Colistin Resistance among Human Clinical Isolates from a Tertiary Care Hospital in Nepal

Background Colistin is increasingly being used for treatment of multidrug resistant (MDR) bacterial infections in human. The plasmid mediated mcr-1 gene was detected recently among the poultry in Nepal. Plasmid mediated colistin resistance among human isolates would severely compromise the treatment of MDR bacterial infections. Objective To find out the prevalence of colistin resistance among the gram-negative bacteria isolated from clinical specimen. Method A descriptive cross-sectional study was conducted in a tertiary care hospital in Kathmandu. Colistin resistance among all the gram negative bacilli (GNB), isolated in a year, from all clinical specimen subjected for aerobic bacterial isolation, was detected by disc diffusion and agar dilution methods. Those with a minimum inhibitory concentration (MIC) > 2 mcg/ml were subjected to polymerase chain reaction for detection of mcr-1 gene. Result A total of 1993 aerobic GNB were isolated from clinical samples received from February 2018 to January 2019. By the agar dilution screening method, 2.1% of the GNBs isolated had MIC of colistin > 2 mcg/ml. None of these possessed the mcr-1 gene. Conclusion Given the occurrence of increased MIC of colistin in the clinical isolates in our set up, nationwide active surveillance would generate data for Nepal. The study for the presence of other genes (chromosomal or plasmid mediated) responsible for the increased MIC of colistin would further guide the control measures.

Cheiro-Oral Syndrome

Cheiro-Oral Syndrome (COS) is a very rare neurological syndrome associated with varied etiology. We report a 53-year-old man presented with left sided perioral and ipsilateral hand/fingers burning sensation for a one-month duration. On examination, he had hypesthesia over left perioral and distal palmar aspect of all five fingers. MRI revealed subacute infarct in the posterior limb of right internal capsule adjacent to and minimally involving thalamus. He was diagnosed as CheiroOral Syndrome as a result of ischemic stroke and managed.

Inducible clindamycin and methicillin resistant Staphylococcus aureus in a tertiary care hospital, Kathmandu, Nepal

Background

Staphylococcus aureus, an important nosocomial pathogen, is frequently associated with infections in human. The management of the infections by it especially methicillin resistant ones is often difficult because methicillin resistant S. aureus is usually resistant to multiple antibiotics. Macrolide-lincosamide streptogramin B family of antibiotics is commonly used to treat such infections as an alternative to vancomycin.

Methods

This study was conducted over the period of one and half year from November 2013–April 2015 in Microbiology laboratory of Nepal Medical College and Teaching Hospital, Kathmandu, Nepal to find the incidence of different phenotypes of MLS_B resistance among S. aureus from clinical samples and their association with methicillin resistance. Two hundred seventy isolates of S. aureus were included in the study. Methicillin resistance was detected by cefoxitin disc diffusion method and inducible clindamycin resistance by erythromycin and clindamycin disc approximation test (D-test).

Results

Of the 270 clinical isolates of S. aureus, 25.1% (68/270) were MRSA. Erythromycin and clindamycin resistance was seen in 54.4% (147/270) and 41.8% (113/270) isolates respectively. Resistance to erythromycin and clindamycin were higher in MRSA as compared to MSSA (erythromycin-resistance: 88.2% Vs 39.1% and clindamycin-resistance: 79.4% Vs 41.8%). The overall prevalence of _iMLS_B and _cMLS_B phenotype was 11.48% (31/270) and 29.25% (79/270) respectively. Both _iMLS_B and _cMLS_B phenotypes predominated in MRSA strains.

Conclusions

Detection rate of MRSA in our study shows the necessity to improve in healthcare practices and to formulate new policy for the control of MRSA infections. Clindamycin resistance in the form of _iMLS_B and _cMLS_B especially among MRSA emphasizes the need of D-test to be performed routinely in our set up while using clindamycin as an alternative choice to anti-staphylococcal antibiotics like vancomycin and linezolid in the treatment of staphylococcal infections.

Prevalence of high level gentamicin and vancomycin resistance among clinical isolates of enterococci from a tertiary care hospital in central Nepal

High level aminoglycoside resistance is an established phenomenon in enterococci. With the increasing use of broad spectrum cephalosporins and glycopeptides, vancomycin resistant enterococci are being increasingly reported from different parts of the world. The objective of our study was to determine the prevalence of high level gentamicin resistant (HLAR) enterococci among the clinical isolates in our hospital and to find the minimum inhibitory concentration (MIC) of vancomycin against these isolates. The enterococci isolated over a year (n = 41) were subjected to HLAR screening by disc diffusion and MIC of vancomycin by agar dilution method. HLAR prevalence was 63%. MIC of vancomycin showed none in the resistant range. However, 4 (9.7%) isolates were in the intermediate range heralding the eminent emergence of VRE if adequate control measures are not implemented in time.

Growing Resistance to Vancomycin among Methicillin Resistant Staphylococcus Aureus Isolates from Different Clinical Samples

INTRODUCTION

Methicillin resistant Staphylococcus aureus (MRSA), majorly associated with nosocomial and community infections worldwide, are emerging as resistant strains to many antibiotics narrowing down the efficacy of antimicrobial therapy. In order to investigate the changing resistant pattern of MRSA to empirical drugs, the study was carried out at KIST Medical College and Hospital, Nepal. It also aims to determine the minimum inhibitory concentration (MIC) of vancomycin among MRSA.

METHODS

Altogether 3500 clinical samples including 1303 blood, 1489 urine and 708 body fluids were collected and processed. Isolated S. aureus were further screened for methicillin resistance by Kirby-Bauer disk diffusion technique using cefoxitin (30µg) disk. All MRSA were subjected to in vitro determination of MIC of vancomycin by agar dilution method as recommended by CLSI guidelines.

RESULTS

Total 287 S. aureus were isolated from the different clinical samples. Altogether 248 (86.41%) were found to be multidrug resistance (MDR) while 42 (14.63%) of the isolates were methicillin resistance with the highest prevalence in the age group of 16-30. All 42 (100%) MRSA isolates were resistant to ampicillin and penicillin followed by 41 (97.62%), 32 (76.19%), 31(73.81%), 29 (69.05%), 9 (21.43%) and seven (16.67%) to cefotaxime, gentamycin, cotrimoxazole, erythromycin, tetracycline and ciprofloxacin respectively. Although all MRSA strains were sensitive to vancomycin on disc diffusion, four isolates were intermediates in vitro determination of MIC of vancomycin. The break point for vancomycin was found to be 15mm.

CONCLUSIONS

The increment in vancomycin MIC among MRSA is alarming. Strict control measures to prevent MRSA spread and a routine surveillance for VRSA must be incorporated in hospitals.

