kapilvastu district in the western plains of Nepal. We used qualitative and quantitative methodologies, conducting eight semi-structured interviews with health workers who provided antenatal care during the pandemic, and a questionnaire containing open and closed questions with 52 female community health volunteers. Antenatal care was severely disrupted during the pandemic. Health workers had to find ways to provide care with insufficient personal protective equipment and guidance whilst facing extreme levels of stigmatisation which prevented them from providing outreach services. Pregnant women were fearful or unable to visit health institutions during the pandemic because of COVID-19 control measures. Pre-pandemic and during the pandemic health workers tried to contact pregnant and postpartum women and families over the phone, but this was challenging because of limited access to phones, and required pregnant women to make at least one antenatal care visit to give their phone number. The pandemic prevented new pregnancies from being registered, and therefore the possibilities to provide services over the phone for these pregnancies were limited. To reach the most marginalised during a pandemic or other health emergency, health volunteers and households need to exchange phone numbers, enabling proactive monitoring and care-seeking. Strengthening procurement and coordination between the municipal, provincial, and federal levels of government is needed to ensure adequacy of antenatal supplies, such as iron folic acid tablets, in health emergencies. Community engagement is important to ensure women and families are aware of the need to access antenatal care and iron folic acid, and to address stigmatisation of health workers.

AB1384 CLINICAL SIGNIFICANCE OF DENSE FINE SPECKLED PATTERN ANA

Background

The clinical significance of Dense Fine Speckled (DFS) pattern Anti-nuclear antibodies (ANA) by indirect immunofluorescence method (IIF) is unclear and has been inversely associated with rheumatic disease 12.

Objectives

Our purpose was to determine associations between DFS pattern ANA and the disease categories of inflammatory arthritis, ANA associated rheumatic diseases (AARD), fibromyalgia/chronic pain syndrome/chronic fatigue syndrome and atopic disorder.

Methods

This retrospective study used data from patients tested for ANA by IIF between August 2017 to August 2019 at the University of Minnesota Medical Center. Comparisons between the diagnostic categories listed in objectives were made for patients with negative ANA, positive ANA (any pattern) and DFS pattern. Individual disease diagnoses belonging to the above categories were also analyzed. The inflammatory arthritis category included seropositive rheumatoid arthritis (RA), seronegative RA, RA with unknown serology, ankylosing spondylitis, and psoriatic arthritis. The disease category of AARD included systemic lupus erythematosus (SLE), systemic sclerosis, mixed connective tissue disease, idiopathic inflammatory myopathies, Sjogren’s syndrome (SS), and undifferentiated connective tissue disorder (UCTD). Atopic disorders included atopic dermatitis, allergic rhinitis, urticaria, and asthma. Frequency of Raynaud’s phenomenon (RP) was also calculated.

Results

13,845 patients with an ANA during the study period were identified. 9106 (65.8%) had negative ANA and 4739 (34.2%) had positive ANA by IIF (including all patterns). 640 (4.6%) had ANA positive DFS patterns. Relative risk (RR) was calculated for diagnostic categories and individual diseases. For patients with positive ANA and DFS pattern, the RR for diagnostic codes of inflammatory arthritis categories [1.35 (1.07- 1.71), p=0.02] was higher when compared to the frequency of codes in ANA negative. RR for AARD among patients with DFS pattern was also higher [1.78 (1.44- 2.2), p <0.001]. There was no significant difference in the frequency of diagnostic codes of chronic pain/fibromyalgia/chronic fatigue syndrome [1.02 (0.9- 1.2), p=0.84] atopic disorder [0.68 (0.4- 1.15), p=0.16] for DFS+ compared to the ANA group. The frequency of AARD diagnostic codes was lower for patients with DFS pattern [0.64 (0.52- 0.79), p<0.001] compared to ANA positive patients with all other patterns, consistent with published data. There was no significant difference of frequency of diagnostic codes for the rest of the disease categories when comparison was made between ANA positive DFS pattern and ANA positive with other patterns.

