Integrated Land Suitability Assessment for Depots Siting in a Sustainable Biomass Supply Chain

A sustainable biomass supply chain would require not only an effective and fluid transportation system with a reduced carbon footprint and costs, but also good soil characteristics ensuring durable biomass feedstock presence. Unlike existing approaches that fail to account for ecological factors, this work integrates ecological as well as economic factors for developing sustainable supply chain development. For feedstock to be sustainably supplied, it necessitates adequate environmental conditions, which need to be captured in supply chain analysis. Using geospatial data and heuristics, we present an integrated framework that models biomass production suitability, capturing the economic aspect via transportation network analysis and the environmental aspect via ecological indicators. Production suitability is estimated using scores, considering both ecological factors and road transportation networks. These factors include land cover/crop rotation, slope, soil properties (productivity, soil texture, and erodibility factor) and water availability. This scoring determines the spatial distribution of depots with priority to fields scoring the highest. Two methods for depot selection are presented using graph theory and a clustering algorithm to benefit from contextualized insights from both and potentially gain a more comprehensive understanding of biomass supply chain designs. Graph theory, via the clustering coefficient, helps determine dense areas in the network and indicate the most appropriate location for a depot. Clustering algorithm, via K-means, helps form clusters and determine the depot location at the center of these clusters. An application of this innovative concept is performed on a case study in the US South Atlantic, in the Piedmont region, determining distance traveled and depot locations, with implications on supply chain design. The findings from this study show that a more decentralized depot-based supply chain design with 3depots, obtained using the graph theory method, can be more economical and environmentally friendly compared to a design obtained from the clustering algorithm method with 2 depots. In the former, the distance from fields to depots totals 801,031,476 miles, while in the latter, it adds up to 1,037,606,072 miles, which represents about 30% more distance covered for feedstock transportation.

Microplastics in environment: global concern, challenges, and controlling measures

Plastic pollution in various forms has emerged as the most severe environmental threat. Small plastic chunks, such as microplastics and nanoplastics derived from primary and secondary sources, are a major concern worldwide due to their adverse effects on the environment and public health. Several years have been spent developing robust spectroscopic techniques that should be considered top-notch; however, researchers are still trying to find efficient and straightforward methods for the analysis of microplastics but have yet to develop a viable solution. Because of the small size of these degraded plastics, they have been found in various species, from human brains to blood and digestive systems. Several pollution-controlling methods have been tested in recent years, and these methods are prominent and need to be developed. Bacterial degradation, sunlight-driven photocatalyst, fuels, and biodegradable plastics could be game-changers in future research on plastic pollution control. However, recent fledgling steps in controlling methods appear insufficient due to widespread contamination. As a result, proper regulation of environmental microplastics is a significant challenge, and the most equitable way to manage plastic pollution. Therefore, this paper discusses the current state of microplastics, some novel and well-known identification techniques, strategies for overcoming microplastic effects, and needed solutions to mitigate this planetary pollution. This review article, we believe, will fill a void in the field of plastic identification and pollution mitigation research.

Assessment of Critical Knowledge on Maternal and Newborn care Services among Primary Level Nurse Mid-wives in Kapilvastu District of Nepal

Background Despite greater emphasis on maternal and neonatal health through policy and programming in Nepal, maternal and neonatal health is still not impressive. Health care providers' knowledge assessment on maternal and neonatal care has been well documented elsewhere, but it is very little understood in Nepal. Objective The primary objective of this study was to assess the critical knowledge of primary level nurse- midwives on maternal and newborn care in Kapilvastu District of Nepal. Method This was an Institution based cross-sectional study, conducted in Kapilvastu district, Nepal among sixty eight nurse-midwives. The participants were selected using simple random sampling technique. For collecting the data, health institutions were visited by enumerators for a month from 1st October to 1st November 2012. Data were entered into Microsoft Excel, cleaned and analyzed using SPSS version 17.0. Result More than 3/4th of the nurse-midwives had 10-20 years of experience. Majority of them (89.7%) had poor knowledge in taking action to prevent mother to child transmission for HIV positive women. More than half of them (54.4%) had some knowledge in performing the active management of third stage of labor whereas almost half (51.5%) had poor knowledge to actions needed on post-partum haemorrhage (PPH). Similarly, more than two third (69.1%) had poor knowledge in newborn care. Conclusion Majority of the nurse-midwives were found to have either poor or some level of knowledge in most of the components of maternal and newborn care services. So, greater emphasis should be given to upgrade the knowledge of nurse mid-wives.

Correlation between electrocardiographic changes and coronary findings in patients with acute myocardial infarction and single-vessel disease

BACKGROUND

Correlation of ST-segment elevation on the 12-lead electrocardiogram (ECG) with the expected affected coronary territory is established in patients with ST-elevation myocardial infarction (STEMI). In patients with non-ST-elevation myocardial infarction (NSTEMI), correlation of ischemic ECG abnormalities with the affected coronary territory has not been well-established. We sought to investigate the correlation of electrocardiographic abnormalities with the location of 1-vessel obstructive coronary artery disease (CAD) in patients with both STEMI and NSTEMI.

METHODS

In this retrospective study, the charts of all patients referred for coronary angiography in 2012 were reviewed. Patients with a single obstructive coronary artery plus angina-equivalent symptoms and an elevated cardiac troponin I was included. Available ECGs were interpreted by an experienced cardiologist (WSA) blinded to the result of angiography. Patients with complete bundle branch block or ventricular pacing were excluded. Ischemic ECG changes were correlated to a coronary territory based on predefined criteria.