Spectrum of bacterial pathogens and their antibiogram from cases of urinary tract infection among renal disorder patients

Urinary tract infection (UTI) is the commonest bacterial infection occurring in renal disorder patients and is associated with significant morbidity. Resistance to antibiotics is highly prevalent in bacterial isolates and is an emerging problem in UTI. A hospital based cross sectional study was conducted from April 2011 to September 2011 to determine the frequency and bacterial profile of urinary tract infections in the patients with renal disorders visiting KIST Hospital along with their antimicrobial susceptibility pattern. Urine samples were collected from 300 clinically-suspected cases of UTI among renal disorder patients and investigated by conventional semi-quantitative culture technique, microscopy and antibiotic susceptibility test. Significant bacteriuria were detected in 34% of the total subjects, mostly from patients with Chronic Kidney Disease. Incidence of bacteriuria was found higher in females (40.40%) than in males (27.52%) and mostly occurred in elderly patients. Escherichia coli (62.75%) was the predominant isolate followed by Klebsiella pneumoniae (10.78%), Staphylococcus aureus (9.80%), Coagulase negative Staphylococcus aureus (CoNS) (5.88%), Enterococcus spp (3.92%), Klebsiella oxytoca (2.00%), Pseudomonas aeruginosa (2.00%), Proteus mirabilis (2.00%) and Proteus vulgaris (1.00%). Multidrug resistance was observed in 68.82% of the total bacterial isolates.

Reduced susceptibility to vancomycin in methicillin resistant staphylococcus aureus: a time for action

Infections by Methicillin resistant Staphylococcus aureus (MRSA) is an often encountered therapeutic challenge. The problem is accentuated by the emergence of MRSA strains which are resistant to Vancomycin, the recommended agent for the treatment of MRSA infections. We therefore carried out this study to determine the MIC values ofvancomycin for the MRSA isolated from different clinical specimens in Nepal Medical College. MICs were determined by agar dilution method. Out of the 82 MRSA isolates tested, 18 showed MIC of 2 μg/ml and 29 isolates had MIC of 1 μg/ml and 35 isolates had MIC of 0.5 μg/ml. Although none had a MIC in the intermediate or resistant zone, 18 (2.9%) had MIC in the upper limit of the sensitive zone which is a matter of concern and calls for prompt preventive actions.

Tobacco and alcohol: the relation to pulmonary tuberculosis in household contacts

Tuberculosis is transmitted commonly by droplet nuclei and facilitated by weak immune system. Lowered immunity may be associated with cigarette smoking, tobacco chewing and alcohol consumption. The co-relationship between these all factors to TB should be explored. This study aims to detect the hidden household contacts (HC) cases early and to examine the relative contribution of tobacco and alcohol use to the risk of TB. Across-sectional study was in Dharan among HCs. From June 2009 to May 2010, 184 index cases with sputum smear positive for AFB and their 802 HCs were included. Three sputum specimens were collected from each HCs and examined microscopically for AFB detection. AFB were detected in sputum of 13 (1.6%) HCs. The association between habits (alcohol user and smoking) and TB was found except with chewing tobacco user (P > 0.05). The risk of contact TB was 4 and 8 times greater in smoker (OR = 3.94 95% CI = 1.26-12.26, P < 0.05) and alcoholic (OR = 8.23 95% CI = 2.71-24.98, P < 0.05) HCs respectively. This study has revealed smoking and alcohols as the risk factors for tuberculosis. Effective campaign to discourage use of alcohol and tobacco, and awareness programme about the mode of transmission of TB are needed in community.

Urinary tract infection in vaginitis: a condition often overlooked

Despite the differences between the organisms that cause vaginitis and urinary tract infections (UTI), it is possible that women with vaginitis develop UTI. The main objective of the study was to find the association of the common types of infectious vaginitis with UTI. Cross sectional study was conducted for six months in a referral hospital at Lalitpur, Nepal. Three hundred and sixmid-stream urine samples and high vaginal swabs (HVS) collected from non pregnant women were investigated by standard microbiological techniques. Among the women with bacterial vaginosis (BV), 75% also had UTI. Similarly, 46% and 13% of those with vaginal candidiasis and trichomoniasis respectively had concurrent UTI. Considering this strong association of UTI and vaginitis, women with either of these conditions should be tested for the other.

Prevalence of tuberculosis in household contacts of sputum smears positive cases and associated demographic risk factors

Pulmonary tuberculosis (PTB) is transmitted by aerosolized droplets nuclei. Home is the vulnerable place for transmission of this disease to its contacts. Risk factors associated with this contact transmission may differ according to locality. This study aims to determine the prevalence of household contact (HC) PTB and examine the risk factors contributing to it. A cross-sectional study was conducted to determine the prevalence of HC TB among HCs aged > 5 years in Dharan. During the study period (June 2009 - May 2010), 184 index cases with sputum smear positive for AFB and their 802 HCs were included. Three sputum specimens were collected from each HCs and examined microscopically for AFB detection. The prevalence of HC TB was found to be 1.6%. The result was statistically associated (P < 0.05) with illiterate HCs (OR= 5.77, 95%CI =1.52-21.81), close proximity with ICs (OR=3.07, 95%CI = 1.02-9.25), primary relatives to ICs (OR= 4.85, 95%CI = 1.07-22.05) and slum dweller (OR = 4.56, 95%CI = 1.25-16.71). Similarly, AFB positivity was associated (P<0.05) with household crowding (OR = 7.46, 95%CI = 2.36-23.49), room size < or = 10 x 10 feet (OR=4.05, 95%CI = 1.23-13.25), firewood user while cooking (OR = 5.96, 95%CI = 1.92-18.45). The prevalence of HCs tuberculosis is found to be 1.6%. Poverty, illiteracy, overcrowding, close proximity, close relation with ICs, firewood while cooking, slum dweller, are major factors highlighted by this study as risk factors of contact TB. Our results recommend a much better contact tracing and treatment program.

Cesarean section without urethral catheterization: a randomized control trial

BACKGROUND

Urethral catheterization is done as a routine procedure in cesarean section. It is associated with high incidence of urinary tract infections, discomfort, delayed ambulation and longer hospital stay.

OBJECTIVE

To determine the feasibility and safety of cesarean section without urethral catheterization.

METHODS

A prospective, randomized controlled trial was carried out from April 2008 to March 2009, in the Department of Obstetrics and Gynecology, B. P. Koirala Institute of Health Sciences. Among 150 patients who had undergone cesarean section 75 were catheterized and 75 were uncatheterized.

RESULTS

First void discomfort was significantly associated with the use of indwelling catheter (OR 6.95, CI 95 %, 3.74 to 12.95; P less than 0.001).Significant number of patients with indwelling catheter had signs and symptoms of urinary tract infection (OR 6,CI 95%, 2.59 to 13. 86; P less than 0.001). Positive urinalysis for urinary tract infection was high in catheterized group (P less than 0.001). Hospital stay was shorter in patients without catheter (p less than 0.05). None of the patients had bladder injury. There were no significant differences in duration of surgery and ambulation time between two groups of patients.

CONCLUSIONS

Cesarean section can be done safely without urethral catheterization with reduced morbidities.

