Integration and evaluation of chest X-ray artificial intelligence in clinical practice

Purpose

To integrate and evaluate an artificial intelligence (AI) system that assists in checking endotracheal tube (ETT) placement on chest x-rays (CXRs) in clinical practice.

Approach

In clinical use over 17 months, 214 CXR images were ordered to check ETT placement with AI assistance by intensive care unit (ICU) physicians. The system was built on the SimpleMind Cognitive AI platform and integrated into a clinical workflow. It automatically identified the ETT and checked its placement relative to the trachea and carina. The ETT overlay and misplacement alert messages generated by the AI system were compared with radiology reports as the reference. A survey study was also conducted to evaluate usefulness of the AI system in clinical practice.

Results

The alert messages indicating that either the ETT was misplaced or not detected had a positive predictive value of 42% (21/50) and negative predictive value of 98% (161/164) based on the radiology reports. In the survey, radiologist and ICU physician users indicated that they agreed with the AI outputs and that they were useful.

Conclusions

The AI system performance in real-world clinical use was comparable to that seen in previous experiments. Based on this and physician survey results, the system can be deployed more widely at our institution, using insights gained from this evaluation to make further algorithm improvements and quality assurance of the AI system.

Systems-level analyses of protein-protein interaction network dysfunctions via epichaperomics identify cancer-specific mechanisms of stress adaptation

Systems-level assessments of protein-protein interaction (PPI) network dysfunctions are currently out-of-reach because approaches enabling proteome-wide identification, analysis, and modulation of context-specific PPI changes in native (unengineered) cells and tissues are lacking. Herein, we take advantage of chemical binders of maladaptive scaffolding structures termed epichaperomes and develop an epichaperome-based 'omics platform, epichaperomics, to identify PPI alterations in disease. We provide multiple lines of evidence, at both biochemical and functional levels, demonstrating the importance of these probes to identify and study PPI network dysfunctions and provide mechanistically and therapeutically relevant proteome-wide insights. As proof-of-principle, we derive systems-level insight into PPI dysfunctions of cancer cells which enabled the discovery of a context-dependent mechanism by which cancer cells enhance the fitness of mitotic protein networks. Importantly, our systems levels analyses support the use of epichaperome chemical binders as therapeutic strategies aimed at normalizing PPI networks.

Maternal Health Services Utilisation in Panchkhal Municipality, Kavrepalanchok, Nepal

Background Maternal Health is a priority program of Nepal. The low utilization of maternal health services is one of the major contributing factors for high maternal morbidity and mortality in developing countries like Nepal. Objective To explore various maternal health services utilized by women and identify various factors affecting the utilization of maternal health services in Panchkhal Municipality. Method A descriptive cross-sectional study was conducted among 355 reproductive-age women who have given birth in the last 2 years in Panchkhal Municipality. The data collection period was from May to July 2020. A convenient sampling method was used to select the study population. The data analysis was done by using Statistical Package for Social Sciences (version 20.0). Variables were defined by the frequency in numbers and percentages. Result The findings from the study showed that the coverage of the antenatal care (ANC) visit was 77% and among them, 25.6% visited at least 4 antenatal care visits as recommended by the government of Nepal. Out of 355 respondents, 52.4% were delivered in the health institution, and only 20% visited postnatal care after the delivery. Among various factors, lack of treatment facilities and health facilities at a far distance were the most common factors for the underutilization of maternal health services. Conclusion The coverage of maternal health services is still low despite free maternal health services with an incentive scheme. A further detailed investigation is required to find the real scenario of the Panchkhal municipality to under-utilization of maternal health services.

Automated Endotracheal Tube Placement Check Using Semantically Embedded Deep Neural Networks

RATIONALE AND OBJECTIVES

To develop artificial intelligence (AI) system that assists in checking endotracheal tube (ETT) placement on chest X-rays (CXRs) and evaluate whether it can move into clinical validation as a quality improvement tool.

MATERIALS AND METHODS

A retrospective data set including 2000 de-identified images from intensive care unit patients was split into 1488 for training and 512 for testing. AI was developed to automatically identify the ETT, trachea, and carina using semantically embedded neural networks that combine a declarative knowledge base with deep neural networks. To check the ETT tip placement, a "safe zone" was computed as the region inside the trachea and 3-7 cm above the carina. Two AI outputs were evaluated: (1) ETT overlay, (2) ETT misplacement alert messages. Clinically relevant performance metrics were compared against prespecified thresholds of >85% overlay accuracy and positive predictive value (PPV) > 30% and negative predictive value NPV > 95% for alerts to move into clinical validation.

RESULTS

An ETT was present in 285 of 512 test cases. The AI detected 95% (271/285) of ETTs, 233 (86%) of these with accurate tip localization. The system (correctly) did not generate an ETT overlay in 221/227 CXRs where the tube was absent for an overall overlay accuracy of 89% (454/512). The alert messages indicating that either the ETT was misplaced or not detected had a PPV of 83% (265/320) and NPV of 98% (188/192).

CONCLUSION

The chest X-ray AI met prespecified performance thresholds to move into clinical validation.

Associations between biomass fuel use and child health: a community-based study in Bhaktapur, Nepal

Background

Biomass fuel use for cooking is widespread in low- and middle-income countries. Previous studies have mainly focused on adverse health outcomes in adults or specific diseases. In a cohort among young children living in Bhaktapur, Nepal, we aimed to describe the association between the use of biomass cooking fuels in families with child health using measures of linear growth, cognition and chronic illness.