RESULTS

Of 131 included patients (mean age 64±13 years; 74% male), 29 had STEMI and 102 had NSTEMI. Eleven of 11 patients (100%) with anterior STEMI had left anterior descending artery (LAD) obstructive CAD. Of 18 patients with inferior STEMI, 14 (78%) had right coronary artery (RCA) obstructive CAD, 3 (17%) had left circumflex artery (LCX) artery obstructive CAD, and 1 (5%) had LAD obstructive CAD. Of 102 NSTEMI patients, 53 (52%) had definite ECG ischemic abnormalities. Of 31 patients with anterior definite ECG ischemic abnormalities, 30 (97%) had LAD obstructive CAD, and 1 (3%) had RCA obstructive CAD. Of 22 patients with inferior definite ECG ischemic abnormalities, 14 (64%) had RCA obstructive CAD, 5 (23%) had LCX obstructive CAD, and 3 (14%) had LAD obstructive CAD.

CONCLUSIONS

Patients with anterior STEMI had LAD obstructive CAD. Patients with inferior STEMI were highly likely to have RCA or LCX obstructive CAD. Only half of NSTEMI patients had definite ischemic ECG abnormalities. When present, anterior ischemic ECG changes in patients with single vessel CAD with NSTEMI were predictive of LAD obstructive CAD.

Factors Associated with Smokeless Tobacco Use among Pregnant Women in Rural Areas of the Southern Terai, Nepal

BACKGROUND

Tobacco use among women during pregnancy leading to poor maternal and child health outcomes has been well documented. However, factors influencing use of smokeless tobacco in Nepal has not yet been well established. This study aims at exploring the factors related to smokeless tobacco use among pregnant women in rural southern Terai of Nepal.

METHODS

A community-based cross-sectional study was performed at 52 wards within 6 Village Development Committee in Dhanusha district of Nepal. A total of 426 expectant mothers in their second trimester were selected using a multistage cluster sampling method. Descriptive and regression analyses were done to explore the factors that influence smokeless tobacco use.

RESULTS

In a total of 426 pregnant mothers, one in five used tobacco in any form. Among the users, 13.4% used smokeless tobacco. Pregnant mothers who were smoking tobacco (AOR 6.01; 95% CI (1.88-19.23), having alcohol consumption (AOR 3.86; 95% CI (1.23-12.08), stressed (AOR 5.04; 95% CI (1.81-14.03), non-vegetarian (AOR 3.31;(1.84-13.03), not attending regular mothers' group meetings (AOR 4.63; (1.41-15.19), and not-exposed to mass media (AOR 5.02; (1.89-13.33) were significantly associated with smokeless tobacco use. Similarly, mothers of age group 20-34 years, dalit, aadibasi and janajati, hill origin, no education and primary education were more likely to use smokeless tobacco than their counterparts.

CONCLUSIONS

Factors such as smoking tobacco, alcohol consumption, stress, and poor education were found to be significantly associated with smokeless tobacco use among pregnant women in southern Terai of Nepal. This requires an immediate attention develop an effective strategy to prevent and control smokeless tobacco use among pregnant women in southern Terai of Nepal.

Association of chest pain versus dyspnea as presenting symptom for coronary angiography with demographics, coronary anatomy, and 2-year mortality

INTRODUCTION

The association of chest pain versus dyspnea with demographics, coronary angiographic findings, and outcomes of patients undergoing coronary angiography is unknown.

MATERIAL AND METHODS

We studied 1,053 patients who had coronary angiography to investigate the association of chest pain versus dyspnea with demographics, coronary angiographic findings, and outcomes.

RESULTS

Of 1,053 patients, 654 (62%) had chest pain, 229 (22%) had dyspnea, and 117 (11%) had chest pain and dyspnea. Patients with dyspnea were older (p < 0.0001) and had higher serum creatinine (p = 0.0011), lower left ventricular ejection fraction (LVEF) (p < 0.0001), more cardiogenic shock (p = 0.0004), less obstructive coronary artery disease (CAD) (p < 0.0001), less percutaneous coronary intervention (p < 0.0001), and similar 2-year mortality. Stepwise Cox regression analysis showed no significant difference in mortality between chest pain and dyspnea. Significant risk factors for time to death were age (hazard ratio (HR) = 1.07, p < 0.0001), serum creatinine (HR = 1.5, p < 0.0001), body mass index (HR = 0.93, p = 0.005), and obstructive CAD graft (HR = 3.2, p = 0.011).

CONCLUSIONS

Patients undergoing coronary angiography presenting with dyspnea were older and had higher serum creatinine, lower LVEF, more frequent cardiogenic shock, less obstructive CAD, and less percutaneous coronary intervention compared to patients presenting with chest pain but similar 2-year mortality.

Knowledge of Maternal and Newborn Care Among Primary Level Health Workers in Kapilvastu District of Nepal

BACKGROUND

Higher maternal and neonatal deaths are common in low- and middle-income countries; due to less access to skilled help. Adequate knowledge and skills on maternal and newborn care (MNC) of community health workers can improve maternal and newborn health.

AIMS

To identify the knowledge of primary level health workers on some components of MNC.

SUBJECTS AND METHODS

Respondents were selected using simple random sampling method. For collecting the data, enumerators visited health institutions for 2 months from 1(st) October to 31(st) November 2012, and structured interview schedule was used to gather the information. A cross-sectional study was conducted in a total of one hundred and thirty-seven primary level health workers in Kapilvastu district, Nepal. The Chi-square test was employed to examine the association between the knowledge of health workers on MNC and designation and work experience. Data were analyzed using SPSS version 17.

RESULTS

In a total of 137 primary level health workers, more than half 53.2% (73/137) were senior auxiliary health workers/health assistant. Health workers having correct knowledge on contents of MNC were-registration 32.1% (44/137), major components of antenatal care 57.7% (79/137), danger signs of pregnancy 39.4% (54/137), five cleans 59.1% (81/137), postnatal health problems 54.0% (74/137), majority to health action to newborn care, newborn bath and meaning of exclusive breastfeeding. There was a statistical association between designation of health workers and above-mentioned components of MNC (P < 0.05).

CONCLUSIONS

The differentials in the knowledge of MNC among primary level health suggest improving knowledge of the grass root level health workers with appropriate training and development programs.