Ciprofloxacin susceptibility of Salmonella enteric serovar Typhi and Paratyphi A from blood samples of suspected enteric fever patients

INTRODUCTION: Enteric fever caused by Salmonella enterica serovars Typhi and Paratyphi A is the common clinical diagnosis among febrile patients presenting to hospital in Nepal. The aim of this study was to evaluate the ciprofloxacin (CIP) and other antibiotics susceptibility patterns of Salmonella enterica serovars Typhi and Paratyphi A from blood samples of suspected enteric fever patients visiting KIST Medical College, Kathmandu. MATERIALS AND METHODS: Antibiotic susceptibility test was performed by Kirby Bauer disc diffusion method as per CLSI guidelines whereas MIC determination of ciprofloxacin was performed by agar dilution method. RESULTS: Altogether 64 presumptive Salmonella spp. were isolated from 840 blood samples of suspected enteric fever patients, of which 41 were S. Typhi and 23 were S. Paratyphi A. All Salmonella spp. isolates were sensitive to ceftriaxone and ofloxacin whereas 4 isolates were resistant to ciprofloxacin. One isolates each of S. Typhi and S. Paratyphi A were multidrug resistant. Fifty five isolates of Salmonella spp. were resistant to nalidixic acid (NA) with higher rate in S. Paratyphi A (91.3%) compared to S. Typhi (82.9%). MIC determination of ciprofloxacin revealed that majority of the isolates were resistant to ciprofloxacin and 2 isolates were resistant with MIC value of 4 µg/ml and 8 µg/ml. Importantly, we found simultaneous presence of NA resistance and decreased susceptibility to CIP suggesting that resistance to NA is a reliable indicator of decreased CIP susceptibility. CONCLUSIONS: Disc diffusion test failed to detect the reduced susceptibility of ciprofloxacin. Hence the MIC determination of ciprofloxacin against Salmonella spp. isolates would be important.  DOI: http://dx.doi.org/10.3126/ijim.v1i1.6938Int J Infect Microbiol 2012;1(1):9-13

Etiological agents of corneal ulcer: five years prospective study in eastern Nepal

To identify the most common isolates from the corneal ulcers with antimicrobial pattern of bacterial isolates. All patients with suspected corneal ulceration presenting to BP Koirala Institute of Health Sciences from Jan 2004 - Dec 2008 were evaluated. Corneal scraping was performed and processed for direct microscopy, bacteriological and fungal culture. Bacterial isolates were subjected to antimicrobial susceptibility testing. Of 351 specimens examined, growth of etiological agents were obtained in 278 (79.20%). Of these, 113 (40.65%) had pure fungal growth, 108 (38.85%) had pure bacterial growth and 57 (20.50%) had mixed fungal and bacterial infection. The commonest fungal pathogen was Aspergillus spp 50 (33.33%) followed by Fusarium spp 19 (12.66%). Staphylococcal aureus 57 (44.53%) was isolated as commonest bacterial agent. Coagulase Negative Staphylococci 20 (15.6%) was second in the list. Pseudomonas spp 12 (9.40%) was the most common gram negative bacilli isolated. Most of the bacterial isolates were sensitive to commonly used antibiotics. Corneal Ulcer is a common problem in eastern Nepal. Knowledge of both fungal and bacterial agents associated with this condition is of value for the prevention and management of corneal ulcers and their complications.

High temperature Z-meter setup for characterizing thermoelectric material under large temperature gradient

To properly estimate a thermoelectric material's performance, one should be able to characterize a single thermoelectric (TE) element with a large temperature gradient. In this work, we present an experimental setup including a Z-meter that can heat the sample to a very high temperature of 1200 °C in vacuum. The Z-meter can simultaneously measure all three thermoelectric parameters (Seebeck coefficient, thermal conductivity, and electrical conductivity), as well as measure the generated power and the efficiency for a single TE leg. Furthermore, this measurement of power conversion efficiency is used to generate a measure of the material's ZT. An in situ metallurgical bond was used to achieve low thermal (0.05 Kcm(2)/W) and electrical (3 mΩ) contact parasitics. An integrated strain gauge ensures reproducible thermal contact. At high temperature (>600 K), radiative heat transfer is modeled and the instrument is optimized to suppress the systematic error to below 7%. The TE parameters and ZT for a bulk-sample (Bi(2)Te(3)) and a thin-film sample (ErAs:InGaAlAs) with a large temperature gradient (ΔT ∼ 200 K) have been measured and are within 3%-7% of the independently measured values.

Values of Lymphocyte Subsets in Nepalese Healthy Adult Population

Introduction: CD4 T lymphocyte is the most commonly used cellular marker in tracking Human Immunodeficiency Virus (HIV) infection progression and monitoring effect of antiretroviral therapy (ART). Due to lack of local reference values of CD4 and other T lymphocytes in Nepal, most clinical decisions are based on the reference renges of western countries.  Methods: This study was conducted at three major hospitals/laboratory of central, eastern and western Nepal during November 2008 through July 2009. Using the predefined criteria, 602 (200, 202 and 200 from central, eastern and western regions respectively) healthy adult volunteers of age range 18-60 years were recruited wiht equal representation from each age group and sex. Blood specimens were screened for HIV following standard algorithm using ELISA and two rapid test kits based on different principles. Samples with discordant test-results were excluded. HIV sero-negative specimens were further analyzed for CD4, CD8 and CD4:CD8 ratio, and absolute lymphocyte count (ALC) by FACS count (Becton Dickinson, USA) and automated cell counter (BC-3000 Plus, Shenzhen Mindray Biomedical Electronics, Germany) respectively. Results: The average value (mean± standard deviation) of CD4, CD8, CD4/CD8 ratio and ALC of Nepalese adult population were found to be 786 ± 248, 567±230, 1.52 ± 0.59 and 2712 ± 836 respectively. All four parameters but CD8 were significantly different with sex and females had relatively higher values. However, none of these parameters reported significant difference with age except the ALC. Conclusions: Nepalese healthy adult populations have significantly different T lymphocyte subsets compared to other countries. The present reference ranges of CD4 and other T lymphocytes may be used for any clinical purposes including classifying and monitoring disease status in HIV infected individuals, immune status evaluation, monitoring ART and accordingly making amendment in national HIV treatment guidelines in Nepal. Keywords:Absolute lymphocyte count, CD4, CD8, human immunodeficiency virus, T lymphocytes.

In vitro activity of cefoperazone-sulbactam combination against gram negative bacilli

Cefoperazone is a â-lactam antimicrobial and Sulbactam is an irreversible â-lactamase inhibitor. The objective of this study was to know the susceptibility pattern of gram negative bacilli (GNB) towards cefoperazone-sulbactum. All GNB isolated from different clinical samples during the period of May, 2010 to Aug, 2010 were tested for susceptibility to cefoperazone-sulbactum, meropenem, ceftazidime, cefotaxime, ceftriaxone, chloromphenicol, cotrimoxazole, ampicillin, amikacin, nalidixic acid, ciprofloxacin, carbenicillin and piperacillin using standard Kirby-Bauer disc diffusion antimicrobial susceptibility testing method. The susceptibilities were recorded according to CLSI guidelines. A total of 406 GNB were isolated (urine: 66.7%, pus: 19.2%, and blood: 7.9%). Escherichia coli (54.4%) was most frequently isolated organisms followed by Acinetobacter species (17.7%), Klebsiella pneumoniae (9.1%) and Pseudomonas species (6.1%). Overall, 11.8% of isolates showed resistance to cefoperazone-sulbactam. Frequencies of isolates showing resistance to meropenem and amikacin were 14.7% and 26.25% respectively. Only 3.9% of Escherichia coli isolates showed resistance to cefoperazone-sulbactam. For other organisms, their lowest frequency ranging from 0-20%, exhibited resistance to meropenem. In Pseudomonas spp, in-vitro activity of amikacin was also better as only 11.1% isolates showed resistance to it. This study demonstrated the in-vitro synergistic effect of cefoperazonerazone-sulbactam and meropenem having good activity against GNB compared to the activity of other commonly tested antimicrobials. Cefoperazone-sulbactam can be recommended for the clinical practice against GNB exhibiting resistant to other antimicrobials as it is cheaper alternative to meropenem. Our results also focused on the continuous surveillance of the trends and features of resistance of common antimicrobials.