Methods

Caregivers of 600 marginally stunted children aged 6-11 months were interviewed about their primary source of cooking fuel at enrolment into a randomized controlled trial. Children's body length (n = 572) was measured at age 18-23 months. At the same time, blood samples (n = 497) were taken, and we measured leukocyte telomere length (LTL) as a marker of chronic disease risk. We chose LTL expressed as z-scores as a measure of chronic disease. Cognitive abilities were measured by the Wechsler Preschool and Primary Scale of Intelligence, 4th edition (WPPSI-IV) and NEPSY-II subtests when the children were 4 years old (n = 531). Associations were estimated in multiple regression models.

Results

About 18% of all families used biomass as primary cooking fuel. Children from families using biomass fuel were on average slightly shorter (mean difference 0.14 Z-scores, 95% CI: 0.28, 0.00), had lower IQ scores (mean difference 2.2 (95% CI: 0.5, 3.9), and shorter LTL (mean difference: 0.09 (95% CI: 0.05 to 0.13) compared to those not using biomass fuel. The observed associations were unaltered after adjusting for relevant confounders.

Conclusions

In children from households in poor, urban neighborhoods in Nepal, biomass fuel use for cooking was associated with health indicators for child growth and cognition as well as longevity and chronic illnesses reflected in shortening of telomeres. As this was an observational study, residual confounding cannot be excluded. Our findings support the ongoing effort to reduce exposure to biomass fuel in low-resource settings.

Key messages

The Postural Effects on Electrical Activities of Heart in Apparently Healthy Young Adults

Background The electrical activities of heart recorded as electrocardiogram (ECG) are mostly done in supine postures. The body postural changes have effects in these electrical activities in heart which needs to be properly recognized. Objective To find the variations in electrocardiogram during postural changes from supine to upright i.e. sitting and standing postures among apparently healthy young adults. Method A cross sectional study was carried out in Manipal College of Medical Sciences after the institutional ethical clearance. The apparently healthy 30 Nepalese male medical students between 18-25 years of age were enrolled. The electrocardiography was elicited in supine, sitting and standing postures in the participants after 5 minutes' interval between each procedure in each participant. Result The highest mean amplitudes of Q wave were seen in sitting postures (0.12±0.04 mm), R wave in standing postures (1.46±0.55 mm) and S wave also in standing postures (0.23±0.2 mm). The mean amplitudes of Q and S waves showed statistically significant difference when compared between supine and upright postures. The maximum QRS duration was found while sitting (0.08±0.01 ms)and maximum heart rate in standing posture (82.43±10.59/min). The mean comparison of heart rate was statistically highly significant when compared between supine and standing postures. The mean QRS frontal axis was comparatively increased while standing (64.30±39.29). Conclusion The electrical activities of heart vary during postural changes among apparently healthy young adults. These changes are most prominent when compared between supine and standing postures which urges for careful interpretation of electrocardiogram if it is done in upright postures.

Feeding practices of pre-school children and associated factors in Kathmandu, Nepal

BACKGROUND

In developing countries such as Nepal, many children aged below 3 years do not grow at a sufficiently high rate and are vulnerable to micronutrient deficiencies (e.g. vitamin A). Challenges to child nutrition can result from poverty, unhealthy traditional practices, inadequate caring and feeding practices. The present study aimed to assess the feeding practices of pre-school children and their associated factors.

METHODS

A cross-sectional study was carried out in pre-schools located in Kathmandu district between February and March 2018. Three levels in terms of price range (lower, medium and higher level) of pre-schools were selected to reach the mothers of children aged ≤3 years. A structured questionnaire was administered to 145 mothers. Descriptive analyses were conducted to observe the characteristics of the population. Multinomial logistic regression analyses were performed to identify the association for the factors of mothers' perception of their current feeding practices.

RESULTS

We found that dal-bhat/jaulo was a common complementary food irrespective of socio-economic background. Interestingly, mothers who had received a higher education were significantly less likely to change their feeding practices (odds ratio = 0.118, confidence interval = 0.01-0.94). The mothers that fed a higher quantity porridge to their children showed a high willingness to change the feeding practices.

CONCLUSIONS

Poor feeding practices are still an important public health problem in Nepal and were observed to be associated with low socio-economic status, unawareness and a lack of knowledge towards dietary diversity combined with strong beliefs related to social forces and cultures.

NECA derivatives exploit the paralog-specific properties of the site 3 side pocket of Grp94, the endoplasmic reticulum Hsp90

The hsp90 chaperones govern the function of essential client proteins critical for normal cell function as well as cancer initiation and progression. Hsp90 activity is driven by ATP, which binds to the N-terminal domain and induces large conformational changes that are required for client maturation. Inhibitors targeting the ATP-binding pocket of the N-terminal domain have anticancer effects, but most bind with similar affinity to cytosolic Hsp90α and Hsp90β, endoplasmic reticulum Grp94, and mitochondrial Trap1, the four cellular hsp90 paralogs. Paralog-specific inhibitors may lead to drugs with fewer side effects. The ATP-binding pockets of the four paralogs are flanked by three side pockets, termed sites 1, 2, and 3, which differ between the paralogs in their accessibility to inhibitors. Previous insights into the principles governing access to sites 1 and 2 have resulted in development of paralog-selective inhibitors targeting these sites, but the rules for selective targeting of site 3 are less clear. Earlier studies identified 5'N-ethylcarboxamido adenosine (NECA) as a Grp94-selective ligand. Here we use NECA and its derivatives to probe the properties of site 3. We found that derivatives that lengthen the 5' moiety of NECA improve selectivity for Grp94 over Hsp90α. Crystal structures reveal that the derivatives extend further into site 3 of Grp94 compared with their parent compound and that selectivity is due to paralog-specific differences in ligand pose and ligand-induced conformational strain in the protein. These studies provide a structural basis for Grp94-selective inhibition using site 3.