Diel trends in stomatal response to ozone and water deficit: a unique relationship of midday values to growth and allometry in Pima cotton?

Plant responses to ozone (O3 ) and water deficit (WD) are commonly observed, although less is known about their interaction. Stomatal conductance (gs ) is both an impact of these stressors and a protective response to them. Stomatal closure reduces inward flux of O3 and outward flux of water. Stomatal measurements are generally obtained at midday when gas exchange is maximal, but these may not be adequate surrogates for stomatal responses observed at other times of day, nor for non-stomatal responses. Here, we find in Pima cotton that stomatal responses to O3 observed at midday do not reflect responses at other times. Stomata were more responsive to O3 and WD near midday, despite being at quasi-steady state, than during periods of active opening or closing in morning or evening. Stomatal responsivity to O3 was not coincident with maximum gas exchange or with periods of active regulation, but coincident with plant sensitivity to O3 previously determined in this cultivar. Responses of pigmentation and shoot productivity were more closely related to stomatal responses at midday than to responses at other times of day under well-watered (WW) conditions, reflecting higher stomatal responsivity, sensitivity to O3 , and magnitude of midday gs . Under WD conditions, shoot responses were more closely related to early morning gs. Root responses were more closely related to early morning gs under both WW and WD. Responses of stomata to O3 at midday were not good surrogates for stomatal responses early or late in the day, and may not adequately predicting O3 flux under WD or when maximum ambient concentrations do not occur near midday.

Pantothenate kinase-associated neurodegeneration is not a synucleinopathy

Aims: Mutations in the pantothenate kinase 2 gene (PANK2) are responsible for the most common type of neurodegeneration with brain iron accumulation (NBIA), known as pantothenate kinase-associated neurodegeneration (PKAN). Historically, NBIA is considered a synucleinopathy with numerous reports of NBIA cases with Lewy bodies and Lewy neurites and some cases reporting additional abnormal tau accumulation. However, clinicopathological correlations in genetically proven PKAN cases are rare. We describe the clinical, genetic and neuropathological features of three unrelated PKAN cases. Methods: All three cases were genetically screened for the PANK2 gene mutations using standard Sanger polymerase chain reaction sequencing. A detailed neuropathological assessment of the three cases was performed using histochemical and immunohistochemical preparations. Results: All cases had classical axonal swellings and Perls' positive iron deposition in the basal ganglia. In contrast to neuroaxonal dystrophies due to mutation of the phospholipase A2, group VI (PLA2G6) gene, in which Lewy body pathology is widespread, no α-synuclein accumulation was detected in any of our PKAN cases. In one case (20-year-old male) there was significant tau pathology comprising neurofibrillary tangles and neuropil threads, with very subtle tau pathology in another case. Conclusions: These findings indicate that PKAN is not a synucleinopathy and, hence the cellular pathways implicated in this disease are unlikely to be relevant for the pathomechanism of Lewy body disorders.

Neuropathology of Beta-propeller protein associated neurodegeneration (BPAN): a new tauopathy

Introduction

Beta-propeller protein associated neurodegeneration (BPAN) is associated with mutations in the WD repeat domain 45 (WDR45) gene on chromosome Xp11 resulting in reduced autophagic flux. This study describes the clinical and neuropathological features of a female 51 year old BPAN case. The clinical history includes learning disability and progressive gait abnormalities since childhood followed by progressive dystonic features in young adulthood. Brain imaging revealed generalised brain atrophy and bilateral mineralisation of the globus pallidus and substantia nigra.

Results

The major pathological findings were observed in the substantia nigra with excess iron deposition, gliosis, axonal swellings and severe neuronal loss. Iron deposition was also observed in the globus pallidus. There was extensive hyperphosphorylated-tau deposition in the form of neurofibrillary tangles, pre-tangles and neuropil threads. Furthermore, histological studies and immunoblotting confirmed a mixed Alzheimer type 3-and 4-repeat tau pathology. Microtubule-associated protein 1A/1B-light chain 3 (LC3) immunoblotting of brain homogenates indicated autophagic activity and may support the role of WDR45 in autophagy.

Conclusions

The widespread Alzheimer-type tau pathology in this disease indicates that this should be considered as a tauopathy and adds further support to the proposal that impaired autophagy may have a role in tauopathies.

Electronic supplementary material

The online version of this article (doi:10.1186/s40478-015-0221-3) contains supplementary material, which is available to authorized users.

Abstract 244: Association of Chest Pain versus Dyspnea as Presenting Symptom for Coronary Angiography with Demographics, Coronary Anatomy, and 2-Year Mortality

Background: The two most common conditions leading to an indication for coronary angiography are known or suspected coronary artery disease (CAD) and heart failure. However, whether the clinical presentation of chest pain (CP) versus dyspnea impacts on the demographics, coronary anatomy findings and outcomes of patients undergoing coronary angiography is unknown.

Methods: We studied 1,053 patients (63% men, mean age 64 years), who underwent coronary angiography during 2012 at Westchester Medical Center and determined their most relevant clinical presentation from their medical records through the admission note. 2-years mortality was obtained from social security death index.

Results: Of 1,053 patients, 654 (62%) had CP, 229 (22%) had dyspnea, 117 (11%) had CP and dyspnea, and 53 (5%) had an abnormal stress test with no symptoms. Patients with dyspnea were older (67 years vs. 63 years, p<0001), had a higher serum creatinine (1.3 mg/dL vs. 1.1 mg/dL, p = 0.0011), lower left ventricular ejection fraction (LVEF) (47% vs. 54%, p <0. 0001), more frequently had cardiogenic shock (5% vs. 1%, p =0.0004), less obstructive coronary artery disease (CAD) (45% vs. 63%, p < 0.0001) and less percutaneous coronary intervention (31% versus 10%, p< 0.0001), and similar 2-year mortality (4% vs. 7%, p=0.75). Log-rank test showed no difference in time to death between CP and dyspnea (p=0.104). Stepwise Cox regression analysis showed no significant difference in mortality rates between CP and dyspnea (p=0.11). Significant risk factors for time to death were age (HR 1.07, p <0.0001), serum creatinine (HR 1.5, P<0.0001), body mass index (HR 0.93, p = 0.005), and obstructive CAD (HR 3.2, p = 0.011).