Values of lymphocyte subsets in Nepalese healthy adult population

INTRODUCTION

CD4 T lymphocyte is the most commonly used cellular marker in tracking Human Immunodeficiency Virus (HIV) infection progression and monitoring effect of antiretroviral therapy (ART). Due to lack of local reference values of CD4 and other T lymphocytes in Nepal, most clinical decisions are based on the reference ranges of western countries.

METHODS

This study was conducted at three major hospitals/laboratory of central, eastern and western Nepal during November 2008 through July 2009. Using the predefined criteria, 602 (200, 202 and 200 from central, eastern and western regions respectively) healthy adult volunteers of age range 18-60 years were recruited with equal representation from each age group and sex. Blood specimens were screened for HIV following standard algorithm using ELISA and two rapid test kits based on different principles. Samples with discordant test-results were excluded. HIV sero-negative specimens were further analyzed for CD4, CD8, and CD4:CD8 ratio, and absolute lymphocyte count (ALC) by FACS count (Becton Dickinson, USA) and automated cell counter (BC-3000 Plus, Shenzhen Mindray Biomedical Electronics, Germany) respectively.

RESULTS

The average value (mean± standard deviation) of CD4, CD8, CD4/CD8 ratio and ALC of Nepalese adult population were found to be 786 ± 248, 567±230, 1.52 ± 0.59 and 2712 ± 836 respectively. All four parameters but CD8 were significantly different with sex and females had relatively higher values. However, none of these parameters reported significant difference with age except the ALC.

CONCLUSIONS

Nepalese healthy adult populations have significantly different T lymphocyte subsets compared to other countries. The present reference ranges of CD4 and other T lymphocytes may be used for any clinical purposes including classifying and monitoring disease status in HIV infected individuals, immune status evaluation, monitoring ART and accordingly making amendment in national HIV treatment guidelines in Nepal.

Prevalence of intestinal worm infestations among school children in Kathmandu, Nepal

Intestinal worm infestation is one of the major childhood health problem in Nepal. This study was done to assess the prevalence of intestinal worm infestations among school children aged 6-16 years in a public high school in Kathmandu Nepal. A total of 142 stool samples from healthy students were collected and reported following formol-ether concentration technique. The overall prevalence of intestinal worm infestation was found to be 17.6% (Boys = 22.0% vs girls = 13.5%). Children aged 6-8 years were found to be highly infected with intestinal worms (21.4%) followed by 9-12 years old (18.6%). Those between 13-16 years of age were significantly less infected (10.7%) compared to others (p < 0.05). Ova/cysts of intestinal parasites detected include Trichuris trichiura (32.0%), Ascaris lumbricoides (20.0%), Hymenolepis nana (16.0%), hookworm (8.0%) and 24.0% cases showed mixed parasitic infections.

Use of gabapentin, esmolol or their combination to attenuate haemodynamic response to laryngoscopy and intubation

BACKGROUND

Laryngoscopy and intubation increases blood pressure and heart rate.

OBJECTIVE

The study aims to investigate the effect and safety of gabapentin, esmolol or their combination on the haemodynamic response to laryngoscopy and intubation.

METHODS

A total of 72 patients undergoing elective surgery were randomly allocated to one of the four groups. First study drug was administered orally as gabapentin 1200mg or placebo. Second study drug was administered intravenously as esmolol 1.5mg/ kg or normal saline. Heart rate, rate pressure product, systolic blood pressure and mean arterial pressure were recorded at baseline and at zero, one, three and five minutes after tracheal intubation.

RESULTS

Baseline values were compared with the values at various time intervals within the same group. In group PE (placebo, esmolol), there was significant decrease in heart rate and rate pressure product at five minutes. In group GN (gabapentin, normal saline), there was significant decrease in systolic blood pressure and mean arterial pressure at five minutes. In group GE (gabapentin, esmolol), there was significant decrease in heart rate at zero, three and five minutes. Systolic blood pressure, mean arterial pressure and rate pressure product was significantly lower at three and five minutes. In group PN (placebo, normal saline), there was significant increase in heart rate at zero, one, three and five minutes; systolic blood pressure at zero and one minutes; mean arterial pressure at zero and one minutes and rate pressure product at zero, one and three minutes. In group GN (gabapentin, normal saline), there was significant increase in heart rate at zero, one and three minutes and rate pressure product at zero, one and three minutes. In group PE (placebo, esmolol), there was significant increase in systolic blood pressure at zero and one minutes and mean arterial pressure at zero and one minutes. However, in group GE (gabapentin, esmolol) none of the variables showed statistically significant increase at any time. Inter-group comparison was made for each time point. At zero minute, there was significant difference in heart rate between groups PN and GE, GN and PE and GN and GE Significant difference was also noted in rate pressure product between PN and GE at zero minute. At one minute there was difference in heart rate between PN and PE, PN and GE, GN and PE and between GN and GE. Significant difference was observed in rate pressure product between PN and PE amd between PN and GE at one minute. No significant side effects of the study drugs were observed.

CONCLUSIONS

Combination of gabapentin and esmolol in this study design is safe and better attenuates both the pressor and tachycardic response to laryngoscopy and intubation, than either agent alone.

Aspergillus species in clinical specimen: a seven year prevalence study from eastern Nepal

Aspergillus species is increasingly being associated with various clinical conditions. The isolation rate however varies from centre to centre owing to the difference in the patient population, the local prevalence of the fungus and the nature of the clinical specimens received in the particular mycology laboratory. The objective of this study was to find the prevalence of Aspergillus species in different clinical specimen submitted in our hospital. Prospective study of the specimens received in mycology laboratory to find the prevalence of Aspergillus species isolated from BP Koirala Institute of Health Sciences (BPKIHS) was done. The overall prevalence of Aspergillus species in clinical samples was 15.06%. Aspergillus species was most frequently isolated (73.21%) from samples from otitis externa. The most number (68/165) of Aspergillus species isolated in this study was from nail samples from cases of onychomycosis. Aspergillus flavus was the commonest species isolated. There was an increasing trend in the isolation rate from 2003 to 2009. This study being the first of its kind from Nepal shows that Aspergillus species is a common pathogen among the spectrum of diseases we encounter here. Mycology laboratories should incorporate reliable, rapid diagnostic tests for early diagnosis as well as antifungal susceptibility tests.

Prevalence of extended spectrum beta lactamase (ESBL) production in gram negative isolates from pyogenic infection in tertiary care hospital of eastern Nepal

Emergence of extended spectrum beta lactamase (ESBL) producing isolates has important clinical and therapeutic implications. A high prevalence of ESBL production among multidrug resistant gram negative isolates has been reported in literature from various clinical samples. Since ESBL detection is not done on a routine basis, its prevalence is not known till date. Thus the present study was undertaken to determine the prevalence of ESBL production in gram negative isolates from pyogenic infection. A total of 300 gram negative bacilli isolated from the pus samples were identified phenotypically and antimicrobial activity was determined. ESBL detection among the isolated organisms was done by Phenotypic confirmatory disc diffusion technique recommended by CLSI. Of the 300 isolates, majority were Escherichia coli; (107) followed by Acinetobacter species; (55), Pseudomonas species; (44), Klebsiella pneumoniae; (32), Proteus mirabilis; (26), Enterobacter species; (25), Citrobacter species; (9) and others; (2). The prevalence of ESBL producing organisms was found to be 54 (18%); amongst which Escherichia coli was 29 (53.7%), Klebsiella pneumonia (14.8%), Proteus mirabilis 7 (12.9%) and others 4 (7.4%). Multidrug resistance were found in 92.6% of ESBL producers. Forty two were resistant to all the three third generation cephalosporins. The continuous surveillance of the ESBL producing isolates is necessary to make aware about the correct treatment regimens and good infection control practices.