Copper Mediated Coupling of 2-(Piperazine)-pyrimidine Iodides with Aryl Thiols using Cu(I)Thiophene-2-carboxylate

A copper-mediated synthesis of diaryl sulfides utilizing Cu(I)-thiophene-2-carboxylate (CuTC) is described. We demonstrate the use of CuTC as a soluble, non-basic catalyst in the coupling of aryl iodides and aryl thiols in the synthesis of synthetically advanced diaryl sulfides. This method allows for the successful coupling of challenging substrates including ortho-substituted and heteroaryl iodides and thiols. Additionally, most of the aryl iodide substrates used here contain the privileged piperazine scaffold bound to a pyrimidine, pyridine, or phenyl ring and thus this method allows for the elaboration of complex piperazine scaffolds into molecules of biological interest. The method described here enables the incorporation of late-stage structural diversity into diaryl sulfides containing the piperazine ring, thus enhancing the number and nature of derivatives available for SAR investigation.

Heat Shock Protein (HSP) Drug Discovery and Development: Targeting Heat Shock Proteins in Disease

Heat shock proteins (HSPs) present as a double edged sword. While they play an important role in maintaining protein homeostasis in a normal cell, cancer cells have evolved to co-opt HSP function to promote their own survival. As a result, HSPs such as HSP90 have attracted a great deal of interest as a potential anticancer target. These efforts have resulted in over 20 distinct compounds entering clinical evaluation for the treatment of cancer. However, despite the potent anticancer activity demonstrated in preclinical models, to date no HSP90 inhibitor has obtained regulatory approval. In this review we discuss the unique challenges faced in targeting HSPs that have likely contributed to their lack of progress in the clinic and suggest ways to overcome these so that the enormous potential of these compounds to benefit patients can finally be realized. We also provide a guideline for the future development of HSP-targeted agents based on the many lessons learned during the last two decades in developing HSP90 inhibitors.

Chemical Tools to Investigate Mechanisms Associated with HSP90 and HSP70 in Disease

The chaperome is a large and diverse protein machinery composed of chaperone proteins and a variety of helpers, such as the co-chaperones, folding enzymes, and scaffolding and adapter proteins. Heat shock protein 90s and 70s (HSP90s and HSP70s), the most abundant chaperome members in human cells, are also the most complex. As we have learned to appreciate, their functions are context dependent and manifested through a variety of conformations that each recruit a subset of co-chaperone, scaffolding, and folding proteins and which are further diversified by the posttranslational modifications each carry, making their study through classic genetic and biochemical techniques quite a challenge. Chemical biology tools and techniques have been developed over the years to help decipher the complexities of the HSPs and this review provides an overview of such efforts with focus on HSP90 and HSP70.

Pulmonary Functions are Impaired among Carpet Factory Workers: A Spirometric Evaluation

INTRODUCTION

Carpet factory produces various types of dusts and workers occupationally get exposed to them continuously. It has adverse health effects and most notably to the pulmonary functions. Nepal is one of the carpet exporter developing countries and still does have many factories within Kathmandu valley. However, the health hazards especially the status of pulmonary function of carpet factory workers from Nepal has not been studied.

METHODS

A cross-sectional comparative study was designed to recruit carpet factory workers and healthy controls to assess their pulmonary functions. A total of 118 subjects (59 males and 59 females) were recruited (60 carpet factory workers and 58 controls). Pulmonary function tests were carried out using Medical International Research Spirolab II portable spirometer.

RESULTS

The carpet factory workers had significantly less FEV1 (90.37 ±16.6 % vs. 103.89±9.79%, p<0.001), FVC (87.78 ± 15.48 % vs. 102.81 ± 8.41 %, p < 0.001) and PEFR (66.19 ± 20.29 % vs. 102.81 ± 11.09 %, p < 0.001) as compared to control group. Similarly the carpet factory workers had significantly higher FEV1/FVC ratio (89.96 ± 6.42 % vs. 87.12 ± 4.58 %, p = 0.007) as compared to control.

CONCLUSIONS

Carpet industry dusts exposure adversely affects pulmonary functions among its workers. The findings significant increase in the FEV1/FVC ratio and decrease in FEV1, FVC, and PEFR suggest that the effects are both restrictive and obstructive patterns of lung disease.

Abstract 1733: Development of chemical tools to study the endogenous Hsp70 interactome in malignant cells

Background: Heat shock protein 70 family members play an important role in cancer. They are up-regulated in wide variety of tumors and the increased Hsp70 protein expression correlates with metastases, resistance to treatment and poor prognosis. Multiple mechanisms explain cancer cells dependence on Hsp70, such as inhibition of apoptosis by Hsp70, induction of autophagy and control of stability of onco-proteins. These Hsp70 activities are mediated in cancer by its ability to chaperone and interact with a large number of proteins in a cell-specific, context dependent manner.

Hypothesis: Reagents that enable the capture of tumor-specific Hsp70 complexes facilitate the identification of context-dependent Hsp70 interactomes.