Conclusions: Patients undergoing coronary angiography who presented with dyspnea were older, had a higher serum creatinine, lower LVEF, more frequent cardiogenic shock, less obstructive CAD, and less percutaneous coronary intervention compared to patients presenting with CP. However, the difference in clinical presentation was not associated with a higher 2-year mortality.

Peritonitis in a continuous ambulatory peritoneal dialysis patient by two different species of enterococci: A rare finding

Peritonitis in a continuous ambulatory peritoneal dialysis patient by two different species of enterococci is a rare condition. We report a case of peritonitis from which vancomycin sensitive Enterococcus faecalis and vancomycin resistant Enterococcusc faecium were isolated. It also emphasizes the effectiveness of linezolid for the treatment of vancomycin resistant enterococcal infection.

Non-ST-elevation myocardial infarction in the United States: contemporary trends in incidence, utilization of the early invasive strategy, and in-hospital outcomes

Background

There has been a paradigm shift in the definition of timing of early invasive strategy (EIS) for patients admitted with non‐ST‐elevation myocardial infarction (NSTEMI) in the last decade. Data on trends of EIS for NSTEMI and associated in‐hospital outcomes are limited. Our aim is to analyze temporal trends in the incidence, utilization of early invasive strategy, and in‐hospital outcomes of NSTEMI in the United States.

Methods and Results

We analyzed the 2002–2011 Nationwide Inpatient Sample databases to identify all patients ≥40 years of age with the principal diagnosis of acute myocardial infarction (AMI) and NSTEMI. Logistic regression was used for overall, age‐, sex‐, and race/ethnicity‐stratified trend analysis. From 2002 to 2011, we identified 6 512 372 patients with AMI. Of these, 3 981 119 (61.1%) had NSTEMI. The proportion of patients with NSTEMI increased from 52.8% in 2002 to 68.6% in 2011 (adjusted odds ratio [OR; per year], 1.055; 95% confidence interval [CI], 1.054 to 1.056) in the overall cohort. Similar trends were observed in age‐, sex‐, and race/ethnicity‐stratified groups. From 2002 to 2011, utilization of EIS at day 0 increased from 14.9% to 21.8% (P_trend<0.001) and utilization of EIS at day 0 or 1 increased from 27.8% to 41.4% (P_trend<0.001). Risk‐adjusted in‐hospital mortality in the overall cohort decreased during the study period (adjusted OR [per year], 0.976; 95% CI, 0.974 to 0.978).

Conclusions

There have been temporal increases in the proportion of NSTEMI and, consistent with guidelines, greater utilization of EIS. This has been accompanied by temporal decreases in in‐hospital mortality and length of stay.

Factors determining non-compliance to mass drug administration for lymphatic filariasis elimination in endemic districts of Nepal

BACKGROUND

Mass drug administration (MDA) has been implemented in Nepal since 2003 for elimination of Lymphatic Filariasis (LF). The objective of this study was to explore the factors that determine the non-compliance to MDA for Lymphatic Filariasis elimination in endemic districts of Nepal.

METHODS

A cross-sectional descriptive study was carried out in three endemic districts namely Dhading, Kapilvastu and Kailali. A total of 900 people were interviewed with structured questionnaire.

RESULTS

The result shows that the respondents who knew the DEC contains Albendazole (84.9% vs 42.5%, P<0.001, Adjusted OR=2.89(1.946-4.29) at 95% CI), who were aware of MDA campaign (78.2% vs 33.8% P<0.001, Adjusted OR=2.87(1.73-4.74) at 95% CI), who were visited by health workers at their home during MDA campaign (75.9% vs 24.1% P<0.001, Adjusted OR=4.85(2.448-9.594) at 95% CI) had significantly higher compliance. The respondents who had knowledge of side effects during MDA campaign had lower prevalence of non-compliance as compared who did not have (9.4% vs 33.2%, P<0.001).

CONCLUSIONS

Advanced age, primary or below education, ever married, inadequate knowledge on drug, inadequate awareness on MDA, no home visit by health workers during MDA, no belief on MDA drugs were significantly associated with higher non-compliance to MDA. In future, MDA program should focus on awareness campaigns related to composition of drugs, side effects of drugs and compulsory home visit during the campaign.

Vertical gaze palsy with skew deviation

With the advancement of neuroradiology, clinical localization followed by radiology, had made neurology more interesting. Vertical gage palsy as presentation cerebrovascular disease is not so common. Vertical gaze palsy usually localizes the lesion to dorsal mid brain. A 56 years male patient presented with sudden onset vertigo, diplopia, transient loss of consciousness and sways toward right side while walking. Clinical examination showed vertical gaze palsy with skew deviation along with swaying towards rt. during walk. MRI brain showed - infarct involving dorsal midbrain at superior colliculus level and medial thalamus.

Risk factors for stunting among children: a community based case control study in Nepal

BACKGROUND

Stunting, a chronic condition, is an underlying cause of child morbidity and mortality in Nepal. This study intends to identify the factors causing stunting among children that will help to prioritize the strategies at the district level.

OBJECTIVE

The objective of the study was to identify the risk factors for stunting among children of age between 6 to 59 months.

METHODS

The study was based on community-based case control design in the mid-west, Surkhet Nepal from August to September 2010. The cases were stunted children and controls were the children without stunting. Data was collected by interviewing those children's mothers and measured length/height of 118 children as cases and 236 children as controls. Logistic regression analysis was performed to identify the best model of factors leading to stunting. Odds ratio and 95% confidence interval were used as a measure of association.