Nocardia brasiliensis primary pulmonary nocardiosis with subcutaneous involvement in an immunocompetent patient

This is a report of an unusual case of Nocardia brasiliensis causing primary pulmonary nocardiosis with disseminated subcutaneous lesions in an immunocompetent patient. This case highlights the importance of considering nocardiosis as a differential diagnosis in patients with pulmonary and cutaneous lesions and the need for vigorous management for complete cure.

Comparison of Acute Physiology, Age, Chronic Health Evaluation III score with initial Sequential Organ Failure Assessment score to predict ICU mortality

Critically ill patients are provided with highest level of monitoring, care and treatment in Intensive Care Unit (ICU), which is very expensive and consumes many hospital resources. Various scoring systems have been developed to predict outcome in ICU patients so as to help physicians to prioritize patient admission and management. The objective of this study was to compare Acute Physiology and Chronic Health Evaluation (APACHE) III score with initial Sequential Organ Failure Assessment (SOFA) score to predict ICU mortality. Hundred seventeen patients admitted consecutively in ICU were enrolled. APACHE III and initial SOFA score of individual patients were calculated based on worst values in first 24 hours of admission. Outcome was recorded as survivors or non survivors in ICU. Both the scores were significantly higher in non survivors (p<0.001). A positive and strong correlation was seen between the scores with Spearman's rho correlation coefficient of 0.866 (p<0.001). Discrimination for APACHE III and initial SOFA score was good with area under ROC curve of 0.895 and 0.879 respectively. Cut off point with best Youden index was e" 61 for APACHE III and e" 8 for initial SOFA score. ICU mortality differed significantly above and below cut off points (p<0.001). Hosmer Lemeshow test showed initial SOFA score to have better calibration than APACHE III score. Initial SOFA score is comparable to APACHE III score for mortality prediction in ICU and so can be helpful for better utilization of limited resources in ICU.

Impalement injury to the heart

Cardiac impalement injury is rare and one of the most severe penetrating chest injuries, often fatal. The management of penetrating cardiac injuries is a challenging one. The success in management of impaling cardiac trauma requires stabilization of the impaling object, expeditious transfer to a facility for open heart surgery, rapid imaging, access to blood and blood products and a ready surgical team. We report a case of impalement injury to the heart by a stick, transfixing the right ventricle and its successful treatment.

Antimicrobial Resistant Streptococcus pneumoniae

Introduction: Pneumococcal infections are important cause of morbidity and mortality. Knowledge of antimicrobial susceptibility patterns plays important role in the selection of appropriate therapy.  Present study was undertaken to analyze the susceptibility patterns of pneumococcal isolates against  commonly used antimicrobials with special reference to determination of minimum inhibitory  concentration (MIC) of penicillin in a tertiary care hospital in eastern Nepal. Methods: Twenty-six strains of S. pneumoniae isolated from various clinical specimens submitted to microbiology laboratory were evaluated. All isolates were tested for antimicrobial susceptibility by  disk diffusion method. MIC of penicillin was tested by broth dilution method. Results: Of the total isolates 19 (73%) were from invasive infections. Seven isolates were resistant to cotrimoxazole. No resistance to penicillin was seen in disk diffusion testing. Less susceptibility to penicillin (MIC 0.1-1.0 mg/L) was observed in five (17%) isolates. High level resistance to penicillin was not detected. One isolate was multidrug resistant. Conclusions: S. pneumoniaeisolates with intermediate resistance to penicillin prevail in Tertiary Care Hospital in eastern Nepal, causing invasive and noninvasive infections. As intermediate resistance is not detected in routine susceptibility testing, determination of MIC is important. It helps not only in the effective management of life threatening infections but is also essential in continuous monitoring and early detection of resistance. In addition, further study on pneumococcal infections, its antimicrobial resistance profile and correlation with clinical and epidemiological features including serotypes and group prevalence is recommended in future. Keywords: antimicrobial susceptibility pattern, penicillin, Streptococcus pneumoniae.

Antimicrobial resistant Streptococcus pneumoniae

INTRODUCTION

Pneumococcal infections are important cause of morbidity and mortality. Knowledge of antimicrobial susceptibility patterns plays important role in the selection of appropriate therapy. Present study was undertaken to analyze the susceptibility patterns of pneumococcal isolates against commonly used antimicrobials with special reference to determination of minimum inhibitory concentration (MIC) of penicillin in a tertiary care hospital in eastern Nepal.

METHODS

Twenty-six strains of S. pneumoniae isolated from various clinical specimens submitted to microbiology laboratory were evaluated. All isolates were tested for antimicrobial susceptibility by disk diffusion method. MIC of penicillin was tested by broth dilution method.

RESULTS

Of the total isolates 19 (73%) were from invasive infections. Seven isolates were resistant to cotrimoxazole. No resistance to penicillin was seen in disk diffusion testing. Less susceptibility to penicillin (MIC 0.1-1.0 mg/L) was observed in five (17%) isolates. High level resistance to penicillin was not detected. One isolate was multidrug resistant.

CONCLUSIONS

S. pneumoniae isolates with intermediate resistance to penicillin prevail in Tertiary Care Hospital in eastern Nepal, causing invasive and noninvasive infections. As intermediate resistance is not detected in routine susceptibility testing, determination of MIC is important. It helps not only in the effective management of life threatening infections but is also essential in continuous monitoring and early detection of resistance. In addition, further study on pneumococcal infections, its antimicrobial resistance profile and correlation with clinical and epidemiological features including serotypes and group prevalence is recommended in future.

Unexplained apnoea and loss of consciousness during sub arachnoid block for caesarean section

Sub arachnoid block (SAB) is often perceived safe by many anesthesiologists and other faculties but is also not completely safe choice especially in pregnant females, as the incidence of complications and local anaesthetic agent toxicity is high in these groups of patients. Here we present four such cases out of the seventeen patients over a period of six months, who developed apnea and transient loss of consciousness after spinal anesthesia for lower segment caesarean section. Typically all these patients after spinal anesthesia developed difficulty in breathing, became apnoea and had loss of consciousness for about a minute or two. The apnea was relieved with bag and mask ventilation following which the patient regained consciousness and start breathing normally. The rest of the procedure was uneventful. We presented these cases with aim of sharing similar experiences, and to aware about the possibility of such events as these events do occur frequently but case reports and literatures are unavailable.

Hookworm causing melaena and severe anaemia in early infancy

Hookworm infestation is usually acquired by transcutaneous penetration of larvae whilst walking barefoot on contaminated soil. We present a small infant who presented with melaena and severe anaemia requiring multiple blood transfusions where the cause of gastro-intestinal bleeding was found to be massive hookworm infestation.