Results: Our laboratory recently reported the identification of a novel allosteric site located in the nucleotide binding domain of Hsp70 (Chem Biol 2013). It has also reported the discovery of ligands that bind to the allosteric pocket of Hsp70, inhibit its function in cancer cells and result in anti-cancer activity (J Med Chem 2013). Structure-activity relationship studies in this ligand series gave insights on the attachment of specific linkers for the design of Hsp70-related chemical tools. Here we present the design of Hsp70-directed reagents and use biochemical and cell-based methods to validate Hsp70-directed affinity purification probes. We demonstrate that these tools lock Hsp70 in complex with onco-client proteins and effectively isolate Hsp70 complexes for identification through biochemical techniques. Using these tools we provide proof-of-concept analyses that glimpse into the complex roles played by Hsp70 in maintaining a multitude of cell-specific malignancy-driving proteins.

Significance: The knowledge derived from the use of such reagents will be extremely valuable not only to understand tumor-specific roles of Hsp70 and associated mechanisms but also to develop rational strategies for the clinical implementation of these agents to cancer treatment. They may also provide clues on the altered functional proteome in individual tumors, a quest yet elusive by today's proteomics methods.

Citation Format: Anna A. Rodina, Tony Taldone, Yanlong Kang, Pallav Patel, John Koren, Pengrong Yan, Erica DaGama Gomes, Chenghua Yang, Maulik Patel, Liza Shrestha, Stefan Ochiana, Ronnie Maharaj, Alexander Gozman, Marc Cox, Hediye Erdjument-Bromage, Ronald Hendrickson, Leandro Cerchietti, Ari Melnick, Monica Guzman, Gabriela Chiosis. Development of chemical tools to study the endogenous Hsp70 interactome in malignant cells. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1733. doi:10.1158/1538-7445.AM2015-1733

Abstract 1740: Allosteric Hsp70-family inhibitors as targeted anticancer therapeutics

Background: Hsp70, a molecular chaperone responsible, in part, for the folding of nascent peptides following translation, has been implicated as a survival factor and a poor prognostic marker in cancer cells. These pro-cancer mechanisms originate in the ability of Hsp70 to preserve and maintain oncogenic and transformative proteins responsible for the cancer phenotype. Hsp70 is a stress response protein such that expression increases under proteomic/proteotoxic stress events. This increased expression is also evident in cancer cells, an environment under proteomic stress brought on by transformation, and is known to be protective against programmed cell death.

Hypothesis: We predict that by interrupting the chaperoning capacity of Hsp70 through allosteric inhibition, we can destabilize oncogenic proteins dependent on Hsp70 for structure and function. Additionally, as Hsp70 is a survival factor, we believe that a loss of Hsp70 activity will result in cancer specific cell death both in vitro and in vivo.

Approach: Using chemical tools, primarily novel allosteric Hsp70 inhibiting small molecules, we will determine the fate of oncogenic proteins dependent on Hsp70 for stability. We will also examine the cellular response to the disruption of cancer-specific networks which require Hsp70. In vivo tumor models will be used to examine the pharmacokinetics and pharmacodynamics of small molecule Hsp70 inhibitors and to evaluate the therapeutic potential of Hsp70 inhibition.

Significance: The stress response machinery is responsible for the stability of proteins, maintenance of signaling pathways, and evasion from programmed cell death while a cell is under stress; stressors including oncogenic transformation. These pathways maintained by the molecular chaperones have been directly linked to deleterious cancer phenotypes including aggressiveness and the emergence of therapeutic resistances. Targeted therapeutics, and uniquely those targeting the molecular chaperone system, can provide therapeutic options capable of ablating the specific mechanisms involved in proteomic stability and cell survival unique to each tumor cell; effects which can be delivered with minimal effect to normal tissue. This work highlights the potential for therapeutics targeting Hsp70 as anti-cancer agents.

Citation Format: John Koren, Chao Xu, Anna Rodina, Liza Shrestha, Tony Taldone, Gabriela Chiosis. Allosteric Hsp70-family inhibitors as targeted anticancer therapeutics. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1740. doi:10.1158/1538-7445.AM2015-1740

Structure-activity relationship in a purine-scaffold compound series with selectivity for the endoplasmic reticulum Hsp90 paralog Grp94

Grp94 is involved in the regulation of a restricted number of proteins and represents a potential target in a host of diseases, including cancer, septic shock, autoimmune diseases, chronic inflammatory conditions, diabetes, coronary thrombosis, and stroke. We have recently identified a novel allosteric pocket located in the Grp94 N-terminal binding site that can be used to design ligands with a 2-log selectivity over the other Hsp90 paralogs. Here we perform extensive SAR investigations in this ligand series and rationalize the affinity and paralog selectivity of choice derivatives by molecular modeling. We then use this to design 18c, a derivative with good potency for Grp94 (IC50 = 0.22 μM) and selectivity over other paralogs (>100- and 33-fold for Hsp90α/β and Trap-1, respectively). The paralog selectivity and target-mediated activity of 18c was confirmed in cells through several functional readouts. Compound 18c was also inert when tested against a large panel of kinases. We show that 18c has biological activity in several cellular models of inflammation and cancer and also present here for the first time the in vivo profile of a Grp94 inhibitor.