RESULTS

Socio-economic risk factors for stunting comprised mothers without earning (OR=3.11, 95% CI 1.26-7.65), food deficit families (OR=4.26, 95% CI 1.73-10.45) and care taker of the children other than mother (OR=3.02, 95% CI 1.19-7.70). Environmental risk factors for stunting consisted of kitchen without ventilation and children exposed to pesticide. Inappropriate exclusive breast feeding (OR=6.90, 95% CI 2.81-16.97), complementary feeding less than four times a day (OR=3.60, 95% CI 1.32-9.95) and dietary diversity below WHO standard (OR=4.06, 95% CI 1.70-9.67) were factors of stunted children. Diarrhea was found significantly associated with stunting (OR=7.46, 95% CI 2.98-18.65).

CONCLUSIONS

Stunting was found to be as a result of multiple factors such as socio-economic, environmental and inappropriate feeding practices.

Examining stratified cesarean section rates using Robson classification system at Tribhuvan University Teaching Hospital

BACKGROUND

Caesarean section rates have been increasing worldwide over the past few decades, with most countries and regions exceeding the World Health Organization recommended rate of 15% of all deliveries.

METHODS

This study was carried out with the objective of reviewing the rates of cesarean sections over five years (2005-2010) and to assess the stratified rates of cesarean sections for audit of intrapartum management in University Teaching Hospital, Institute of Medicine. Data was stratified into 10 mutually exclusive groups, by using the method presented by Michael Robson.

RESULTS

A total of 5907 women had under gone caeserean section over a period of five years. The results showed a growing trend of cesarean section rate from 16.6% to 25.4%. The results of this analysis using the Robson classification has shown that group 1(Nulliparous, single cephalic ≥ 37 weeks gestation in spontaneous labour) has the largest number of cesarean deliveries followed by group 3(Multiparous, single cephalic ≥37 weeks gestation in spontaneous labor, no previous CS), although Robson classification showed that group 5 was the biggest contributor.

CONCLUSIONS

The growing and uniform distribution (throughout the year) of cesarean section has been observed for five years. This analysis provides evidence-based data so we can analyze where to aim our preventive measures and focus efforts in reducing the rate of CS. We would like to suggest that all hospitals and health authorities apply this standardized classification system as to monitor their CS rates and find ways to reduce it, and improve quality care.

Acute intermittent porphyria with SIADH and fluctuating dysautonomia

Three cases of acute intermittent porphyria are reported. While in first case severe pain in abdomen with intermittent exacerbation was the only presentation, the second patient presented as accelerated hypertension and acute abdominal crises in whom the clinical course was characterized by development of deep coma due to inappropriate secretion of antidiuretic hormone before she made complete recovery. The third patient, initially manifested as acute encephalitic syndrome. After initial improvement, she developed features of acute intermittent porphyria i.e. acute abdomen, neuropsychiatric symptoms, and rapidly progressing acute motor neuropathy leading to respiratory and bulbar paralysis. In addition, she developed severe and fluctuating dysautonomia leading to cardiac arrest and fatal termination. The importance of early diagnosis, recognition of autonomic disturbances, prompt treatment and counseling for avoidance of precipitating factors is stressed.

Genetic screening of Greek patients with Huntington’s disease phenocopies identifies an SCA8 expansion

Huntington’s disease (HD) is an autosomal dominant disorder characterized by a triad of chorea, psychiatric disturbance and cognitive decline. Around 1% of patients with HD-like symptoms lack the causative HD expansion and are considered HD phenocopies. Genetic diseases that can present as HD phenocopies include HD-like syndromes such as HDL1, HDL2 and HDL4 (SCA17), some spinocerebellar ataxias (SCAs) and dentatorubral-pallidoluysian atrophy (DRPLA). In this study we screened a cohort of 21 Greek patients with HD phenocopy syndromes formutations causing HDL2, SCA17, SCA1, SCA2, SCA3,SCA8, SCA12 and DRPLA. Fifteen patients (71%) had a positive family history. We identified one patient (4.8% of the total cohort) with an expansion of 81 combined CTA/CTG repeats at the SCA8 locus. This falls within what is believed to be the high-penetrance allele range. In addition to the classic HD triad, the patient had features of dystonia and oculomotor apraxia. There were no cases of HDL2, SCA17, SCA1, SCA2, SCA3, SCA12 or DRPLA. Given the controversy surrounding the SCA8 expansion, the present finding may be incidental. However, if pathogenic, it broadens the phenotype that may be associated with SCA8 expansions. The absence of any other mutations in our cohort is not surprising, given the low probability of reaching a genetic diagnosis in HD phenocopy patients.

Association of seizure, facial dysmorphism, congenital umbilical hernia and undescended testes

With the advances in neurogenetics association of epilepsy and intellectual disability with chromosomal abnormalities are being increasingly recognized. While onset of seizures with mental retardation at an early age indicate chromosomal abnormality, combination of characteristics facial dysmorphism and congenital abnormalities gives a clue of a particular syndrome. In addition MRI findings may help in confirming the diagnosis. A nine years old boy is presented where early onset seizure, mental retardation, delayed development of speech, presence of facial dysmorphism,, umbilical hernia and undescended testes suggested possibility of chromosomal 6q deletion disorder. Important deletion disorders are discussed and importance of clinical examination is stressed.