Iliopsoas abscess: analysis and perspectives from an endemic region of Eastern Nepal

OBJECTIVE

To evaluate the clinical profile and outcome in patients with iliopsoas abscess.

METHODS

A descriptive study was carried out in B.P. Koirala Institute of Health Science, Dharan, Nepal from February 2005 to March 2006. The medical records of all thirty six patients admitted in surgery ward with diagnosis of iliopsoas abscess during the study period were analyzed.

RESULTS

Thirty six patients were included the study. There were 22 (61.1%) males and 14 (38.9%) females with a mean age of 24.33 +/-19.19 years. Demographic distribution of the patients revealed the highest number 13 (36.1%) from Sunsari district, eastern part of the country. Right sided unilateral involvement was the most common presentation and only 2 cases had bilateral involvement. In none of our patients the dorsolumbar spine radiograph revealed any involvement of the bone. The most common complaints were pain in lower abdomen and lump in iliac fossa with flexion deformity at hip joint. All the patients underwent open surgical drainage and their outcomes were analyzed in term of cure, morbidity and mortality. Staphylococcus aureus was the most common organism 24 (61.5%) isolated. Twenty two (91.66%) of Staphylococcus aureus samples were sensitive to ciprofloxacin. There was one mortality in the group who died of septicaemia secondary to necrotizing fascitis. Six patients had wound infection, which were cured by regular dressing.

CONCLUSION

On the basis of our experience and review of available relevant literature, we can conclude that a high index of suspicion and awareness of the varying clinical picture are required to diagnose this condition properly. Ultrasonography should still be the preferred imaging modality as it is cheap, safe, cost effective and readily available. Ciprofloxacin should be used as a first line drug. Image guided aspiration may be practical in selected cases having little pus and traditional open drainage should be considered without hesitation.

Estimates of the maternal mortality ratio in two districts of the Brong-Ahafo region, Ghana

OBJECTIVE

To estimate the maternal mortality ratio (MMR) by the sisterhood method in two districts of the Brong-Ahafo region of Ghana, and to determine the impact of different assumptions and analytical decisions on these estimates.

METHODS

Indirect estimates of the MMR were calculated from data collected in 1995 by Family Health International (FHI) on 5202 women aged 15-49 years, using a household screen of randomly selected areas in the two districts. Other data from the nationally representative 1994 Ghana Infant, Child and Maternal Mortality Survey (ICMMS) and from the 1997 Kassena-Nankana District study were also used for comparison.

FINDINGS

Based on the FHI data, the MMR was estimated to be 269 maternal deaths per 100,000 live births for both districts combined, a figure higher than ICMMS estimates. Biases during data collection may account for this difference, including the fact that biases underestimating mortality are more common than those overestimating it. Biases introduced during data analysis were also considered, but only the total fertility rate used to calculate the MMR seemed to affect the estimates significantly.

CONCLUSIONS

The results indicate that the sisterhood method is still being refined and the extent and impact of biases have only recently received attention. Users of this method should be aware of limitations when interpreting results. We recommend using confidence limits around estimates, both to dispel false impressions of precision and to reduce overinterpretation of data.

Two randomized controlled trials comparing the tubal ring and filshie clip for tubal sterilization

OBJECTIVE

To compare the effectiveness and safety of the Filshie Clip and Tubal Ring systems when applied via minilaparotomy and laparoscopy.

DESIGN

Prospective, multicenter randomized controlled clinical trial, with postoperative evaluation by a physician who was masked to the operative technique.

SETTING

Healthy volunteers in a variety of hospital settings.

PATIENT(S)

2746 women (915 in the minilaparotomy study and 1831 in the laparoscopy study) who had requested permanent surgical sterilization.

INTERVENTION(S)

Surgical tubal ligation, using either Filshie Clips or Tubal Rings. A physician other than the surgeon evaluated the patients after the operation and again at 1, 6, and 12 months after surgery.

MAIN OUTCOME MEASURE(S)

Pregnancy rates and safety-related events.

RESULT(S)

During the 12 months after surgery, two women who received the Filshie Clip and two women who received the Tubal Ring became pregnant, giving a 12-month life-table pregnancy probability of 1.7 per 1000 women in both groups. The Tubal Ring was more difficult to apply and had higher rates of tubal or mesosalpingeal injuries at surgery. The Filshie Clip group had three cases of spontaneous clip expulsion during the follow-up period.

CONCLUSION(S)

Both the Filshie Clip and Tubal Ring are effective and safe for use in tubal occlusion.

Twelve-month comparative multicenter study of the TCu 380A and ML 250 intrauterine devices in Bangkok, Thailand

The long-term effectiveness of the copper-bearing intrauterine device (IUD) has been documented. This paper reports 12-month results from a multiyear comparative study of the Copper T (TCu) 380A and Multiload (ML) 250 IUD in Bangkok, Thailand, among 1396 women. Continuation of the assigned IUD was relatively high after 12 months of use, with continuation rates of 90.17 and 87.54 per 100 women, respectively. Whereas the accidental pregnancy rate was higher for the ML 250 IUD than for the TCu 380A IUD (1.0 and 0.2 per 100 women, respectively), this difference was not considered statistically significant (p < 0.69). The rate of IUD expulsion was significantly higher among women using the ML 250 IUD than for women using the TCu 380A IUD (4.61 and 2.40 per 100 women, respectively, p = 0.05).

Non-physician insertion of IUDs: clinical outcomes among TCu380A insertions in three developing-country clinics

Insertion of IUDs by trained non-physicians is increasing. This secondary analysis of TCu380A IUD acceptors collected at clinics in Nigeria, Turkey and Mexico involved 367 women; 193 insertions were performed by physicians and 174 by non-physicians. Women having their IUD inserted by a non-physician were more likely to experience a pain-free insertion, but also likelier to have the IUD removed for bleeding and pain or to experience an expulsion than women who had their IUD inserted by a physician. Early discontinuation rates were similar between the two groups. Overall continuation rates were statistically higher for IUDs inserted by physicians only at the Mexico site. Trained non-physicians can probably safely insert the TCu380A IUD. Appropriate competency-based training is required to limit the number of expulsions and removals for bleeding and pain by non-physicians.

Safety, functionality and acceptability of a prototype polyurethane condom

Male condoms made from synthetic materials offer an alternative to latex condoms that may be more acceptable to users, thereby potentially resulting in more protected acts of intercourse. A prospective, noncomparative clinical study was conducted to evaluate the safety of using certain polyurethane materials to make condoms. Fifty-one healthy, contracepting, mutually monogamous couples were recruited between June 30 and November 24, 1993 to use a prototype roll-on polyurethane condom developed by Family Health International. Couples were to use the condoms for 10 consecutive acts of vaginal intercourse over a 4-week period. Baseline and postexposure genital examinations, including colposcopy for female participants, were performed. Fifty couples completed the study requirements and 517 acts of intercourse occurred using the condoms. Two adverse events were reported: irritation of introitus in a female participant and a small irritated erythematous lesion on a male participant's penis. Neither event was considered to be serious and both were resolved without treatment. Breakage and slippage rates were similar to those reported for latex condoms. These results suggest that polyurethane condoms represent a safe, functional and acceptable alternative to latex condoms.