From medical images to flow computations without user-generated meshes

Biomedical flow computations in patient-specific geometries require integrating image acquisition and processing with fluid flow solvers. Typically, image-based modeling processes involve several steps, such as image segmentation, surface mesh generation, volumetric flow mesh generation, and finally, computational simulation. These steps are performed separately, often using separate pieces of software, and each step requires considerable expertise and investment of time on the part of the user. In this paper, an alternative framework is presented in which the entire image-based modeling process is performed on a Cartesian domain where the image is embedded within the domain as an implicit surface. Thus, the framework circumvents the need for generating surface meshes to fit complex geometries and subsequent creation of body-fitted flow meshes. Cartesian mesh pruning, local mesh refinement, and massive parallelization provide computational efficiency; the image-to-computation techniques adopted are chosen to be suitable for distributed memory architectures. The complete framework is demonstrated with flow calculations computed in two 3D image reconstructions of geometrically dissimilar intracranial aneurysms. The flow calculations are performed on multiprocessor computer architectures and are compared against calculations performed with a standard multistep route.

Affinity purification probes of potential use to investigate the endogenous Hsp70 interactome in cancer

Heat shock protein 70 (Hsp70) is a family of proteins with key roles in regulating malignancy. Cancer cells rely on Hsp70 to inhibit apoptosis, regulate senescence and autophagy, and maintain the stability of numerous onco-proteins. Despite these important biological functions in cancer, robust chemical tools that enable the analysis of the Hsp70-regulated proteome in a tumor-by-tumor manner are yet unavailable. Here we take advantage of a recently reported Hsp70 ligand to design and develop an affinity purification chemical toolset for potential use in the investigation of the endogenous Hsp70-interacting proteome in cancer. We demonstrate that these tools lock Hsp70 in complex with onco-client proteins and effectively isolate Hsp70 complexes for identification through biochemical techniques. Using these tools we provide proof-of-concept analyses that glimpse into the complex roles played by Hsp70 in maintaining a multitude of cell-specific malignancy-driving proteins.

Validation of simulation of calcifications for observer studies in digital mammography

Studies using simulated calcifications can be performed to measure the effect of different imaging factors on calcification detection in digital mammography. The simulated calcifications must be inserted into clinical images with realistic contrast and sharpness. MoCa is a program which modifies the contrast and sharpness of simulated calcification clusters extracted from images of mastectomy specimens acquired on a digital specimen cabinet at high magnification for insertion into clinical mammography images. This work determines whether the use of MoCa results in simulated calcifications with the correct contrast and sharpness. Aluminium foils (thickness 0.1-0.4 mm) and 1.60 µm thick gold discs (diameter 0.13-0.8 mm) on 0.5 mm aluminium were imaged with a range of thicknesses of polymethyl methacrylate (PMMA) using an amorphous selenium direct digital (DR) system and a powder phosphor computed radiography (CR) system (real images). Simulated images of the tests objects were also generated using MoCa. The contrast of the aluminium squares and the degradation of the contrast of the gold discs as a function of disc diameter were compared in the real and simulated images. The average ratios of the simulated-to-real aluminium contrasts over all aluminium and PMMA thicknesses were 1.03 ± 0.04 (two standard errors in the mean) and 0.99 ± 0.03 for the DR and CR systems, respectively. The ratio of the simulated-to-real degradations of contrast averaged over all disc diameters and PMMA thicknesses were 1.007 ± 0.008 and 1.002 ± 0.013 for DR and CR, respectively. The use of MoCa was accurate within the experimental errors.

Geriatric health in Nepal: concerns and experience

Ageing is a natural phenomenon and an inevitable process. Population ageing is pervasive since it is creating humanitarian, social and economic problems in many countries of the world including Nepal. Nepalese society is in a phase of modernization. There is modification in the cultural norms and traditional family support systems for elderly in Nepal which have placed substantial strain in caring elderly people. In Nepal, there were 1.5 million in 2001 and 2.1 million in 2011, elderly inhabitants, which constitute 6.5 percent and 8.1% of the total population in the country. During the years 1991-2001, the annual elderly population growth rate was 3.39 percent, higher than the annual population growth rate of 2.3 percent. Growing numbers of elderly people are suffering problems in different aspect, but there are limited studies in relation to general morbidities as well as specific in this group of people. The government of Nepal has formulated a National policy, act and regulations on ageing and the problems of elderly; however, this has not been operationalised because of limited resources. In this background of problems that elderly people are facing and government slow initiatives, this paper is illustrated with the objective to explore the different dimensions of ageing and health and health related services for aging people in Nepal using different information for the purpose of further concrete steps in the benefits for elders.

Oxygen saturation of hemoglobin in healthy children of 2-14 years at high altitude in Nepal

BACKGROUND

Individuals residing at higher altitude may have oxygen saturation of hemoglobin different to those living at lower altitude.

OBJECTIVES

To find out the baseline value of SpO2 in healthy Nepali children (2-14 years) living permanently at high altitude using pulse oximeter and also to study the relation of SpO2 with age, sex and ethnicity.

METHODS

A descriptive observational study was conducted at 4 different altitudes ranging from 2700 to 3800 m in Mustang district. The mean pulse oximery values at different altitudes were calculated and compared.

RESULTS

One hundred six children were enrolled with the median age of 10 years. The mean SpO2 value of children permanently residing at altitude 2700m was 95.18%, at 2800m was 94.82%, at 3550m was 94.1% and 3800m was 93.1%.The difference in the SpO2 values at different altitude was statistically significant. No sex or age wise differences were noted on the mean SpO2 values in the study group.