Multiple simultaneous hypertensive supratentorial and infratentorial hemorrhages: A rare kind of hypertensive bleed

Multiple simultaneous intracranial hemorrhages are very uncommon and both supra- and infratentorial hemorrhages are even more rare. Here we report a case of 56 year old hypertensive male with no other significant medical history who presented with a hypertensive emergency. Emergency head computed tomography showed bilateral basal ganglia and midbrain hemorrhages extending to right cerebellar peduncle. The patient made a progressive recovery and finally achieved functional independence. This report shows that hypertension may cause multiple simultaneous supra- and infratentorial hemorrhages and have good prognosis. Journal of College of Medical Sciences-Nepal,2011,Vol-6,No-4, 53-56 DOI: http://dx.doi.org/10.3126/jcmsn.v6i4.6728

Tired heart and mute brain: handle with care

Managing a case of stroke is complex. Presence of variable sized brain infarct and heart failure is even more complex to manage. On top of this, presence of clot in the heart adds to confusion in medical management of stroke patients because of limited scientific evidences. With increasing number of stroke patients and improving diagnostic facility, it is interesting to find thrombus in ventricles of few of these patient, which otherwise were uncommon previously in our set up. We present a 64-year-old man, a case of ischemic stroke caused by left ventricular thrombus secondary to dilated cardiomyopathy and highlight the present recommendation to manage the condition. DOI: http://dx.doi.org/10.3126/jcmsn.v7i3.6714 Journal of College of Medical Sciences-Nepal, 2011, Vol-7, No-3, 68-70  

Knowledge and perception about the Medical Humanities before and after a national workshop

Medical Humanities programs are common in medical schools in developed nations. In Nepal modules have been conducted at Manipal College of Medical Sciences (MCOMS), Pokhara and KIST Medical College (KISTMC), Lalitpur. A workshop was conducted on 26th September 2010 to familiarize participants with MH. Faculty members, medical and nursing students and doctors participated. Pre and post test were administered to study knowledge and perception about MH. Differences in scores among different subgroups of participants and before and after the workshop were explored.The workshop used interactive small group learning strategies to introduce participants to different aspects of MH. Group work, group presentations, facilitator presentations, interpretation of paintings, brainstorming sessions, and role-plays were the main learning modalities used. Participants’ knowledge and perception about MH was studied by noting their agreement with a set of 25 statements using a modified Likert-type scale. Median total scores were compared among different subgroups of respondents and before and after the module.Twenty-three of the 26 participants (88.5%) completed the pre and post-test. Thirteen respondents were male and 10 female. Only three respondents (13%) had been previously exposed to MH. The median total score before the workshop was 85 (maximum possible score 125). The score was higher among male respondents. The median total score after the workshop was 98 and was significantly higher compared to that before the workshop.The workshop was effective in increasing knowledge and perception of participants about MH. A follow up workshop to consolidate the initial gains is required and is being planned.Journal of College of Medical Sciences-Nepal, 2011, Vol-7, No-2, 72-79DOI: http://dx.doi.org/10.3126/jcmsn.v7i2.6688

Clinical and socio-economic factors among epileptic patients in Nepal: A big challenge

Epilepsy is commonly found neurological disorder in developing countries where huge treatment gap exists. Amongst many etiologies, neuroinfection is found to be prevalent in developing countries. We designed a self-structured goal directed questionnaire and interviewed 20 consecutive patients with epilepsy. We also collected their clinical symptoms and neuroimaging reports. 70% were males. Majority (30%) had neuroinfection (20% neurocysticercosis and 10% meningitis). Eighty percent of patients had a belief on traditional healer. Epilepsy in Nepal still remains a big challenge. Public awareness to reduce infections may help in reducing seizure incidence and prevalence in developing countries like ours.Journal of College of Medical Sciences-Nepal, 2011, Vol-7, No-2, 29-33DOI: http://dx.doi.org/10.3126/jcmsn.v7i2.6677

People's Perspective on Access to Health Care Services in a Rural District of Nepal

Introduction: Over the past several decades, Nepal has attempted to increase the access of health care services, however progress toward achieving high coverage of health care services in rural communities is still low. Therefore this study attempts to provide a perspective on access to basic healthcare services in government health facility. Methods: Descriptive cross-sectional study with quantitative and qualitative methods was designed and applied to identify the access to health care services. The study population were people who were sick within three months prior to the study where basic sampling unit was household. Total sample size was 96 through the application of simple random sampling method. Bivariate analysis with 95% confidence interval was used to identify the association of variables with access to health care services. Results: Among the total population, 28% of households in the study area received health care services at government health facility. The reasons for not accessing health care were insufficient drugs (61%), distance (22%), staff unavailability (19%), sickness (9%), money (7%), and facility hours (4%). Sex, ethnicity and distance were found significantly associated with access to health care services. Conclusions: Less than one third of households had access to health careservices in government health facility. Addressing the important factors such as drug problems, staff unavailability, long distance to health institutions and inconvenient health facility hours may help to increase access to health care services at government health facility. Keywords: Access, government health facility, health care services, perspective.

High-level gentamicin resistance and vancomycin resistance in clinical isolates of enterococci in a tertiary care hospital in eastern Nepal

High-level gentamicin resistance and vancomycin resistance in enterococci, a family of important opportunistic pathogens, have emerged as a significant clinical problem over recent years. The present study was conducted to determine the high-level gentamicin and vancomycin resistance among the clinical isolates of enterococci. A total of 110 phenotypically identified enterococcal isolates were subjected to determination of high-level gentamicin resistance (by disk diffusion and agar dilution methods) and vancomycin resistance (by agar screening and agar dilution methods). About 36% of the isolates were found to have high-level gentamicin resistance, which indicates that gentamicin no longer remains an appropriate choice for inclusion in combination therapy with cell wall-active agents. Ten percent isolates exhibited resisance to vancomycin during screening. However, agar dilution confirmed that the isolates did not have resistance to vancomycin but had reduced susceptibility to it, which indicates their impending emergence of resistance to vancomycin.

People's perspective on access to health care services in a rural district of Nepal

INTRODUCTION

Over the past several decades, Nepal has attempted to increase the access of health care services, however progress toward achieving high coverage of health care services in rural communities is still low. Therefore this study attempts to provide a perspective on access to basic health care services in government health facility.

METHODS

Descriptive cross-sectional study with quantitative and qualitative methods was designed and applied to identify the access to health care services. The study population were people who were sick within three months prior to the study where basic sampling unit was household. Total sample size was 96 through the application of simple random sampling method. Bivariate analysis with 95% confidence interval was used to identify the association of variables with access to health care services.