Individual disease diagnostic codes of RA were higher among DFS+ patients when compared to ANA- patients. The frequency of diagnostic codes of SLE, SS, UCTD, fibromyalgia, Raynaud’s phenomenon, and autoimmune thyroid disease was also higher among patients with DFS pattern compared to ANA- patients. The frequency of diagnostic codes of seropositive RA was lower among patients with DFS pattern compared to ANA+ with all other patterns. The frequency of diagnostic codes of SLE, SSc, UCTD, and chronic pain was also lower among DFS+ patients, compared to those with ANA of all other patterns, consistent with prior reports.

Conclusion

The frequency of diagnostic codes of RA, SS and Raynaud’s was higher among DFS pattern ANA compared to ANA negative group but was not significantly different from ANA positive with other patterns. This suggests that the presence of a DFS pattern should not be used to indiscriminately exclude the presence of a rheumatic disease.

References

[1]Mariz HA, Sato EI, Barbosa SH, Rodrigues SH, Dellavance A, Andrade LEC. Pattern on the antinuclear antibody-HEp-2 test is a critical parameter for discriminating antinuclear antibody-positive healthy individuals and patients with autoimmune rheumatic diseases. Arthritis Rheum. 2011;63(1):191-200. doi:10.1002/art.30084

[2]Watanabe A, Kodera M, Sugiura K, et al. Anti-DFS70 Antibodies in 597 Healthy Hospital Workers. ARTHRITIS Rheum. 2004;50(3):892-900. doi:10.1002/art.20096

Disclosure of Interests

None declared

Medical Products for Cardiovascular Disease Management in Nepal: a needs assessment study

Background Medical Products and Technologies is a key component of the health system. Quality medicines and efficient management of the medical products can secure effective cardiovascular diseases management. Objective To collate information and identify strengths, weaknesses, opportunities and threats (SWOT) associated with medical products and technology component for cardiovascular disease management in Nepal. Method This study is a part of a larger rapid assessment of Nepal's health system for cardiovascular disease management and based on The Health System Assessment Approach: A How-To Manual (USAID). The authors conducted a desk review of documents related to the WHO "medical product and technology" building block component and key informant interviews using a pre-tested interview protocol. The first eight interviews were transcribed verbatim and analysed inductively to generate a codebook; and the remaining, transcribed and deductively coded based on the codebook. Findings were categorised into relevant topical area and SWOT components. Result Nepal has laws and provisions for medicine regulation, pharmacovigilance, post marketing surveillance, registration and licensing provisions for pharmacy industries/ outlets, essential medicine lists and national formulary. These provisions also apply to medicines used for cardiovascular diseases. The challenge however, is the lack of effective implementation and monitoring, due to shortages of technical workforce and state of art information and technologies. Information on pharmaceutical expenditures for cardiovascular disease management is scarce; there are no standard national level guidelines that are consistently used to manage cardiovascular diseases in health facilities. Conclusion There are limited provisions and information on medical products for cardiovascular disease management in Nepal, and a need to strengthen existing provisions for medicine regulations and surveillance.

Vitamin D and bisphosphonate therapy in systemic lupus erythematosus patients who receive glucocorticoids: are we offering the best care?

OBJECTIVE

This study aimed to evaluate management practices for glucocorticoid (GC)-induced osteoporosis (GIOP) in systemic lupus erythematosus (SLE) patients using 2017 American College of Rheumatology guidelines as a gold standard.

METHODS

We conducted a retrospective cohort study using a clinical database from the years 2011 to 2016. SLE cases with >90 days continuous prednisone use at doses of ≥7.51 mg daily were identified. Osteoporosis risk factors were assessed via chart review. The Fracture Risk Assessment (FRAX) score was estimated for patients > 40 years of age. Vitamin D, bisphosphonate prescriptions, and osteoporotic (OP) fractures were ascertained through chart review. A classification tree was used to identify the key patient-related predictors of bisphosphonate prescription.