CONCLUSIONS

The mean SpO2 values were higher than several other studies done in the altitude above 2500 meters. Enrollment of older children and the different ethnic background could be the contributing factors for the differences.

Trends in Perinatal Mortality in Tribhuvan University Teaching Hospital: 13 Years Review

Introduction: The perinatal mortality rate (PMR) in Nepal is still very high. In major hospitals of Nepal, it is still ranging from 20-30 per thousand births. This study was carried out with the objective to review PMR and classifying it according to Wigglesworth classification to identify the causes of perinatal deaths at Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal over the past 13 years and assess need for improvement in care. Material and Methods: It was a retrospective study carried out in TUTH. Data of all stillbirths from 28 weeks of pregnancy and neonatal deaths within first seven days of life in the hospital was taken from monthly perinatal audit and annual mortality review. All the perinatal deaths were then classified according to Wigglesworth classification. Results: Over a 13 year period, there were total 42,746 births and 921 perinatal deaths giving a perinatal mortality of 21.5 per thousand births. Over this period PMR has decreased from 31 to 18 per thousand births. Still births contributed almost 50% of the perinatal deaths; deaths related to prematurity show an increasing trend and have increased by almost 70% in past 5 years. Deaths due to perinatal asphyxia were static. Conclusion: PMR over the years has shown declining trend at TUTH. There is need to improve antenatal, obstetric as well as intrapartum services to further reduce the still birth as well as deaths due to prematurity and perinatal asphyxia. J. Nepal Paediatr. Soc. 32(2) 2012 150-153 doi: http://dx.doi.org/10.3126/jnps.v32i2.6898

Prevalence study of H. pylori infection in dyspeptic patients coming to Nepal Medical College Teaching Hospital, Jorpati, Kathmandu

Helicobacter pylori (H. pylori) is one of the most common human infections worldwide particularly in the developing countries. It has been established as etiology of chronic gastritis and peptic ulcer disease, gastric adenocarcinoma and mucosal associated lymphoid tissue lymphoma (MALT). During this decade, there have been some reports showing a decline in global prevalence of H. pylori infection and peptic diseases including many Asian countries. Hence to determine prevalence of Helicobacter pylori infection in dyspeptic patients, this descriptive, non-interventional study was carried out at the Endoscopy sub-unit of the Surgery Department from April 2011 to February 2012. Three hundred nineteen dyspeptic patients (Male 161 and female 152) with a mean age of 20.12 years were examined for the presence of H. pylori infection by histology staining. The prevalence of H. pylori infection was 50.47%. The most common endoscopic findings was gastritis (47.6%) followed by normal findings 57 (17.87%). A total of 8.47% of gastric Ulcer, oesophagitis 5.64% and gastric cancer 0.94% were detected. All three cases of gastric cancer were positive for H. pylori infection. Among gastritis, H. pylori was observed in 67 (44%) cases and 18 out of 57 (5.6%) of normal gastric mucosa showed H. pylori. The endoscopic findings such as gastritis, gastric ulcer, duodenal ulcer and gastro duodenal reflux are significantly associated with H. pyloric infection. The prevalence of H. pylori infection is still high in peptic diseases. H. pylori infection is significantly correlated with peptic ulcer diseases than with non-ulcer dyspepsia. Further studies are required to establish the H. pylori positive cases with that of other tests such as serological detection of anti H. pylori antibody by ELISA/ICT and culture to establish a diagnosis quickly without any invasive method and institute proper management thus reducing morbidity.

Vitamin D status among individuals attended in Health Home Care Centre, Lalitpur, Nepal

There is widespread prevalence of vitamin D deficiency from new-born to infancy, childhood and adult male and female. Despite the numerous reports of the association of vitamin D with spectrum of development, disease treatment and health maintenance, vitamin D deficiency is common. There is limited information of the vitamin D status in Nepalese people. Based on the information in relation to importance of Vitamin D, we proposed to see the level of vitamin D among the care seeker individuals attended in this Health Home Care Centre, Nepal. Within three months interval (March to May 2012), whole blood test was done by 148 individuals. Among them vitamin D3 test was recommended for 50 individuals done by doctor on the basis of relevant health problems in relation to vitamin D deficiency. Analysis was done with SPSS package 17 version to see the relation between Vitamin D deficiency and other health related tests. The study found significant association between vitamin D deficiency with calcium level and hemoglobin level. There are presences of studies with evidences regarding relation of vitamin D with different health outcomes in different parts of the world. The widespread deficiency of vitamin D merits consideration of widespread policies including increasing the awareness among the public and health care professionals. In addition the study results highlight the need for additional high quality studies in Nepal in order to prevent the impacts of vitamin D deficiency and also to plan for prevention of vitamin D deficiency.

