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Sunil Shrestha,1 Simit Sapkota,2,3 Vibhu Paudyal,4,5 Zoe Moon,6 Rob Horne,6 Siew Hua Gan1 1School of Pharmacy, Monash University Malaysia, Bandar Sunway, Subang Jaya, Selangor, Malaysia; 2Department of Clinical Oncology, Kathmandu Cancer Center, Tathali, Bhaktapur, Bagmati Province, Nepal; 3Department of Clinical Oncology, Civil Service Hospital, Minbhawan, Kathmandu, Bagmati Province, Nepal; 4Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College, London, UK; 5School of Pharmacy, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham Edgbaston, Birmingham, UK; 6Centre for Behavioural Medicine, Research Department of Practice and Policy, UCL School of Pharmacy, University College London, London, UKCorrespondence: Sunil Shrestha, Email sunilcresta@gmail.comBackground: Adherence to pain medication is crucial for cancer patients, since non-adherence can lead to increased suffering, reduced quality of life and increased healthcare costs. Although the five‐item Medication Adherence Report Scale (MARS-5) is a validated tool for assessing medication adherence, but it has not been translated and validated into the Nepalese language. This study aimed to translate, culturally adapt and validate the MARS-5 in Nepalese language for Nepalese cancer patients who were experiencing pain.Materials and Methods: The cross-sectional validation study utilized a convenience sampling method. Initially, a pre-test was conducted with 25 patients. The MARS-5 was then forward and backward translated following the EORTC QLG translation procedure. The final translated version was reviewed by experts and subjected to a second pre-test. Construct validity was assessed through principal component analysis, and internal consistency was measured using Cronbach’s alpha coefficient. Inter-rater reliability was evaluated using the Intra-Class Correlation coefficient (ICC).Results: The study included 204 cancer patients (ages 18– 86, 55% female). The Nepalese version of the MARS-5 was translated without significant issues and underwent pre-testing with participants. Participants discussed the scale during these pre-tests, providing feedback on its clarity and comprehensibility. While formal assessment tools were not employed, the iterative nature of the pre-testing process allowed for the refinement of the translation based on participant feedback, indicating a robust understanding of the scale among participants. The ICC of test-retest reliability was found to be 0.860. The Kaiser Meyer Olkin’s value was 0.690, and Cronbach’s alpha was 0.72, indicating good construct validity and high internal consistency. The medication non-adherence rate was 11.3%.Conclusion: The MARS-5 was successfully translated, culturally adapted, and validated in Nepalese for use among Nepalese cancer patients experiencing pain. The Nepalese version of MARS-5 is a reliable tool for evaluating medication adherence in this population.Keywords: cancer pain, cultural adaptation, MARS-5, medication adherence, Nepalese patients, validation

Abstract Over the past three decades, there has been increasing interest in miniaturized percutaneous nephrolithotomy (mPCNL) techniques featuring smaller tracts as they offer potential solutions to mitigate complications associated with standard PCNL (sPCNL). However, despite this growing acceptance and recognition of its benefits, unresolved controversies and acknowledged limitations continue to impede widespread adoption due to a lack of consensus on optimal perioperative management strategies and procedural tips and tricks. In response to these challenges, an international panel comprising experts from the International Alliance of Urolithiasis (IAU) took on the task of compiling an expert consensus document on mPCNL procedures aimed at providing urologists with a comprehensive clinical framework for practice. This endeavor involved conducting a systematic literature review to identify research gaps (RGs), which formed the foundation for developing a structured questionnaire survey. Subsequently, a two-round modified Delphi survey was implemented, culminating in a group meeting to generate final evidence-based comments. All 64 experts completed the second-round survey, resulting in a response rate of 100.0%. Fifty-eight key questions were raised focusing on mPCNLs within 4 main domains, including general information (13 questions), preoperative work-up (13 questions), procedural tips and tricks (19 questions), and postoperative evaluation and follow-up (13 questions). Additionally, 9 questions evaluated the experts’ experience with PCNLs. Consensus was reached on 30 questions after the second-round survey, while professional statements for the remaining 28 key questions were provided after discussion in an online panel meeting. mPCNL, characterized by a tract smaller than 18 Fr and an innovative lithotripsy technique, has firmly established itself as a viable and effective approach for managing upper urinary tract stones in both adults and pediatrics. It offers several advantages over sPCNL including reduced bleeding, fewer requirements for nephrostomy tubes, decreased pain, and shorter hospital stays. The series of detailed techniques presented here serve as a comprehensive guide for urologists, aiming to improve their procedural understanding and optimize patient outcomes.

Abstract Background Provision of essential newborn care at home, rapid identification of illness, and care-seeking by caregivers can prevent neonatal mortality. Mobile technology can connect caregivers with information and healthcare worker advice more rapidly and frequently than healthcare visits. Community health workers (CHWs) are well-suited to deliver such interventions. We developed an interactive short message service (SMS) intervention for neonatal health in Kenya, named CHV-NEO. CHV-NEO sends automated, theory-based, actionable, messages throughout the peripartum period that guide mothers to evaluate maternal and neonatal danger signs and facilitate real-time dialogue with a CHW via SMS. We integrated this intervention into Kenya’s national electronic community health information system (eCHIS), which is currently used at scale to support CHW workflow. Methods The effect of CHV-NEO on clinical and implementation outcomes will be evaluated through a non-blinded cluster randomized controlled trial. Twenty sites across Kisumu County in Western Kenya were randomized 1:1 to provide either the national eCHIS with integrated CHV-NEO messaging (intervention) or standard of care using eCHIS without CHV-NEO (control). We will compare neonatal mortality between arms based on abstracted eCHIS data from 7200 pregnant women. Secondary outcomes include self-reported provision of essential newborn care (appropriate cord care, thermal care, and timely initiation of breastfeeding), knowledge of neonatal danger signs, and care-seeking for neonatal illness, compared between arms based on questionnaires with a subgroup of 2000 women attending study visits at enrollment in pregnancy and 6 weeks postpartum. We will also determine CHV-NEO’s effect on CHW workflows and evaluate determinants of intervention acceptability, adoption, and fidelity of use through questionnaires, individual interviews, and messaging data. Discussion We hypothesize that the CHV-NEO direct-to-client communication strategy can be successfully integrated within existing CHW workflows and infrastructure, improve the provision of at-home essential newborn care, increase timely referral of neonatal illness to facilities, and reduce neonatal mortality. The intervention’s integration into the national eCHIS tool will facilitate rapid scale-up if it is clinically effective and successfully implemented. Trial registration ClinicalTrials.gov, NCT05187897 . The CHV-NEO study was registered on January 12, 2022.