Results of a pilot study of the time to azoospermia after vasectomy in Mexico City

In a joint pilot study by Family Health International (FHI), AVSC International, and the Instituto Mexicano del Seguro Social (IMSS), information was gathered on the determinants of azoospermia following vasectomy on 38 healthy men who chose vasectomy for contraception. The time and number of ejaculations associated with loss of sperm motility and loss of sperm eosin vital staining were also evaluated. "Azoospermia" was defined on the basis of two consecutive azoospermic semen samples collected at least 3 days apart. The single decrement life table method was used to calculate weekly gross cumulative life table rates for the time to azoospermia, zero motility, and zero viability. The Kaplan-Meier method was used to calculate the product-limit estimates of the cumulative rates for the total number of ejaculations to azoospermia, 0% motility and 0% viability. The median time to azoospermia was 10 weeks and at the end of week 20, the life table rate (+/- standard error) was 93.0 (+/- 6.30) weeks/100 men. The median number of ejaculations to azoospermia was between 25 and 30, and the cumulative rate (+/- standard error) at 60 ejaculations reached 94.5 (+/- 5.16)/100 men.

An evaluation of the copper-T 380A IUD's safety and efficacy at three African centers

The use of intrauterine devices in Africa is low compared with other contraceptive methods such as oral contraceptives. This study, coordinated by Family Health International, evaluated the clinical performance (safety and efficacy) of the TCu 380A IUD in three African centers, respectively, in Cameroon, Egypt, and Nigeria from 1986-1989. The 12-month unintended pregnancy rates were low for all three centers, ranging from none to 1.6 per 100 women. The 12-month discontinuation rates for all reasons ranged from 8.8 to 26.9 per 100 women. Statistically significant differences were observed among clinics for discontinuation rates for bleeding and/or pain and for planned pregnancy. The overall performance of the TCu 380A IUDs was considered satisfactory. Thus, the limited use of IUD in Africa could be due to the lack of accessibility, lack of information about, and confidence in the method rather than to documented clinical performance.

Clinical performance of the TCu 380A and Lippes Loop IUDs in three developing countries

The clinical performance of the Copper T 380A (TCu 380A) and the Lippes Loop intrauterine devices (IUDs) were evaluated for 12 months in a group of 710 women who had one of the two IUDs inserted. Results are from a randomized clinical trial conducted at three collaborating research sites located in three developing countries. The gross cumulative life-table pregnancy rate of the TCu 380A IUD was found to be lower than that of the Lippes Loop IUD at 12 months (0.7 and 2.1 per women, respectively). Although this difference was not statistically significant (p = 0.25), it is similar to findings from other studies. The 12-month cumulative removal rate due to personal reasons was significantly different (1.4 and 0.0, respectively, p = 0.05). Statistically significant differences between the two study IUDs were not found with regard to IUD expulsion or IUD removal due to bleeding/pain, medical reasons, planned pregnancy or investigator's choice. A statistically significant difference (p = 0.03) was observed in the number of TCu 380A IUD users experiencing dysmenorrhea (26.1%) during the 12-month study period, compared to Lippes Loop IUD users (18.8%).

Clinical evaluation of Norplant in Kumasi, Ghana

A non-comparative study of the Norplant contraceptive subdermal implant system was conducted in Kumasi, Ghana. A total of 100 acceptors were enrolled in the clinical trial, which began in 1987. There were no pregnancies during the first two years of use. Only nine post-insertion medical problems were reported during the first two years of use. One woman in this study requested removal for menstrual pattern changes through two years of use. As assessed through user-satisfaction questionnaires administered at approximately six months of use, there has been an overall positive user experience with Norplant in this study. Although the sample size in this study is small, our results seem to be consistent with other studies and it appears that Norplant offers an effective, safe and acceptable method of contraception for Ghanaian women.

Clinical performance of the TCu 380A and TCu 220C IUDs in four developing country family planning clinics

The clinical performance of the Copper T 380A (TCu 380A) and the Copper T 220C (TCu 220C) intrauterine devices (IUDs) were evaluated for 12 months in a group of women who had one of the two IUDs inserted. Results are from a randomized clinical trial conducted at four collaborating research sites located in two developing countries. The gross cumulative life-table pregnancy rate of the TCu 380A IUD was found to be lower than that of the TCu 220C IUD at 12 months (0.3 and 0.8, respectively), although this difference was not statistically significant (p > 0.05). Statistically significant differences between the two study IUDs were not found with regard to IUD expulsion or IUD removal due to bleeding/pain, personal reasons, medical reasons, or planned pregnancy. No statistically significant differences were observed in the frequency of experiencing menstrual disturbances (i.e., dysmenorrhea, intermenstrual pelvic pain or intermenstrual bleeding) between the two IUD groups. These data suggest that the TCu 380A and TCu 220C IUDs are both appropriate options for contracepting women. The TCu 380A IUD, however, may be a more appropriate option for those women wishing to space births over a longer period of time.

An analysis of the personal reasons for discontinuing IUD use

The objective of this study was to evaluate possible factors associated with discontinuing use of TCu 380A IUDs due to personal reasons among 2748 users. Overall, a total of 88 subjects discontinued using the TCu 380A IUD within 12 months postinsertion for personal reasons. The most common reasons were planned pregnancy (32%) and husband or family opinion against IUD use (26%). The gross cumulative 12-month life table discontinuation rate for all personal reasons was 4.0 per 100 women. Having no education and/or living in a rural area were the sociodemographic characteristics associated with an increased risk of discontinuation for personal reasons. Effective and regular counseling about IUD use, especially among illiterate women, may help prevent IUD discontinuations related to personal reasons.

The effect of husband counseling on NORPLANT contraceptive acceptability in Bangladesh

A pilot study of the effect of husband counseling on NORPLANT contraceptive acceptability was conducted at four family planning clinics in Bangladesh. The study objectives were to compare discontinuation rates and user satisfaction among acceptors whose husbands received counseling about the method versus those who did not. Of a total 617 subjects enrolled in the study which began in 1988, about two-thirds (408) of the husbands were counseled at admission or at the one-month follow-up visit while the remainder of the husbands (209) were not counseled. Follow-up visits were scheduled at one and six months after NORPLANT implants insertion, and every six months thereafter until the close of the study in 1991. Some evidence was found that counseling husbands of NORPLANT implants acceptors may reduce discontinuation rates. At the end of 36 months, a difference of 10 percentage points in total discontinuation rates was observed between the husband-counseled group (32 per 100 women) and the husband-not-counseled group (42 per 100 women). The husband counseling had the most impact at clinics with higher discontinuation rates. Based on Cox's proportional hazards regression model results, the hazard for discontinuation among the acceptors in the husband-not-counseled group. Satisfaction with NORPLANT implants did not differ between the two groups. Although these results are not striking, they do suggest a potential positive effect of husband counseling on NORPLANT contraceptive accept-ability. In future studies, the counseling of husbands should be more intensive and standardized.

Clinical evaluation of the TCu 380A IUD at six Latin American centers

Compared with other contraceptive methods such as sterilization and oral contraceptives, the prevalence of IUD use in Latin American countries is relatively low. This study evaluated the clinical performance of the TCu 380A IUD in six Latin American clinics to determine whether its performance was a determining factor in its low prevalence, and to provide efficacy and safety data based on local data sets to Latin American service providers. The 12-month unintended pregnancy rate ranged from 0.0 to 1.7 per 100 women and the 12-month discontinuation rates for all reasons, from 3.3 to 21.0 per 100 women. Statistically significant differences in discontinuation rates were observed among clinics, and could be explained, in part, by the different sociodemographic and clinical characteristics of women attending the clinics. The overall performance and acceptability of the TCu 380A IUD was considered satisfactory and comparable to those reported from other countries. Thus, the low prevalence of IUD use in Latin America is probably related to barriers to its use rather than its clinical performance.