RESULTS

Among the total population, 28% of households in the study area received health care services at government health facility. The reasons for not accessing health care were insufficient drugs (61%), distance (22%), staff unavailability (19%), sickness (9%), money (7%), and facility hours (4%). Sex, ethnicity and distance were found significantly associated with access to health care services.

CONCLUSIONS

Less than one third of households had access to health care services in government health facility. Addressing the important factors such as drug problems, staff unavailability, long distance to health institutions and inconvenient health facility hours may help to increase access to health care services at government health facility.

Factors affecting retention of child health card in a rural area

BACKGROUND

The child health card is a tool used by Health Management Information System in Nepal. It contains records on immunization, vitamin A and a weight-for-age growth chart. The objective of this study was to identify the magnitude of and the factors affecting retention of child health card.

METHODS

A cross sectional descriptive design using quantitative methodology was applied. Divyapuri VDC was selected purposively and simple random sampling was applied to obtain a sample of 282 households with children between one to 36 months. Information was collected by interview with mothers of one to 36 months children and by observation of child health cards. Descriptive analysis was performed to assess the magnitude of retention of child health card. Then, bivariate analysis was performed; odds ratio and corresponding 95% confidence interval were used to test the significance of association. Logistic regression model was used for control of confounding.

RESULTS

Only 41% of the mothers produced child health card at the time of survey. For about 7% respondents, child health card was not issued and only 45% of the respondents who were issued child health card have retained it. Younger age group of the child, mothers living nearer to health facility, mothers with knowledge on use of child health card for recording immunization and recording growth monitoring; and mothers who were explained child health card by health worker were found significantly higher odds of retaining it.

CONCLUSIONS

The retention of child health card was low in the study area. Health workers should be trained to educate mothers on retention and use of child health cards.

Health care waste management practice in a hospital

BACKGROUND

Health-care waste is a by-product of health care. Its poor management exposes health-care workers, waste handlers and the community to infections, toxic effects and injuries including damage of the environment. It also creates opportunities for the collection of disposable medical equipment, its re-sale and potential re-use without sterilization, which causes an important burden of disease worldwide. The purpose of this study was to find out health care waste management practice in hospital.

METHODS

A cross-sectional study was conducted in Narayani Sub-Regional Hospital, Birgunj from May to October 2006 using both qualitative and quantitative methods. Study population was four different departments of the hospital (Medical/Paediatric, Surgical/Ortho, Gynae/Obstetric and Emergency), Medical Superintendent, In-charges of four different departments and all sweepers. Data was collected using interview, group discussion, observation and measurement by weight and volume.

RESULTS

Total health-care waste generated was 128.4 kg per day while 0.8 kg per patient per day. The composition of health care waste was found to be 96.8 kg (75.4%) general waste, 24.1 kg (8.8%) hazardous waste and 7.5 kg (5.8%) sharps per day by weight. Health staffs and sweepers were not practicing the waste segregation. Occupational health and safety was not given due attention. Majority of the sweepers were unaware of waste management and need of safety measures to protect their own health.

CONCLUSIONS

Health care waste management practice in the hospital was unsatisfactory because of the lack of waste management plan and carelessness of patients, visitors and staffs. Therefore the hospital should develop the waste management plan and strictly follow the National Health Care Waste Management Guideline.

THAP1 mutations (DYT6) are an additional cause of early-onset dystonia

BACKGROUND

The clinical phenotype of DYT6 consists mainly of primary craniocervical dystonia. Recently, the THAP1 gene was identified as the cause of DYT6, where a total of 13 mutations have been identified in Amish-Mennonite and European families.

METHODS

We sequenced the THAP1 gene in a series of 362 British, genetically undetermined, primary dystonia patients (78 with focal, 186 with segmental, and 98 with generalized dystonia) and in 28 dystonia-manifesting DYT1 patients and 176 normal control individuals.

RESULTS

Nine coding mutations were identified in the THAP1 gene. Two were small deletions, 2 were nonsense, and 5 were missense. Eight mutations were heterozygous, and 1 was homozygous. The main clinical presentation of cases with THAP1 mutations was early-onset (<30 years) dystonia in the craniocervical region or the limbs (8 of 9 patients). There was phenotypic variability with laryngeal or oromandibular dystonia present in 3 cases. Four of 9 THAP1 cases developed generalized dystonia.

CONCLUSIONS

The number of THAP1 mutations has been significantly expanded, indicating an uncommon but important cause of dystonia. Coding mutations account for 9 of 362 dystonia cases, indicating a mutation frequency of 2.5% of dystonia cases in the population that we have screened. The majority of cases reported here with THAP1 mutations had craniocervical- or limb-onset segmental dystonia, but we also identified 1 homozygous THAP1 mutation, associated initially with writer's dystonia and then developing segmental dystonia. Three of our patients had a nonsense or frameshift THAP1 mutation and the clinical features of laryngeal or oromandibular dystonia. These data suggest that early-onset dystonia that includes the involvement of the larynx or face is frequently associated with THAP1 mutations.

Parkisonism with Shy-Drager syndrome--a case report

A previously healthy 60 years old female patient presented with bradykinesia, postural instability and increased rigidity of both upper and lower limbs for 2 years and was diagnosed as Parkinsonism for last years. Later on she developed features of autonomic dysfunction including postural hypotension, hyperhydrosis and urinary incontinence so was diagnosed as Shy-Drager Syndrome. She was treated with fludrocortisone and nefidipine for the management of postural hypotension. Patient developed aspiration pneumonia during oral feeding, despite of ICU management for the same cause patient died of respiratory arrest.

When left ventricular failure complicates chronic obstructive pulmonary disease: hypoxia plays the major role

INTRODUCTION

As the chronic obstructive pulmonary disease (COPD) progress, is usually accompanied by involvement of the both left ventricle (LV) and right ventricle (RV), and their systolic and diastolic function. Signs and symptoms of LV failure can be difficult to distinguish from those of COPD.