Introduction: Nearly three quarters of the suicides occur in developing world, however few evidenced-based health systems strategies exist to detect and prevent suicide in these contexts. This pilot study evaluates the feasibility of implementing a universal suicide risk screening program in a Nepalese emergency department. Methods: This study reports the preliminary training phases of a pilot implementation trial in the emergency department to evaluate the program. The approval was obtained from the Nepal Health Research Council (Approval no. 447/2021 P), and the Kathmandu University School of Medical Sciences Institutional Ethical Review Board (Approval no. 237/2021) and Yale University IRB (Protocol ID 2000029480). Implementation assessments included suicide screening acceptability, appropriateness, confidence, system priority, and myth knowledge of staff. Implementation strategies were selected, decolonized, and preliminarily trained followed by phased supportive coaching to initiate the screening package. We designed the implementation package through co-design staff focus groups and embedded ethnography. Results: Co-design focus groups (n=8) occurred with staff and leadership. We trained 26 (76.47%) the staff on the Nepali suicide screening tool followed by supported phased initial screening over two months. Implementation assessments demonstrated increased scores on appropriateness, confidence, system priority, and myth knowledge. The implementation package included key strategies to be deployed over six months. The embedded ethnographic observations revealed barriers to effective implementation, such as anticipated stigma, reluctance to engage families, and distrust in referral processes. Conclusions: The pilot study demonstrated that training improves staff appropriateness, confidence, system priority, and myth knowledge. Despite initial barriers, co-designed strategies and phased coaching facilitates screening uptake, highlighting the program's potential for sustainable implementation.

Key Clinical Message Pneumomediastinum (PM) and subcutaneous emphysema (SCE) following foreign body aspiration are very rare. Pneumomediastinum (PM) occurs due to alveolar rupture, whereas subcutaneous emphysema occurs if air leak persists. It is benign in nature, but in some cases, it might be fatal. Therefore, proper assessment and management are required to limit the life‐threatening complications and FB should always be suspected whenever spontaneous PM and SCE is seen. PM and SCE are very rare presentations of foreign body aspiration in children of age less than 3 years and in such circumstances, the possibility of foreign body should be considered. There is also a rare possibility of spontaneous expectoration of a foreign body dislodged in the trachea.

Key Clinical Message Brucellosis, especially with osteoarticular involvement, is uncommon and difficult to diagnose, but it should be considered in a case presenting with prolonged fever, joint pain, and back pain. The diagnosis requires a combination of history, serological examinations, and radiographic studies. When the condition is detected and treated early, the prognosis is good. Abstract Brucella exploits host immune defenses to establish the chronic infection brucellosis, an endemic zoonotic disease. While human brucellosis affects multiple organs, osteo articular involvement is rare. We report the case of a 41‐year‐old woman with a history of goat farming who presented with fewer associated with low back pain and multiple joint pain for 4 months. Brucellosis was documented by positive serological tests (ELISA). Radiological findings suggested of right sacroiliitis and fracture line on the right sacral ala though had no history of trauma. Treatment consisted of NSAIDs and multiple antibiotic therapy. At follow‐up, her low back pain, joint pain, and fever had subsided. After 4 weeks of follow‐up, her symptoms were completely relieved with no recurrence. Brucellosis with atypical localization should be considered with a high index of suspicion based on detailed history and physical examination to ensure timely diagnosis and treatment.

ABSTRACT Autoimmune pulmonary alveolar proteinosis (PAP) is characterized by antibodies to granulocyte–macrophage colony‐stimulating factor (GM‐CSF), alveolar macrophage dysfunction, and surfactant accumulation. Whole lung lavage (WLL) is the treatment of choice in patients with PAP and severe hypoxemia. In resource‐limited settings, WLL can be performed in the intubated, anesthetized patient who is being one lung ventilated using a Y‐type bladder irrigation catheter for saline instillation and drainage.

Key Clinical Message Invasive fungal mucormycosis and its outcome as SIADH and orbital apex syndrome is uncommon. Mucormycosis in paranasal sinuses can even lead to intracranial invasion and its treatment with the use of amphotericin B can cure improve the prognosis of the disease. Early diagnosis and prompt treatment with antifungal, endoscopic surgery, and controlling of diabetes can be beneficial. Abstract Mucormycosis is an opportunistic invasive fungal infection which is rare and fatal and can even cause intracranial invasion leading to SIADH. The infrequency with which mucormycosis with SIADH is encountered makes it a formidable diagnostic challenge. 70‐year‐old women uncontrolled diabetes mellitus presented with bilious vomiting and persistent headache with ptosis, proptosis, absence of extraocular movement, pupillary light reflex, and light perception of left eye. Radiographic investigation, KOH mount, and Biopsy showed mucormycosis in sinus with intracranial extension leading to SIADH. Further investigation revealed hyponatremia, decreased plasma osmolality. Then, when diabetes was controlled and hydrocortisone and amphotericin was given along with Endoscopic sinus debridement, SIADH was well controlled. This case illustrates the potential of mucormycosis in paranasal sinuses can even lead to intracranial invasion and its treatment with the use of amphotericin B can cure improve the prognosis of the disease. Prompt diagnosis through clinical history, radiological investigation, and laboratory parameters are important and its treatment is crucial for the better prognosis.