Evaluation of substrate and inhibitor binding to yeast and human isoprenylcysteine carboxyl methyltransferases (Icmts) using biotinylated benzophenone-containing photoaffinity probes

Isoprenylcysteine carboxyl methyltransferases (Icmts) are a class of integral membrane protein methyltransferases localized to the endoplasmic reticulum (ER) membrane in eukaryotes. The Icmts from human (hIcmt) and Saccharomyces cerevisiae (Ste14p) catalyze the α-carboxyl methyl esterification step in the post-translational processing of CaaX proteins, including the yeast a-factor mating pheromones and both human and yeast Ras proteins. Herein, we evaluated synthetic analogs of two well-characterized Icmt substrates, N-acetyl-S-farnesyl-L-cysteine (AFC) and the yeast a-factor peptide mating pheromone, that contain photoactive benzophenone moieties in either the lipid or peptide portion of the molecule. The AFC based-compounds were substrates for both hIcmt and Ste14p, whereas the a-factor analogs were only substrates for Ste14p. However, the a-factor analogs were found to be micromolar inhibitors of hIcmt. Together, these data suggest that the Icmt substrate binding site is dependent upon features in both the isoprenyl moiety and upstream amino acid composition. Furthermore, these data suggest that hIcmt and Ste14p have overlapping, yet distinct, substrate specificities. Photocrosslinking and neutravidin-agarose capture experiments with these analogs revealed that both hIcmt and Ste14p were specifically photolabeled to varying degrees with all of the compounds tested. Our data suggest that these analogs will be useful for the future identification of the Icmt substrate binding sites.

Hospital-based study in children with rotavirus gastroenteritis and other enteropathogens

BACKGROUND

Rotavirus is the most common cause of life threatening gastroenteritis in infants and young children in the world. The objective of the study is to find out current trends and incidents of rotavirus, including other enteropathogens related with children diarrhoea and lastly identify the most common rotavirus serotypes that circulate in Nepal.

METHODS

A total of 1721 stool samples from less than 5 years of children were collected. Rotavirus in the stool samples were detected by Enzyme Immuno Assay (EIA) and strains were genotyped by Reverse-Transcription Polymerase Chain Reaction (RT-PCR). Bacteria and parasites were detected by following standard microbiological procedures.

RESULTS

In between 2009 to 2010, of the total 1721, the prevalence of rotavirus was 24.7%. Of them, 906 (52.6%) were collected in the year 2009 and 815(47.5%) in the year 2010. Rotavirus was frequently detected in inpatients (31.6%) than outpatient (16.8%). Rotavirus detection was higher in female (26.4%) than male (23.7%). The prevalence was seen higher in age group 0-23 months in both years. Among six different bacterial isolates, Escherichia coli was most frequently isolated (6.5%). Similarly, Giardia lamblia (1.3%) was most common among six different parasites detected. A total of rotavirus positive 425 stool samples were detected over 2 years (2009-230, and 2010-195), G12P6 was the predominant strain circulating in both (45% in 2009 and 28% in 2010) years. G9P6 emerged in 2010 (6%). There were significant numbers of mixed infections (14.0% in 2009 and 29.8% in 2010). Thirty five samples were partially typed and 15 were completely untyped over the two year period.

CONCLUSIONS

The study helps comprehend the prevalence of rotavirus along with other intestinal pathogens including bacteria and parasites. Major genotypes of rotavirus are also introduced in the study.

A case of precocious puberty in a setting with limited resources

Precocious puberty is a rare condition characterized by the development of secondary sexual characteristics before the median age for the sex. It is either gonadotropin dependent also called as central or gonadotropin independent also known as peripheral type. Hypothalamamic Hamartoma is a common cause of the central or precocious puberty due to organic brain lesion. Here we present a two year male who presented us with precocious puberty due to a hypothalamic Hamartoma.

Changing tuberculosis trends in Nepal in the period 2001-2008

To assess the trends on indicators of TB control in Nepal over a period from 2001-2008. Retrospective analysis of information from Annual Reports of NTP, Nepal from 2001-2008. The incidence of New Smear Positive (NSP) TB declined from 58.9 in 2001 to 53.4 in 2006 per 100000 populations then reversed in the period 2006-2008. This TB incidence decreased in males and the age group <45 years (except 0-14 years). The notification rate of all cases of TB declined by 3 % overall over the entire period from 2001 to 2008. Mortality among smear negative and extra pulmonary declined significantly. The failure rate and defaulter rate were declined significantly and the case detection rate (CDR) was increased significantly within the study period. Increasing trend in CDR, Treatment success rate and decreasing trend in failure rate, defaulter rate are the evidence of progress of NTP, in Nepal. Since there is reversal of incidence of NSP from 2006, a detailed analysis of existing TB control measures is required. If the success is continued and quality care is provided as per International Standard of TB Care, the Millennium Development Goals will be an achievable target.

Clinical predictors of outcome following mild and moderate neonatal encephalopathy in term newborns in Kathmandu, Nepal

We describe a clinical grading system for the assessment of neonatal encephalopathy developed for a large prospective study in Kathmandu. Inter-observer variability testing of our system on 27 infants showed high agreement (kappa value 0.87). Validity for the prediction of major neurodevelopmental impairment at 1 y of age was tested using a cohort of 57 survivors of encephalopathy, all of whom were assessed using a combination of the Denver Developmental Screening Test and Bailey 2 at 1 y. We compared this with a modification of a scoring system previously validated in Cape Town. Both schemes converted a pretest probability of 31% (the prevalence of major impairment at 1 y of age in this cohort) to a post-test probability of 55%. This showed only marginal improvement over the traditional risk marker of neurological abnormality at discharge (post-test probability 51%). At 6 wk of age acquired microcephaly increased the probability of major impairment to 79%.

CONCLUSIONS

It seems to make little difference both in practical or predictive terms whether one describes the neurological condition of the neonate using a descriptive or scoring system. The important thing is to perform repeated systematic neurological examinations on a daily basis during the neonatal period. Many clinicians will justifiably continue to use the discharge examination as the deciding factor for the need for continued neurodevelopmental surveillance.