RESULTS

A total of 203 SLE patients met the inclusion criteria. The recommended dose of vitamin D supplement was prescribed to 58.9% of patients < 40 years of age and 61.5% of patients ≥ 40 years of age. Among patients aged ≥ 40 years, 25% were prescribed bisphosphonates compared to 36% who met indications for bisphosphonates per the ACR guidelines. Another 10% were prescribed a bisphosphonate, despite not having indication per the ACR guidelines, which was considered as overtreatment. Among patients aged ≥ 40 years, older age and a higher FRAX score for major OP fracture and hip fracture predicted bisphosphonate prescription. In a classification tree analysis, patients with FRAX scores (for major OP fracture) of ≥ 23.5% predicted bisphosphonate prescription in this SLE population. Among patients who had OP fractures in the follow-up period, nine (6.50%) were inpatients receiving appropriate GIOP care versus 12 (13.6%) who were inpatients not receiving ACR-appropriate care (p = 0.098).

CONCLUSIONS

In clinical practice, fewer SLE patients with or at risk for GIOP are prescribed vitamin D and bisphosphonates than recommended by the 2017 ACR guidelines. Also, in this study, another 10% were prescribed a bisphosphonate, despite not having an indication per the ACR guidelines. Patients were most likely to receive a bisphosphonate prescription if they had a major OP FRAX score of > 23.5%.

Multi-drug Resistant and Extended Spectrum β-lactamase Producing Salmonella Species Isolated from Fresh Chicken Liver Samples

Background Emergence of antibiotic resistance among microbes contaminating the fresh meat products is a global public health concern as they can be easily transmitted to humans through their consumption and contact. Objective The current study was conducted to determine the distribution of antimicrobial resistance among Salmonella species isolated from fresh chicken liver samples with special emphasis on extended spectrum beta-lactamase (ESBL) production. Method A total of 200 fresh chicken liver samples were cultivated for the isolation of Salmonella and further subcultivated to detect extended spectrum beta-lactamase production among them. Antimicrobial susceptibility testing (AST) was done by disk diffusion method using a panel of 7 antimicrobials. Result Out of 200 samples analyzed, 61 (30.5%) samples harbored Salmonella species out of which 15 (7.5%) samples showed the presence of Salmonella Typhi. A significant association was noted in the incidence of Salmonella with various factors pertaining to the butchers, such as age, sex, literacy rate, practices of washing knives and chopping board, wearing aprons and gloves and type of water used (p < 0.05). Salmonella isolates were highly sensitive to amikacin (82.0%) and least sensitive to tetracycline (3.3%). All the isolates were resistant to colistin. Sixty (98.4%) isolates were identified as multi-drug resistant (MDR). The total number of extended spectrum betalactamase producers reported among Salmonella isolates was 29 (47.5%). Conclusion The results indicate that the fresh chicken liver samples sold in Bharatpur Metropolis are reservoirs of multi-drug resistant Salmonella, including extended spectrum betalactamase producers, that could potentially be transmitted to the humans by direct contact or through inadequate cooking.

Neuritic Leprosy; An Intriguing Re-visit to a Forbidden Ailment

Leprosy is a chronic infectious disease that presents with varied manifestations. Pure neuritic leprosy is one of the rarest forms of the disease which is characterized by nerve involvement without the characteristic cutaneous stigmata. Eleven year old, healthy male presented with progressively increasing painful swelling at the medial aspect of the arm near to the right elbow joint with difficulty in extending right ring and little fingers at interphalangeal joint and numbness in the same region for last 1 year with no cutaneous abnormalities. Physical examination revealed 6x3 cm firm, tender lesion 3 cm proximal to the right elbow joint with positive tinel's sign, without signs of inflammation, along with characteristic claw hand deformity of right hand and atrophy of hypothenar and interossei muscle. Electro-diagnostic testing revealed findings consistent with a right ulnar axonal neuropathy above the elbow. Magnetic resonance imaging revealed well defined heterogeneously hyper intense linear lesion along the course of thickened ulnar nerve in the distal arm extending posterior to the medial condyle. It also showed an oval shaped lesion (2.1x1.0 cm) arising from the same segment of the nerve, without any bony or muscular involvement of that area. The patient underwent surgical exploration and ulnar nerve decompression with biopsy. Pathology revealed necrotizing granulomatous inflammatory acid fast bacilli stain negative lesion, which was histologically consistent with caseous abscess caused by tuberculoid leprosy, pathognomonic for Hansen's disease. He has been started on antibiotic therapy and is referred to leprosy center for further course of management. Pure neuritic leprosy, though rare, should be considered as differential diagnosis in cases presenting with peripheral neuropathy at leprosy-endemic areas. Prompt diagnosis and treatment is imperative to prevent permanent neurological injury.