Firearm injuries can result in varying degrees of trauma, depending on factors such as the type of firearm, range, and wound location. This case report presents the role of X-ray imaging in detecting a projectile causing fatal penetrating abdominal trauma in a 45-year-old male. The patient was found with a gunshot wound in his abdomen, and despite medical interventions, he succumbed to his injuries. X-ray imaging revealed a hyper-dense area resembling a bullet lodged in the abdominal cavity. Autopsy confirmed a close-range gunshot with significant internal damage to the peritoneum, mesentery, liver, and the bullet lodged near the L1 vertebra. This case underscores the value of radiological imaging in identifying projectile trajectory and injury severity, particularly in resource-limited settings. X-rays assist in distinguishing between penetrating and perforating wounds, aiding both forensic investigation and legal procedures. The integration of imaging in forensic autopsies improves the accuracy of injury assessment, especially in cases involving gunshot wounds.

Abstract Background Forensic anthropological examinations help in identification of unidentified human remains. This study aims to establish population-specific standards for age estimation from the sternal ends of left fourth ribs in the Nepalese population. A quantitative, observational study was conducted on 387 Nepalese deceased (106 females, 281 males) between November 2021 and March 2023. Left fourth ribs were collected, macerated and examined for the study. The variables examined included pit depth, pit shape, rim and wall configurations and rib phase. Results Pit depth significantly predicted age, β = 0.642, t(385) = 16.42, p

Summary: Background: Current literature informs us that bivalent vaccines will generate a broader serum neutralizing antibody response to multiple SARS-CoV-2 variants, but studies on how this breadth relates to the memory B cell (MBC) and T cell responses are sparse. This study compared breadth of neutralising antibody, and memory B and T cell responses to monovalent or a bivalent ancestral/Omicron BA.1 COVID-19 booster vaccine. Methods: At baseline and 1-month post-booster, neutralisation activity and frequencies of receptor binding domain (RBD)-specific MBCs and Spike-specific memory T cells were measured against a panel of variants. Findings: Both vaccines boosted neutralising antibodies to 5 variants - Wuhan-Hu-1, Delta, BA.1, BA.5 and JN.1, the latter of which had not yet emerged at the time of sample collection. The bivalent vaccine induced a significantly larger increase in nAb against BA.1 and JN.1. Both vaccines boosted RBD-specific MBC responses to Wuhan-Hu-1, Delta, BA.1 and BA.5 variants with a significantly greater increase for BA.1 in the bivalent group. The breadth of MBCs was significantly higher in those who received the bivalent boost and correlated with nAb breadth. Both vaccines significantly boosted Spike-specific T cell responses to the Wuhan-Hu-1 and BA.5 variants, but only the bivalent vaccine boosted BA.1 responses. Interpretation: These results suggest that the bivalent vaccine confers an advantage against future novel variants due to increased frequency of broadly reactive RBD-specific B cells. Funding: Work supported by NSW Health for the NSW Vaccine, Infection and Immunology Collaborative (VIIM).

Introduction: Supraclavicular brachial plexus block is effective for upper limb surgeries, with ropivacaine offering prolonged action. Adding dexmedetomidine as an adjuvant may enhance block duration and quality. This study aimed to evaluate the mean duration of anesthesia with dexmedetomidine as an adjuvant to ropivacaine in supraclavicular brachial plexus blocks. Methods: A observational cross-section study was conducted among patients undergoing supraclavicular brachial plexus block for elective upper limb surgery in a tertiary care center. The block was performed using ultrasound-guided, single-injection technique with 0.25% ropivacaine and 0.5 µg/kg dexmedetomidine. Sensory and motor block durations, along with analgesia, were assessed using standardized scales. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. An ethical approval was taken from Institutional review Committee (Reference number: 026-077/078). Results: The mean duration of anesthesia was 592.42±137.73 minutes (548.62-636.21, 95% Confidence Interval). Sensory and motor block durations were 553.95±138.54 and 555.42±156.24 minutes, respectively, with median onset times of 15 (IQR: 5-22.5) and 24 (IQR: 17-30) minutes. Conclusions: The mean duration of anesthesia with dexmedetomidine as an adjuvant to ropivacaine in supraclavicular brachial plexus blocks was similar to other studies showing prolonged duration and accelerated sensory and motor block.

Introduction: Hemiarthroplasty is recognized as a prominent therapeutic option for neck of femur fracture without preexisting acetabular pathology; however, there are controversies in the scientific literature regarding this. The study aims to analyze epidemiology of patients sustaining neck of femur fracture and the functional outcomes following hemiarthroplasty. Methods: This is a observational cross-section study in a single tertiary care center of Nepal. Senior citizens, 60 years or above patients, with neck of femur fracture who underwent hemiarthroplasty from January 2017 to December 2022 were included in the study. Patient related data were retrieved from the medical record department of the hospital. A semi-structured proforma was designed which included patient demographic information, operative details and follow up evaluation using Modified Harris Hip Score. Ethical approval was obtained from the Institutional Review Committee (Reference number: 34/24). Results: The median Modified Harris Hip score for patients who received hemiarthroplasty for neck of femur fracture from January 2017 to December 2022 was 79 (IQR: 74-86), with 4 (9.30%) achieving excellent results, 19 (41.19%) good, 14 (32.56%) fair, and 6 (13.95%) poor outcomes. Conclusions: Hemiarthroplasty emerges as a valuable treatment for femoral neck fractures in senior citizens, aged 60 and above, providing good functional results.

Ectodermal dysplasia is a rare disease that belongs to a diverse group of inherited monogenic disorders involving defects in one or more ectodermally or mesodermally derived tissues. Hypohidrotic ectodermal dysplasia, also known as Christ-Siemens-Touraine syndrome is a type of ectodermal dysplasia characterized by a triad of anhidrosis, dysodontia, and hypotrichiasis. The most prevalent method of transmission is X-linked recessive, manifesting fully in men and only partially in female carrier heterozygotes. Atrophic rhinitis and nasal myiasis are rare characteristics of this condition. We hereby report a case of a 52-year-old female with atrophic rhinitis and nasal myiasis who was managed conservatively.