Outcome at 1 year of neonatal encephalopathy in Kathmandu, Nepal

To determine the outcome at 1 year of neonatal encephalopathy (NE) and to estimate the possible contribution of birth asphyxia to childhood disability in a low-income South Asian country, a prospective cohort study was undertaken in the principal maternity hospital of Kathmandu, where over 50% of local women give birth. From a total population cohort of 21609 live births, 131 term infants with NE (after exclusion of cases associated with neonatal sepsis, congenital malformations, or primary hypoglycaemia) and 208 term control infants were recruited. Of these, 102 (78%) infants with NE and 106 (51%) control infants were followed-up to 1 year of age. Outcome measures were death or neurodevelopmental impairment, graded as major, minor or none. Of the 131 term infants with NE, 83 were graded with moderate or severe NE according to conventional definition. By 1 year of age, 45 (44%) of the infants with NE had died, 18 (18%) had severe impairments, and two (2%) had minor impairments; four (4%) of the control subjects had died and two (2%) had minor impairments. Most deaths in subjects with NE occurred in the early neonatal period; NE carried no excess risk of death beyond the neonatal period. Of the 18 children with major impairment, 14 (78%) had spastic tetraplegic cerebral palsy and eight (44%) had multiple impairments. Compared with the control group the relative risk of death by 1 year was 5 (95% CI 1.4 to 15) for mild NE, 8 (95% CI 3 to 23) for moderate, and 26 (95% CI 10 to 67) for severe. Twenty-seven of 38 (71%) infants with moderate NE either died or survived with major impairment. An upper estimate for the prevalence of major neuroimpairment at 1 year attributable to birth asphyxia is 1 per 1000 live births in this population.

The effect of divorce on intergenerational transfers: new evidence

This paper draws on new data on intergenerational transfers of time and money that were collected in the Panel Study of Income Dynamics. We use these data to examine the effects of divorce on these transfers. We find that the timing of divorce is critical. Fathers and mothers involved in late divorces have similar levels of transfers with their adult children, while divorce during a child's childhood years increases transfers with mothers and sharply lowers them with fathers. Somewhat surprisingly, we find no evidence that divorced fathers who paid child support are more likely to be involved in intergenerational transfers than those who did not pay child support.

Type 2 diabetes mellitus with early phase acute inflammatory protein on serum protein electrophoresis

Background: The onset of Type 2 diabetes has been associated with low grade systemic inflammation. The inflammatory status has been studied by measuring acute phase reactant proteins like hsCRP, α1- antitrypsin, α1-acid glycoprotein, ceruloplasmin, fibrinogen. Most of these acute phase reactants form α1 and α2 bands on electropherogram of serum proteins. The aim of this study was to evaluate inflammatory status in controlled and uncontrolled type 2 diabetes using cellulose acetate electrophoresis and to find the impact of glycemic status as indicated by HbA1c on inflammation process. Materials and Methods: Serum protein electrophoresis was done on serum samples of 60 cases of Diabetes [controlled and uncontrolled] using cellulose acetate paper technique. The electropherogram obtained was stained with Ponseu S and then quantitated using densitometer. Glycemic status was studied by HbA1c analysis. The density of α1and α2 bands in electropherogram were correlated with HbA1c level. Result: A significant increase in the percentage of α1 and α2 band proteins (0.765 and 0.716, p<0.001) were found with the increasing level of HbA1c. With cutoff of HbA1c 7% (American Diabetic Association recommended), the α1 and α2 serum proteins concentration are significantly higher (p<0.001) in uncontrolled diabetes mellitus compared to controlled diabetes mellitus Conclusion: Cellulose acetate electrophoresis of serum proteins show early phase acute inflammatory status in uncontrolled type 2 diabetes mellitus. The process of systemic inflammation worsens with uncontrolled glycemia as indicated by HbA1c. Inflammatory status should be studied adjunct to glycemic status. DOI: http://dx.doi.org/10.3126/jpn.v2i3.6024 JPN 2012; 2(3): 211-214

Profile of Asphyxiated Babies at Tribhuvan University Teaching Hospital

Objective: To assess risk factors and outcome in the early neonatal period of babies who were asphyxiated at birth. Methodology: This was a retrospective study conducted at Tribhuvan University Teaching Hospital (TUTH) over a period of one year from 15th Feb 2007 to 14th Feb 2008. All the term babies who had Apgar score of less than < 6 at 1 minute of birth were included. Detailed maternal risk factors during pregnancy and labor were analyzed. The newborn babies who required admission in neonatal unit were again analyzed for development of hypoxic ischemic encephalopathy (HIE) and their outcome. Results: During the study period, out of 3594 term babies, 327 babies (9%) were asphyxiated. Of the total asphyxiated babies, 85% and 15% had moderate and severe asphyxia, respectively, at 1 minute of birth. Out of these asphyxiated babies, 51% and 7% had intrapartum and maternal risk factors, respectively. Intrapartum risk factors like meconium stained liquor, non-vertex presentation, and fetal heart rate abnormalities accounted for 4 fold risk of asphyxia. Of these babies, 26% required admission in nursery and 29% developed hypoxic ischemic encephalopathy. Among the admitted babies 6% expired, 2% left against medical advice and rest were discharged. Conclusion: Early identification and close monitoring of high risk mothers studies with maintaining partograph during labor will help to reduce neonatal asphyxia. Key words: Asphyxiated babies doi:10.3126/jnps.v29i1.1592 J. Nepal Paediatr. Soc. Vol.29(1) p.3-5