Identification of six Listeria species by real-time PCR assay

The Listeria genus comprises 10 recognized species. Listeria monocytogenes causes listeriosis in humans and other animals primarily via contaminated food or animal feed. Listeria ivanovii causes listeriosis in animals and on rare occasions in humans. The identification of nonpathogenic species of Listeria in foods indicates that conditions exist that support the growth of pathogenic strains and is used to facilitate the implementation of control and prevention measures. This study shows the development and evaluation of a 5'exonuclease real-time PCR assay for the rapid identification of Listeria seeligeri, Listeria welshimeri, L. monocytogenes, L. ivanovii, Listeria grayi and Listeria innocua. The assay consists of two triplexes that were evaluated using 53 cultures of Gram-positive bacteria, including 49 Listeria spp. from human, animal, food or food-processing environments. The assay was rapid, specific and reproducible and could identify each of the six species from a mixture of strains. The developed assay proved to be a powerful means of rapidly identifying Listeria species and could be usefully implemented in busy specialist reference laboratories.

SIGNIFICANCE AND IMPACT OF THE STUDY

The identification of species of Listeria from foods is important to monitor pathogenic strains and facilitates the implementation of control measures. This study shows the development and evaluation of a 5'exonuclease real-time PCR assay for the rapid identification of L. seeligeri, L. welshimeri, L. monocytogenes and L. ivanovii, L. grayi, L. innocua. The developed assay proved to be specific, rapid and reproducible and therefore could be implemented in busy specialist reference laboratories.

Clinical profile and outcome of acute encephalitis syndrome (AES) patients treated in College of Medical Sciences-Teaching Hospital

Objective: Acute encephalitis syndrome is a cause of significant morbidity and mortality in Nepal. Although Japanese encephalitis virus (JEV) was thought to be a major cause for acute encephalitis syndrome, more non-Japanese encephalitis virus cases are reported. The outcome of patients with acute encephalitis syndrome is variable. Our study was designed to study the clinical profile and outcome of patients with acute encephalitis syndrome managed in tertiary care center in central Nepal. Methods: The record of patients admitted with diagnosis of acute encephalitis syndrome,from January 2010 to December 2010 in College of Medical Sciences-Teaching Hospital (CMS-TH) was reviewed. They were classified clinically as meningitis, encephalitis and meningoencephalitis. The clinical details and reports of the patients were recorded and analyzed. Results: Total of 85 cases of meningitis and encephalitis were identified. Mean age was 19.18 years. Fifty-six (65.9%) patients were males and 29 (34.1%) were females. Sixty (70.58%) patients had meningitis, 8 (9.41%) had encephalitis, and 17 (20.0%) had meningoencephalitis. JE serology was positive in 4 patients (4.7%). Seventy-two (84.7%) patients made full recovery and were discharged from hospital. Thirteen (15.3%) patients left against medical advice (LAMA). Conclusion: Acute encephalitis syndrome is still a major public health problem in Nepal. Few of these patients have Japanese Encephalitis. There is a trend towards improved outcome because of availability of improved health services. However, financial constraint remains a challenge in management of acute encephalitis syndrome. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-2, 31-37 DOI: http://dx.doi.org/10.3126/jcmsn.v9i2.9685

Bile duct injuries during open and laparoscopic cholecystectomy: management and outcome

BACKGROUND

The widespread application of laparoscopic cholecystectomy has led to a rise in the numbers of major bile duct injuries (BDI). Perioperative management of these injuries is complex and challenging. There are few published reports locally regarding the perioperative management of BDI. Purpose of this review was to analyze our experience in diagnosis, management and prevention of BDI.