Background: Electrocardiogram has been widely applied as a diagnostic tool for cardiovascular disease. The concept of the cardiac vector is crucial for the clinical application in ECG interpretation. Methods: A prospective cross-sectional study was conducted among 116 male subjects, aged 18-25 years, comprising students and staff of Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal, over the period from June to September 2023. Electrocardiograms (ECGs) were recorded using a standard ECG machine with conventional limb leads. The mean electrical axis of the heart for each individual was determined by plotting the net voltage of the QRS complex in Lead-I and Lead-III. The study aimed to analyze the correlation between the cardiac vector and physical measurements, such as height, weight, Body Surface Area (BSA), and Body Mass Index (BMI). Data analysis was performed using SPSS version 27.0. Results: The normal mean electrical axis of the healthy male subjects was observed as 57.88±24.55°. There was significant positive correlation of cardiac vector with height (p< 0.05), whereas negative correlation was observed with weight and BMI (p< 0.01). However, there was no significant correlation with BSA. In our study we observed the maximum left axis cardiac vector as -10° and right axis as 90° among 116 male subjects. Conclusion: We established a cardiac vector with values differing from those reported in other studies, using standard bipolar limb leads in normal, healthy male subjects. It is also examined that greater BMI has shifted the electrical activity of the ventricles to the left.

Ulnar neuropathy is a common peripheral neuropathy, with cubital tunnel compression being the second most frequent upper extremity compression syndrome. Ganglion cysts, though rare, can contribute to ulnar nerve compression in the cubital tunnel. Here, we present a case of a 62-year-old farmer with longstanding diabetes and dyslipidemia who experienced progressive pain and numbness in his medial fingers, exacerbated by elbow flexion. Initially misdiagnosed and treated for Hansen’s disease. Clinico-radiological evaluation revealed a multiloculated cystic lesion in the posteromedial aspect of his left elbow, compressing the ulnar nerve. Surgical excision of the ganglion cyst alleviated symptoms, though residual motor deficits persisted postoperatively. This case underscores the importance of considering ganglion cysts in the differential diagnosis of cubital tunnel syndrome, highlighting the diagnostic challenges and therapeutic considerations in managing this rare etiology.

Introduction: Spinal cord injuries result in severe neurological impairments and disabilities. With an estimated 15.4 million cases globally in 2021, spinal cord injuries are more common in low- and middle-income countries, yet research in these areas is limited. This study aimed to find the pattern of spinal injuries and outcomes associated with spine injuries over a five-year duration at a tertiary trauma care center. Methods: This observational cross-section study was conducted at the National Trauma Center, Kathmandu from 2075 to 2080 B.S. with ethical clearance from the Nepal Health Research Council (Reference number: 968). Total-population sampling was used. A structured proforma was employed as the primary data collection tool. Data was analyzed using SPSS. Results: Of the 20843 patients, 2070 (9.93%) had spinal injuries. The median age was 43 (IQR 32-56) years, with 1391 (67.20%) male patients. The median hospital stay was 12 (IQR 7-20) days. Falls accounted for 1221 (58.99%) cases, and road traffic accidents for 195 (9.42%). Spinal fractures were present in 1076 (51.98%) patients with 456 (42.38%) in lumbar vertebra. There were 225 (10.87%) cases of subluxation with 214 (95.11%) in cervical level. Conclusions: The study provides insights into the patterns and outcomes of spinal injuries over five years of time. The mortality rate and cases of patients leaving against medical advice highlight areas for improvement in patient care and follow-up.

Introduction: Osteoporosis and low bone mass affect millions of people worldwide, leading to severe consequences ranging from disability to mortality. This study aimed to determine the prevalence and risk factors of osteoporosis among postmenopausal women in a district of Nepal. Methods: An analytical cross-sectional study involving postmenopausal women from Nuwakot, Dhading, and Rasuwa districts in Nepal was conducted at Trishuli Hospital, Nuwakot. Ethical approval was taken from the Institutional Review Board of Nepal Health Research Council (Reference number: 1768). The prevalence of osteoporosis was determined, and the associated factors were analyzed using multivariate logistic regression. Dual-Energy X-ray Absorptiometry (GE-Lunar Prodigy) was used to measure Bone Mineral Density (g/cm2) at the proximal femur and lumbar spine. Various factors related to osteoporosis were also analyzed. Results: There were 384 postmenopausal women and the prevalence of osteoporosis was 82 (21.35%; 95% CI: 17.25%-25.45%)e. The mean age of female with osteoporosis was 67.52±8.84 years and that without osteoporosis was 55.70±7.69 years (p

Introduction: Globally, over two billion people suffer from vision impairment, almost half preventable. In Nepal, the Eastern Regional Eye Care Program introduced self-vision assessment charts in 137 schools for early eye issue detection. This study assessed the charts' use and perceived impact. Methods: A multi-method study was conducted to evaluate the use of self-vision assessment charts in schools in Eastern Nepal. Ethical approval was obtained from Institutional Review Board (Refrence number: 72-079-040). Quantitative data were collected through a questionnaire survey. Quantitative data were analyzed using descriptive statistics, while qualitative data were analyzed using framework analysis. Both methods were integrated to enhance understanding of participants' experiences. Results: In this study, 400 students participated in questionnaire survey, 180 in self vision assessment, and 16 teachers in in-depth interviews. Among the participants, 198 (49.50%) of students used the chart, 125 (65.78%) expressed satisfaction, 241 (60.25%) found it useful, 276 (69%) as beneficial, and 253 (63.25%) stated improved health. There were 93 (23.25%) students who felt knowledgeable about its use, with 18 (10%) using it correctly. In 162 (90%) of schools there were adequate chart placement, 23 (12.77%) provided clear signage for viewing points. Teachers recognized the chart's benefits and encouraged its use, but students lacked awareness. Regular use was viewed as beneficial for early detection of eye issues, though challenges included a need for more awareness among students and teachers and reliance on home remedies. Conclusions: Most students and teachers acknowledged self-vision assessment charts’ benefits but had low utilization and accuracy rates. Strategic interventions such as regular informational sessions, teacher motivation, and engagement with eye health experts are essential.