Contraceptive efficacy of the Copper T380A and the Multiload Cu250 IUD in three developing countries

The clinical performance of the Copper T380A (TCu380A) and the Multiload 250 (MLCu250) intrauterine devices (IUDs) were evaluated for 12 months in a group of women who had one of the two IUDs inserted. Results are from a randomized clinical trial conducted at four collaborating research sites located in three developing countries. The gross cumulative life-table pregnancy rate of the TCu380A IUD was significantly lower than the rate with the MLCu250 IUD at 12 months (0.5 and 1.2, respectively, p < 0.01). No statistically significant differences between the two study IUDs were found with regard to IUD expulsion or IUD removal due to bleeding/pain, personal reasons, medical reasons, or planned pregnancy. TCu380A IUD users were more likely to report experiencing increased dysmenorrhea (p < 0.01) or intermenstrual pelvic pain (p < 0.01) than were MLCu250 IUD users. However, few of these users discontinued use of their assigned IUD because of having experienced menstrual bleeding disturbances or intermenstrual pelvic pain. These data indicate that the TCu380A IUD may be a better option than the MLCu250 IUD for women wishing to practice highly effective long-term birth control without having to resort to hormonal methods.

Contraceptive efficacy of the Copper T 380A and Copper T 200 intrauterine devices: results from a comparative clinical trial in six developing countries

The clinical performance of the Copper T 380A (TCu 380A) and the Copper T 200 (TCu 200) intrauterine devices (IUDs) was evaluated for 12 months in a group of women who had one of the two IUDs inserted. Results are from a multicenter randomized clinical trial at one site in each of six developing countries. The pregnancy rate with the TCu 380A IUD was significantly lower than the pregnancy rate with the TCu 200 IUD at 12 months (0.5 and 2.6 per 100 women, respectively, p < 0.01). No statistically significant differences between the two study IUDs were found with regards to expulsion or removals due to bleeding/pain, personal, medical, or planned pregnancy. The TCu 380A IUD did not have a disproportionately higher incidence of side effects such as intermenstrual bleeding or pain, inflammations or infections, or insertion-related events compared to the TCu 200 IUD. TCu 380A IUD users, however, were significantly more likely to report increased dysmenorrhea than were TCu 200 IUD users. The performance of the TCu 380A IUD in preventing pregnancy during this trial indicates that this IUD may be a better option than the TCu 200 IUD for women wishing to practice effective, long-term, reversible birth control without having to resort to hormonal methods.

Fresh gas flow and carbon dioxide rebreathing in a low pressure semi-open anaesthesia system

We have constructed a simple system for field anaesthesia by using a Farman entrainer and a semi-open circuit to convert a draw-over apparatus to a continuous flow air/O2 system. Compressed O2 was the driving gas for the entrainer; fresh gas (FG) delivered to the semi-open circuit was a mixture of O2, entrained air and anaesthetic vapour. The purpose of this study was to examine FG flow rate and CO2 rebreathing during intermittent positive pressure ventilation (IPPV). A non-rebreathing inflation valve (Laerdal) placed at the end of the expiratory (efferent) limb of the circuit vented both expiratory gas and excess FG. Ambient air IPPV was applied through the Laerdal valve from a self-inflating bag or ventilator. Since this circuit is functionally similar to a T-piece, the gas from the efferent limb (340 ml, containing FG) entered the lungs first. If tidal volume was larger than 340 ml the balance was ambient air. Minute ventilation of the lungs with efferent limb gas was defined as Veff. Respiratory gas was sampled at the endotracheal tube and the CO2 tension was measured with a NIHON-KOHDEN CO2 analyzer. Thirty-seven adult patients having intra-abdominal or pelvic surgery under general tracheal anaesthesia were studied. Four FG flow rates (5.7, 8.0, 9.3, and 10.4 L.min-1), corresponding to driving gas pressures of 40, 60, 80, and 100 mmHg, were introduced in random order. Although inspired CO2 was detected at FG flow rates of 5.7-9.3 L.min-1, there were no differences in PETCO2 among the four groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Anaesthesia services and the education of anaesthetists in Nepal: a model for sustainable development?

In 1985 the University of Calgary in Canada and Tribhuvan University in Kathmandu, Nepal Jointly established the Diploma in Anaesthesiology (DA) programme in Nepal. To evaluate the impact of the DA Programme and provide a data base for long-term planning we conducted a national survey in 1992. We sought to describe anaesthesia manpower and workloads, and to make an inventory of facilities, equipment, and supplies in different sized hospitals. Twenty-seven hospitals providing surgical services were included, nine inside and 18 outside the Kathmandu valley. Seventeen of the 21 respondent hospitals had at least one specialist anaesthetist. The results identify both strengths and weaknesses in Nepal's anaesthesia services and provide important guidelines for planning. When the DA course was launched there were only seven specialist anaesthetists in Nepal. The shortage of anaesthetists was an important factor limiting surgical services, and after DA graduates were posted to zonal (50 bed) and regional (150-200 bed) hospitals the surgical case loads doubled. There are now about 40 specialist anaesthetists in the country, of which half are DA graduates, but many hospitals have only one anaesthetist. That isolation, plus lack of continuing education (CME), are important factors threatening quality of care. Recognizing the singular role of the DA programme in alleviating Nepal's shortage of anaesthetists, we conclude that it should be renewed and strengthened to meet the needs of the next decade. Techniques commonly used at the zonal level: regional, draw-over, and total IV anaesthesia, should be stressed. At the same time fresh initiatives are required in CME and higher education for the renewal of teaching staff.(ABSTRACT TRUNCATED AT 250 WORDS)

Anaesthesia training and development in Nepal 1985-1990

In 1985 a diploma program in anaesthesia was established in Kathmandu, Nepal, as a joint venture between the Institute of Medicine in Kathmandu and the University of Calgary. Development of the program and of the specialty in the capital city of Kathmandu was continuously documented during the next five years by local and visiting faculty. In 1990 teams of two Nepali and one Canadian anaesthetist also conducted a survey of each of the seven 50-100 bed zonal hospitals which did not previously have a trained anaesthetist and which are now staffed by graduates of the diploma program. In 1985 Nepal, with a population of 16 million, had seven trained Nepali anaesthetists all of whom worked in two hospitals in Kathmandu. By the end of 1989, 19 physicians had graduated. Seven of these continue to work in Kathmandu hospitals, nine work in zonal hospitals throughout the country and two are taking higher anaesthesia training in the United Kingdom. Additional Nepali anaesthetists have returned from training abroad, and the Society of Anaesthesiologists of Nepal, which joined the World Federation of Societies of Anaesthesiologists in 1988, now has 34 members. An annual anaesthesiology symposium is held, and weekly clinical meetings are organized in the major hospitals in Kathmandu. Anaesthetists who work in the zonal hospitals have limited supplies of drugs and equipment and opportunities for continuing medical education are virtually nonexistent.(ABSTRACT TRUNCATED AT 250 WORDS)