METHODS

This study was conducted in department of surgery at B. P. Koirala Institute of Health Sciences. From January 2001 to September 2010, a observational study of all patients with a BDI following cholecystectomy was maintained. Patients' charts were retrospectively reviewed to analyze incidence, type of injury, presentation, and perioperative management of BDI.

RESULTS

A total of 92 patients had BDI which occurred during cholecystectomy, were analysed retrospectively. There were 60/92 (65.5%) patients with BDI resulting from the wrong identification of the anatomy of the Calot's triangle during cholecystectomy. Abdominal ultrasonography was diagnostic for BDI in 71/90 (78.8%). Magnetic resonance cholangiography could reveal the site of injury, the length of injured bile duct and variation of bile duct tree with a diagnostic rate 22/23 (95.6%). The most common injury was Strasberg's E2 in 65/92 (70.7%). A transection or stricture of the bile duct was repaired by hepaticojejunostomy (83 cases in this series). Seventy-five (81.5%) patients were followed up. The mean follow-up time was 2.6 years (range 0.16-6). Good results were achieved in 62/75 (82.6%) of the patients.

CONCLUSIONS

The high success rate of bile duct repair in the present study can be attributed to the appropriate timing, meticulous technique and the tertiary care experience.

Colonic inflammatory myofibroblastic tumours: an institutional review

AIM

The aim of the study was to present the largest series of colonic inflammatory myofibroblastic tumour (C-IMFT) in the literature so far and to provide a review of this condition.

METHOD

A retrospective review was carried out of a consecutive series of patients diagnosed with a C-IMFT at a community-based hospital with a specialized gastrointestinal unit between 2002 and 2011. The main outcome measures were success rate and postoperative complications. Using a set of terms we searched the PubMed database for papers published on C-IMFT. We reviewed the data from these studies and case reports.

RESULTS

There were seven patients with a histopathologically proven C-IMFT. The patients' mean age was 39 ± 11.3 years. Four presented with clinical features of intestinal obstruction of varying severity and three with symptoms of anaemia. Complete surgical resection with end-to-end anastomosis was performed. The gross morphology included polypoidal myxoid tumours that served as a lead point for intussusception in two cases, a whorled mass in two and a circumferential infiltrative tumour in three. Microscopically, all tumours had typical features of IMFT with a variable expression of anaplastic lymphoma kinase (ALK-1) and tumour-free resection margins. All patients were well without local recurrence or metastasis at a mean follow-up of 46.8 ± 11.9 months.

CONCLUSION

Surgical resection is effective for this rare tumour which mostly behaves in a benign manner. Our review supports the need for patients to be followed up for long periods because of the possibility of metastasis or late recurrence.

Incidence of hypertension in patients undergoing surgery at Dhulikhel Hospital-Kathmandu University Hospital

BACKGROUND

Hypertension is an important public health challenge worldwide and is most important modifiable risk factor for cardiovascular, cerebrovascular and renal disease. Blood pressure determination forms an integral part of anaesthesiologist evaluation of his patient condition prior to and during surgery. Data are not available which indicate changes in blood pressure occurring preanaesthetically in hospitalized patients. There are several risks from untreated preoperative hypertension in perioperative and postoperative phase.

OBJECTIVE

To know the incidence of hypertension in preoperative patients undergoing major surgery.

METHODS

This retrospective observational study was based on the data collected from preanaesthetic checkup record book from January 2010 to December 2010.