Introduction: Children with beta thalassemia are on regular blood transfusions, which could result in iron deposition in the liver causing decreased synthesis of Vitamin D-25OH. There are limited publications on the association of Vitamin D deficiency with blood transfusion-dependent thalassemia in the Nepalese population. This study aims to determine the prevalence of Vitamin D deficiency among blood transfusion-dependent beta-thalassemia patients. Methods: This was a descriptive cross-sectional study conducted among beta-thalassemia major patients under 15 years of age, receiving regular blood transfusion, from July 17, 2022, to July 16, 2023, after ethical approval obtained from Ethical Review Committee, Kanti Children’s Hospital (reference number 155). Data were collected using convenience sampling, and descriptive analyses were performed using Microsoft Excel and Statistical Package for Social Sciences (SPSS) 2024. Results: A total of 127 blood transfusion-dependent beta-thalassemia major patients were included in the study, of whom 82 (64.56%) were male. Among these patients, 104 (81.88%) were aged between 5 and 14 year. Almost one-third 41 (32.28%) had Vitamin D insufficiency, and a quarter, 34 (26.77%), had Vitamin D deficiency. Ten percent of the children were underweight, and a quarter were stunted. Conclusions: Children with blood transfusion dependent beta thalassemia major are at a greater risk for Vitamin D deficiency and iron overload

Key Clinical Message Appropriate anesthetic technique for fracture fixation in multiple myeloma is crucial in minimizing perioperative complications. The use of pericapsular nerve group block followed by spinal anesthesia for the operative management of pathological fracture in multiple myeloma patient along with proper pre‐ and postanesthetic care ensures better outcome for the patient. Abstract Multiple myeloma is a malignant plasma cell disease that often presents with anemia, renal failure, hyperkalemia and osteolytic bone lesions. The advancements in drug therapy of multiple myeloma have prolonged the lifespan of the affected people, resulting in a rise in cases of surgical management of fractures in such patients. Anesthetic management, despite being of utmost importance in minimizing perioperative complications in such patients, has not been widely studied, especially in this part of the world. Hence, we report a case of 64 years diabetic, HbSAg positive male with hypothyroidism and a known case of multiple myeloma since the last 6 years, under medication for his comorbidities who suffered acetabular fracture. In this case report, the use of pericapsular nerve group block followed by spinal anesthesia for the operative management of the fracture has been discussed along with several pre‐ and postanesthetic considerations. With appropriate anesthetic techniques and proper pre‐ and postanesthetic care, better outcomes can be guaranteed.

Introduction: Emergency departments serve as the initial point of contact for patients with a wide range of conditions. Not all patients visiting get admitted to the hospital. The admission rate varies from 20% in the United States to 40.83% in Nepal. Given the variability in these results across different regions, there is a need to better understand the admission rates from the Emergency Department. Methods: A descriptive cross-sectional study was conducted after obtaining ethical approval( Reference Number: 58 (6-11)E2 081/082) in the Emergency Department of a tertiary health care center. Retrospective data was collected from the data register. The data from April 2023 to April 2024 was collected. A sample size of 222 was calculated and convenience sampling was done. Demographic details like age, sex, and data regarding admission status were collected. Data was collected in MS Excel and was analyzed using JASP software. Results: Out of 222 patients that presented to the emergency department, 53 (23.87%)(18.26-29.47,95 % Confidence Interval) were admitted to the ward or intensive care unit of the hospital, whereas 167 (75.23) got discharged, 1 (0.45%) was brought dead and 1 (0.45%) expired. The median age of patients was 43 (IQR: 26-62). The admission rate of females was 20 (17.24%), whereas for males it was 33 (31.13%). Conclusions: The prevalence of admission of patients visiting the emergency department was higher than similar US based studies. There was a higher percentage of female patients presenting to theemergency department, while those being admitted were mostly males.

Background: Sodium glucose cotransporter 2 inhibitors are recommended for the treatment of heart failure due to their cardioprotective effects, despite primarily being used as antidiabetic medications. However, the comparative profile of two antidiabetic drugs, sodium glucose cotransporter 2 inhibitors with dipeptidyl peptidase 4 inhibitor remains unclear. Study hypothesis: This study aims to compare the safety and efficacy profiles of sodium glucose cotransporter 2 inhibitors versus dipeptidyl peptidase 4 inhibitor drugs. Methods: A comprehensive search was conducted in PubMed, Scopus, Web of Science, Google Scholar, and ClinicalTrials.gov using appropriate Medical Subject Headings terms from inception until February 23, 2023. The outcomes were pooled using a random-effects model for hazard ratio with a 95% confidence interval. A p -value of

Key Clinical Message Lateral medullary syndrome, resulting from cerebellar/brainstem infarction, can occur due to cardioembolic stroke from atrial fibrillation caused by rheumatic heart disease. This rare association highlights the importance of strict arrhythmia management, prophylactic anticoagulation, and timely diagnosis to prevent debilitating neurological outcomes.

Filariasis is a very important public health problem endemic in tropical and subtropical countries. It is a debilitating disease with significant socioeconomic burden. In 2016, lymphatic filariasis was successfully eliminated from the Maldives, which was certified by WHO. We report a case of filariasis detected by a rapid antigen test while undergoing a screening program conducted by Health Protection Agency, Maldives in December 2023. The patient was asymptomatic and showed no peripheral blood eosinophilia. Conventional blood smears were negative. Nevertheless, buffy coat smear served as a promising test in detection of parasite, thus confirming the re-emergence of the disease in the country. Therefore, our study highlight the significance of buffy coat smears in detection of hemoparasites. We also focus on the importance of surveillance system in order to sustain the disease elimination goal that was already achieved.