OBJECTIVE

The study was carried out to determine the prevalence of LV systolic dysfunction in the COPD patients and to assess the possible risk factor behind such development.

MATERIAL AND METHODS

It is a prospective study of 60 cases of COPD patients with or without cor-pulmonale attending Manipal Teaching Hospital.

RESULTS

The prevalence of LV systolic dysfunction was found to be 26.7%, and the findings directly correlate with the severity of COPD i.e., the more the severity of the lung disease more the probability for the incidence of LV systolic dysfunction. These data are in support of the hypothesis that hypoxia and the excess accumulation of toxic metabolic products like lactic acid, significant right-to-left shunting through the bronchial circulation explains the diminished LV ejection fraction in severe COPD patients.

CONCLUSION

Routine echocardiography investigation of the severe COPD patients is required for assessing the status of LV function and to rule out the possible association of LV systolic dysfunction.

Why treat? Better prevent: adult immunization

Immunization is a safe, effective and simple way to prevent life threatening illnesses not only in children but also in adults. Vaccines are some of the safest medicines available which can relieve suffering costs related to these preventable diseases. The reason for underutilization of vaccines in adults are 1) Low prioritization of the importance of vaccines preventable diseases among adults 2) Uncertainty or lack of knowledge about the safety and efficacy 3) Lack of universal recommendations for all adults and 4) Financial constraints, especially in developing countries. Adult immunizations are administered in primary series like previously immunized, booster doses and periodic doses. Agents include Toxoids (Diphtheria and Tetanus), Live Virus Vaccines (Measles, Mumps and Rubella), and inactivated virus vaccines (Influenza), Inactive viral particles (Hepatitis B), inactivated bacterial polysaccharide vaccine (Pneumococcal) and Conjugate / Polysaccharide vaccine (Meningococcal). And also vaccines like Hepatitis A, Polio and Varicella may be recommended in some. Since the economy and literacy rate has shown a steady rise in the South Asia and people are being aware of different health problems through the recently advanced global communication, the education and awareness for immunization not only in children but also in adults need a special consideration. Keeping in view the statistical data of suffering costs related to the non-utilization of immunization in adults, the need of hour has come for utilization of immunization to emphasize its importance.

Sarcoidosis--three clinical vignettes with a short review

Sarcoidosis is a multi system disorder of unknown cause most commonly affecting the young and middle age adults and frequently presents bilateral hilar lymph-adenopathy. The diagnosis of sarcoidosis is often delayed following the onset of symptoms. The reason being first, the disease is often sub clinical; second as the disease affects any system, the diagnosis of sarcoidosis may not be considered; third, the symptoms are not disease specific hence often treated as other chronic pulmonary diseases; finally economic issues or barriers to access for further workup may affect the timeliness of the diagnosis. No laboratory diagnosis is specific for diagnosing sarcoidosis but histological confirmation from the lymph nodes accessible for biopsy either direct or by intervention may be more specific.

Understanding the essentials of drug interactions: a potential need for safe and effective use of drugs

Drug interactions (DIs) represent an important and widely under recognized source of medication errors. An interaction is said to occur when the effects of one drug are changed by the presence of another drug(s), food, drink or an environmental chemical. When a therapeutic combination could lead to an unexpected change in the condition of the patient, this would be described as an interaction of potential clinical significance. DIs can arise in numerous ways; such as pharmacodynamic interaction, in which receptor effects of different agents interacts to produce synergy or antagonism of drug effects. In pharmacokinetic interaction, the blood levels of given agents may be raised or lowered based on the type of interaction. Special attention and thorough monitoring is needed for the patients who are predisposed to develop DIs and those on drugs with narrow therapeutic index. DIs can be a very important contributory factor for the occurrence of adverse drug reactions and adverse drug events. DIs monitoring programs should be initiated and strengthened in order to minimize their occurrence. Herbal drug interactions and DIs comprising over the counter medicines should also be considered seriously.

Drug induced hepatitis with anti-tubercular chemotherapy: challenges and difficulties in treatment

Tuberculosis is a major health burden worldwide. In Nepal, it is a significant cause of morbidity and mortality. Although better drugs are available for managing tuberculosis, treatment failure is one of the common problems encountered. Among the various causes which can cause treatment interruption, drug induced hepatotoxicity is a common cause. Isoniazid and Pyrazinamide are the common drugs causing hepatotoxicity. Upon occurrence of hepatotoxicity, the hepatotoxic drugs should be stopped and reintroduced as per the available guidelines. The healthcare professional should also counsel the patients for recognizing the early symptoms due to hepatotoxicity which could prevent morbidity.

Interaction between warfarin and tamoxifen: a case report

Warfarin is a commonly used anticoagulant with documented reports of drug interactions. Tamoxifen is used in the adjuvant hormonal treatment of women with oestrogen-receptor- positive breast cancer. Warfarin and tamoxifen are known to interact with each other with a resultant increase in the bleeding tendency. These reports are mainly from the white population. We report a case of drug interaction between warfarin and tamoxifen with an acute onset. This report suggests that when these drugs are co administered, careful monitoring of the coagulation profile is needed.

A rolling blackout oral cavity

We have heard of rolling black outs as a staple of daily life in many Asian countries. We from Nepal, a country suffering rolling blackout, present a case that we refer as "Rolling blackout oral cavity". Aspiration of gastric and oral content into airway is a well known complication during endotracheal intubation but aspiration of a part of equipment during the procedure is rare. We report a case of lost bulb of laryngoscope during endotracheal intubation. Keywords: Endotracheal intubation; foreign body; laryngoscope bulb DOI: 10.3126/jcmsn.v6i3.4075Journal of College of Medical Sciences-Nepal, 2010, Vol. 6, No. 3 pp.44-45