RESULTS

A total of 955 patients were studied and analyzed in terms of hypertension and demographic characteristics. The total incidence of hypertension in preoperative phase was 10.16%. Among them 64.9% being male and 35.1% female. Maximum incidence was found in age group 50-59 years i.e. 26.6%. Among the case detected maximum patients i.e. 52% were patients with newly diagnosed hypertension and among those under medications 61.1% were using calcium channel blockers.

CONCLUSION

Knowing the incidence will help in proper preoperative optimization of the hypertensive patients and also help in decreasing the incidence of postoperative complications.

Supplementation of Broilers Diet with Different Sources of Growth Promoters

A study was conducted at the Institute of Agriculture and Animal Sciences (IAAS), Rampur, Chitwan from 29 August to 17 October, 2007 to compare the effects of antibiotic (chlortetracycline) and probiotic (Lactobacillus acidophilus) with three herbal growth promoters, Amala (Emblica officinalis),(EO), Tulsi (Ocimum sanctum), (OC) and Aswogandha (Withania somnifera),(WS) on growth performance, feed consumption, feed conversion efficiency, carcass characteristics, and economics of broiler production. The experiment was laid out in a completely randomized design with day-old broiler chick (192) randomly assigned to eight groups containing 8 chick in each and replicated three times. The control group received the maize-soybean based basal diet. In the treatment groups, the basal diet was supplemented with one of the following: antibiotic, probiotics, Tulsi, Amala, and Aswogandha and also in combination of herbs, forming eight treatments respectively. Results showed significantly better production in herbs. Significantly higher digestibility of all the nutrients (P<0.05) was observed in Amala+Tulsi+Aswogandha (T8) supplemented group. Highest body weight (1.440kg) was recorded in birds fed diet supplemented with Amala and Tulsi, and the lowest body weight (1.317kg) was seen in antibiotics (T2) fed birds. The highest income over expenditure (Rs.26.36) was recorded in birds fed diet supplemented with Tulsi (T6), although the difference was not significant among the treatments. Looking at the benefit cost ratio, highest B/C ratio was found in birds supplied with Tulsi (1.19) supplemented diet and minimum (1.12) was recorded in Amala supplied diet. Hence, this experiment showed that herbs as growth promoters can replace antibiotics in the diet of broiler chicken. However, it needs multilocational trials before recommendation for adoption by poultry growers.DOI: http://dx.doi.org/10.3126/njst.v12i0.6478 Nepal Journal of Science and Technology 12 (2011) 41-50 

Profile of ascites patient admitted in Nepal Medical College Teaching Hospital

Ascites is one of the frequently encountered problems in internal medicine. Common causes of ascites are portal hypertension including cirrhosis of liver and congestive heart failure, hypoalbuminemia associated with nephrotic syndrome, intra-abdominal malignancy and abdominal tuberculosis. We evaluated 43 patients presented with ascites in Nepal Medical College Teaching Hospital (NMCTH). After history taking, clinical examination, imaging studies and laboratory evaluation alcoholic liver disease and abdominal tuberculosis were diagnosed in 19 and 5 patients restively. Constrictive pericarditis was diagnosed in 2 patients and 2 patients were suffering from HCV related liver disease. Present study revealed alcoholic liver disease as the commonest cause of ascites.

Evidence for a Great Medieval Earthquake (~1100 A.D.) in the Central Himalayas, Nepal

The Himalayan orogen has produced three thrust earthquakes with moment magnitude (Mw) 7.8 to 8.5 during the past century, yet no surface ruptures associated with these great earthquakes have been documented. Here, we present paleoseismic evidence from east central Nepal that, since approximately 700 A.D., a single earthquake ruptured the Frontal Thrust fault at approximately 1100 A.D., with a surface displacement of approximately 17 (+5/-3) meters and a lateral extent and size that could have exceeded 240 kilometers and approximately Mw 8.8, respectively. Ruptures associated with Mw <8.2 events would contribute to the frontal Himalayas folding but would stop before reaching the surface. These findings could require substantial modifications to current regional seismic hazard models.