Abstract Background Context (work environment) plays a crucial role in implementing evidence-based best practices within health care settings. Context is multi-faceted and its complex relationship with best practice use by care aides in long-term care (LTC) homes are understudied. This study used an innovative approach to investigate how context elements interrelate and influence best practice use by LTC care aides. Methods In this secondary analysis study, we combined coincidence analysis (a configurational comparative method) and qualitative analysis to examine data collected through the Translating Research in Elder Care (TREC) program. Coincidence analysis of clinical microsystem (care unit)-level data aggregated from a survey of 1,506 care aides across 36 Canadian LTC homes identified configurations (paths) of context elements linked consistently to care aides’ best practices use, measured with a scale of conceptual research use (CRU). Qualitative analysis of ethnographic case study data from 3 LTC homes (co-occurring with the survey) further informed interpretation of the configurations. Results Three paths led to very high CRU at the care unit level: very high leadership; frequent use of educational materials; or a combination of very high social capital (teamwork) and frequent communication between care aides and clinical educators or specialists. Conversely, 2 paths led to very low CRU, consisting of 3 context elements related to unfavorable conditions in relationships, resources, and formal learning opportunities. Our qualitative analysis provided insights into how specific context elements served as facilitators or barriers for best practices. This qualitative exploration was especially helpful in understanding 2 of the paths, illustrating the pivotal role of leadership and the function of teamwork in mitigating the negative impact of time constraints. Conclusions Our study deepens understanding of the complex interrelationships between context elements and their impact on the implementation of best practices in LTC homes. The findings underscore that there is no singular, universal bundle of context-related elements that enhance or hinder best practice use in LTC homes.

Barsha Shrestha,1 Sheetal Maria Rajan,1 Sultan Aati,1,2 Emielda Yusiharni,3 Omar Kujan,1 Martin Saunders,4 Amr Fawzy1 1UWA Dental School, The University of Western Australia, Perth, WA, Australia; 2Dental Health Department, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia; 3UWA XRD Facility, Material & Environmental Analysis Platform, The University of Western Australia, Perth, WA, Australia; 4Centre for Microscopy, Characterisation and Analysis, The University of Western Australia, Perth, WA, AustraliaCorrespondence: Amr Fawzy, UWA Dental School, The University of Western Australia, 17 Monash Avenue, Nedlands, WA, 6009, Australia, Tel +61894572434, Email amr.fawzy@uwa.edu.auBackground: Remineralization of dental enamel is an important intervention strategy for the treatment of demineralized lesions. Existing approaches have limitations such as failure to adequately reproduce both the ideal structural and mechanical properties of the native tooth. The ability of ultrasound to control and accelerate the crystallization processes has been widely reported. Therefore, a new approach was explored for in-vitro enamel remineralization involving the synergistic effect of high-intensity focused ultrasound (HIFU) coupled with calcium phosphate ion clusters (CPICs).Methods: The demineralized enamel was treated with CPICs, with or without subsequent HIFU exposure for different periods (2.5, 5, and 10 min). The specimens were characterized by scanning electron microscopy (SEM), atomic force microscopy (AFM), and Raman spectroscopy. The surface hardness and crystallographic properties of the treated specimens were evaluated using Vickers microhardness testing and X-ray diffraction (XRD), respectively.Results: SEM revealed distinct, organized, and well-defined prismatic structures, showing clear evidence of remineralization in the combined CPIC/HIFU treatment groups. AFM further revealed a decrease in the surface roughness values with increasing HIFU exposure time up to 5 min, reflecting the obliteration of interprismatic spaces created during demineralization. The characteristic Raman band at 960 cm− 1 associated with the inorganic phase of enamel dominated well in the HIFU-treated specimens. Importantly, microhardness testing further demonstrated that new mineral growth also recovered the mechanical properties of the enamel in the HIFU-exposed groups. Critical to our aspirations for developing this into a clinical process, these results were achieved in only 5 min.Conclusion: HIFU exposure can synergise and significantly accelerate in-vitro enamel remineralization process via calcium phosphate ion clusters. Therefore, this synergistic approach has the potential for use in future clinical interventions. Keywords: enamel remineralization, high intensity focused ultrasound, calcium phosphate ion cluster

Abstract Background Malignant pleural effusion (MPE) is a debilitating condition as it commonly causes disabling breathlessness and impairs quality of life (QoL). Indwelling pleural catheter (IPC) offers an effective alternative for the management of MPE. However, IPC-related infections remain a significant concern and there are currently no long-term strategies for their prevention. The Australasian Malignant PLeural Effusion (AMPLE)-4 trial is a multicentre randomised trial that evaluates the use of topical mupirocin prophylaxis (vs no mupirocin) to reduce catheter-related infections in patients with MPE treated with an IPC. Methods A pragmatic, multi-centre, open-labelled, randomised trial. Eligible patients with MPE and an IPC will be randomised 1:1 to either regular topical mupirocin prophylaxis or no mupirocin (standard care). For the interventional arm, topical mupirocin will be applied around the IPC exit-site after each drainage, at least twice weekly. Weekly follow-up via phone calls or in person will be conducted for up to 6 months. The primary outcome is the percentage of patients who develop an IPC-related (pleural, skin, or tract) infection between the time of catheter insertion and end of follow-up period. Secondary outcomes include analyses of infection (types and episodes), hospitalisation days, health economics, adverse events, and survival. Subject to interim analyses, the trial will recruit up to 418 participants. Discussion Results from this trial will determine the efficacy of mupirocin prophylaxis in patients who require IPC for MPE. It will provide data on infection rates, microbiology, and potentially infection pathways associated with IPC-related infections. Ethics and dissemination Sir Charles Gairdner and Osborne Park Health Care Group Human Research Ethics Committee has approved the study (RGS0000005920). Results will be published in peer-reviewed journals and presented at scientific conferences. Trial registration Australia New Zealand Clinical Trial Registry ACTRN12623000253606. Registered on 9 March 2023.

Shaylen Foley,1 Danya E Keene,1 Roman Shrestha,2– 4 Shan-Estelle Brown,5 Kamal Gautam,2 Ryan A Sutherland,3 Francesca Maviglia,3 Rumana Saifi,4 Jeffrey A Wickersham3,4 1Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, CT, USA; 2Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA; 3Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA; 4Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; 5Department of Anthropology, Rollins College, Winter Park, FL, USACorrespondence: Shaylen Foley, 135 College Street, Suite 323, New Haven, CT, 06510, USA, Tel +419 343-4606, Email shaysf@gmail.comIntroduction: Pre-exposure prophylaxis (PrEP) is an effective method for prevention of HIV transmission. Female sex workers (FSW) in Malaysia are at substantially increased risk of acquiring HIV compared to the general female population, yet little is known about this population’s current HIV prevention practices or acceptance of PrEP. This study aims to inform the culturally relevant implementation of PrEP through the qualitative exploration of (1) the potential need for PrEP in this population and (2) the factors that determine FSW willingness to use oral PrEP.Methods: In-depth, semi-structured interviews (n = 30) were conducted with FSW in English, Malay, or Tamil. Transcribed and translated interviews were analyzed using a grounded theory approach.Results: FSW express positive interest in PrEP but prefer it as a supplement to condoms, not a replacement. Perceived challenges to PrEP use include cost, adherence, and side effects.Conclusion: The findings suggest that in combination with condom use, PrEP may be an acceptable method of HIV prevention. Effective PrEP rollout may also include condom promotion using a peer-driven model, cost subsidies, and sex work harm reduction and empowerment components.Keywords: sex work, HIV, pre-exposure prophylaxis, Malaysia

Background: Since the development of the Death Literacy Index (DLI) in 2019 in Australia, subsequent internationally validated versions have prompted rewording and refinement of the original survey questions. Use of the DLI in the community has also resulted in requests for a short format. Objectives: To examine and report on the psychometric properties of a revised version of the DLI-R and develop a short format DLI-9. Design: A cross-sectional national survey was conducted for the validation of the revised DLI. Methods: The DLI items were revised by the research team using the international literature. DLI data were collected from a representative online non-probability panel of 1202 Australian adults, based on age, gender, and geographical location. Confirmatory factor analysis (CFA) was conducted to ensure the revised version (DLI-R) was consistent with the original. To develop a short format version of the DLI (DLI-9), items were first removed based on face validity, followed by an exploratory factor analysis (EFA) and CFA. The internal reliability of the DLI-R and the DLI-9 was assessed using Cronbach’s alpha. The intraclass correlation coefficient was calculated to examine the inter-rater reliability between the DLI-R and DLI-9. Results: Twenty-four questions in the DLI were reworded for clarity. A CFA on the 29 items of this modified version of the DLI indicated a good model fit (Tucker-Lewis Index (TLI): 0.93; Comparative Fit Index (CFI): 0.93; root mean square of approximation (RMSEA): 0.06; standardized root mean residual (SRMR): 0.06), with six latent variables and an underlying latent variable “death literacy.” For the DLI-9, an EFA identified a nine-item, two-factor structure model (DLI-9). A subsequent CFA in a separate sample demonstrated a good model fit for the DLI-9 (TLI: 0.92; CFI: 0.94; RMSEA: 0.089; SRMR: 0.07). Excellent inter-rater reliability (0.98) was observed between DLI-9 and DLI-R. Cronbach’s alpha coefficients for DLI-R scales and subscales and the DLI-9 all exceeded 0.8, indicating high internal consistency. Conclusion: The DLI-R and the DLI-9 were found to have acceptable psychometric properties. The development of a shorter version of the DLI provides a valid measure of overall death literacy.

Introduction: Knee osteoarthritis commonly occurs in the medial compartment. Arthroscopic debridement eases pain by irrigating debris and inflammatory cytokines. Proximal fibular osteotomy shifts the loading force more laterally from the medial compartment, eliminating pain and delaying degenerative progression. This study aims to evaluate pain relief by combining both procedures in knee osteoarthritis of the medial compartment. Methods: The study was conducted in Nepal Medical College Teaching Hospital from November 2021 to December 2022 after the ethical approval from institutional review committee (IRC Ref. No. 025-078/079). The outcome was assessed by visual analog score and knee society scores, who underwent a combined procedure of arthroscopic debridement and proximal fibular osteotomy during a study period of 12 months. Results: Diagnostic arthroscopy was done in 32 patients, out of which, 27 patients underwent combined procedure with arthroscopic debridement and proximal fibular osteotomy. The mean visual analog score in combined procedure was 6.89 ± 0.93 initially and 3.11 ± 0.69 at 12 months follow up. The mean knee society score in combined procedure was 46.85 ± 6.1 preoperatively and 84.26 ± 8.27 postoperatively at 12 months follow up. Common peroneal nerve neuropraxia was observed in 8 (29.62%) patients, which resolved spontaneously during 6 months of time period. Conclusions: Combined arthroscopic debridement and proximal fibular osteotomy procedure is effective in treating knee osteoarthritis of the medial compartment, as it decreases pain and improves knee society score.

Neuroscience is being integrated into criminal investigations, offering new opportunities for understanding, predicting, and potentially preventing criminal behavior. In Nepal, brain-mapping techniques like P300 wave tests and Brain Electrical Oscillation Signature profiling were used in a murder investigation in 2024. However, ethical concerns include privacy concerns, false positives, and the potential for false positives. Consent regarding neurobiological evidence in criminal cases is crucial, as intrusive procedures may require individuals to be informed. The legal implications of using neurobiological evidence could be severe if it serves to wrongfully accuse or convict an individual. Therefore, the use of neuroscience in criminology must be carefully balanced to ensure ethical considerations. This viewpoint interprets the potential of neuroscience in criminal investigations, addressing ethical, privacy, consent, and legal issues within the Nepal Police and criminal justice system.

Introduction: Most developing regions of the world are undergoing gradual epidemiological transition resulting in high burden of both communicable and noncommunicable diseases. Morbidity and mortality pattern is a reflection of disease burden. Detailed assessment of these parameters tends to aid in formulating pivotal aspects of in-hospital policies, standards of care and so consequently promoting efficient work systems. The aim of this study is to identify the pattern of mortalities in medical wards in a tertiary care hospital. Methods: This retrospective descriptive cross-sectional study was conducted in National Academy of Medical Sciences, Bir hospital focusing on all patients admitted to the medical wards (General Medical, Hepatology, Nephrology, Neurology, Endocrinology, Pulmonology, Cardiology and Gastrology) between January 1 to December 31, 2023 after obtaining ethical approval from Institutional Review Committee (Reference Number: 390/2080/81). Total population sampling was done. Data were analyzed using Microsoft Excel and SPSS. Results: Among 10124 admitted patients in medical wards, mortality was reported in 732 (7.22%). The number of deaths seen in general medical ward was 389 (53.14%) and in liver ward was 85 (11.61%). Systemic cause of death due to respiratory diseases was 157 (21.5%) and liver disease was 143 (19.6%). Conclusions: The respiratory disease is responsible for a higher proportion of deaths among admitted patients. However, the deaths due to liver disease are increasing because of the rise in cirrhosis of the liver in the younger age group.

Introduction: Poor sleep quality is a global public health issue particularly more prevalent in medical professionals and students. Despite various health and occupational risks, research is still lacking regarding the quality of sleep and its irelated factors among medical professionals and students in our region. Therefore, our study aimed to estimate the prevalence of poor sleep quality in this population. Methods: This observational, cross-sectional study was conducted among medical professionals and students of Devdaha Medical College from December 2023 to June 2024 after ethical approval from the Institutional Review Board. Data regarding sleep quality and excessive daytime sleepiness were collected using the Pittsburg Sleep Quality Index (PQSI) and Epworth Sleepiness Scale with pre-made questionnaires in Google Forms. Results: Among 395 participants, 260 (65.83%) were in the age group 20-25 years and 200 (50.63%) were nursing students. The prevalence of poor sleep quality was 146 (36.96%; 95% CI: 32.19%-42.93%) and the global mean score of PSQI was calculated to be 5.12. Out of the total participants, 255 (64.55%) had excessive daytime sleepiness, 84 (21.26%) participants had one or more sleep problems out of which, snoring was in 40 (10.12%) participants. Conclusions: About one-third of the study population poor sleep quality and day time sleepiness was reported in more than half of the respondents.

Introduction: One of the most prioritized programs of Government of Nepal is maternal health. Optimum utilization of maternal health services during pregnancy, delivery and post-natal period is an effective approache to reduce the maternal morbidity and mortality that helps us achieve the sustainable development goals target. This study aimed to assess the utilization of maternal health services including antenatal, intranatal and postnatal services among women in the Palpa district of Nepal. Methods: A descriptive cross-sectional study was conducted among 168 mothers in their reproductive age using a convenient sampling method. The study included those mothers who had a delivered a child in the past two years, in Palpa district. The data collection commenced from March to September 2023. The data analysis was conducted using Statistical Package for Social Sciences software (v 21.0). Results: A remarkable finding in the present study was 88.1% of mothers had utilized a minimum of four antenatal check-ups, as recommended by the Government of Nepal. Out of 168 mothers included in the present study 89.9% had institutional delivery while the remainder had home delivery. Post-natal check-ups following delivery was surprisingly uncommon as it was observed that only 28% mothers sought such care. Adequate utilization of maternal health services is influenced by factors such as proximity of health facilities, education level, and knowledge of maternal incentives. Conclusion: While service utilization for pregnancy and delivery in Palpa district aligns with national standard, further research is needed to identify factors contributing to underutilization of postnatal services.

Objective To describe antibiotic prescription patterns in the emergency department (ED) of a tertiary healthcare center in Nepal. Methods This was a descriptive cross-sectional study of hospital records of patients who visited the ED. Results Of the 758 ED patients included in the study, 384 (50.6%) received a total of 536 antibiotic prescriptions. Common indications for antibiotic prescriptions included respiratory infection (37.5%), gastrointestinal infection (19.3%), urinary infection (10.4%), and prophylaxis (29.9%). Antibiotics listed as essential in the National List of Essential Medicines (NLEM) and generic formulations were used in 77.1% and 61.9% of the antibiotic prescriptions, respectively. Injectable antibiotics were prescribed to 54.9% of the 384 patients. Frequently prescribed antibiotics included ceftriaxone (34.1%), metronidazole (18.5%), amoxicillin + clavulanic acid (15.9%), and cefixime (14.3%). Bacterial culture testing was performed in 15.1% of the patients who received antibiotics. Conclusions This study showed that overuse of antibiotics, prescription of branded antibiotics, prescription of antibiotics not listed in the NLEM, prophylactic use of antibiotics, and empirical treatment of suspected infections without isolation of pathogens were all prevalent. We recommend more research to determine the causes underlying these practices and develop interventions to limit such practices.

Background: Cricoid cartilage is crucial during endotracheal intubation, yet its dimensions in the Nepali population remain uncharacterized. This study aimed to measure cricoid cartilage dimensions in adult Nepalese. Methods: A total of 105 cadavers (75 males, 30 females) were dissected at *** Medical Campus, Nepal. Measurements of outer and inner transverse and anteroposterior diameters, as well as heights of the cricoid arch and lamina, were taken using digital vernier calipers. Statistical analyses included gender comparisons and correlations with age. Results: The mean age of the 105 cadavers studied was 34.11 years (SD = 12.08). The measurements of outer anteroposterior diameter, outer transverse diameter, inner anteroposterior diameter, inner transverse diameter, arch height and lamina height were respectively 22mm (SD=4), 21mm (SD=4), 18mm (SD=3), 17mm (SD=3), 9mm (SD=3) and 24mm (SD=4). Inner AP (p = 0.009) and inner TR (p = 0.021) measurements correlated significantly with age. Males had significantly larger cricoid cartilage dimensions than females (p < 0.001). Conclusions: This study provided essential data for selecting appropriately sized endotracheal tubes in Nepalese patients, reducing airway complications. It underscored the need to tailor medical devices to local anatomical variations, supporting advancements in biomechanical modeling and medical research.

Carpal tunnel syndrome is an entrapment neuropathy of median nerve in wrist presenting with symptoms like pain, numbness, and paresthesia in hand and lateral three fingers. Conservative treatments are effective for mild to moderate cases, whereas severe or refractory carpal tunnel syndrome may require surgical intervention. Hydrodissection, a technique involving the separation of the nerve from surrounding tissues, has emerged as a minimally invasive and effective treatment option for carpal tunnel syndrome, leading to faster recovery and lower complication. In this case report, a 48 years female with two years history of severe pain and paresthesia in right hand, underwent ultrasound-guided hydrodissection of median nerve with 5% dextrose. Following intervention, the patient reported decreased symptoms and expressed satisfaction with the treatment during subsequent follow-up after 2 weeks. Ultrasound-guided hydrodissection of median nerve with 5% dextrose is effective treatment modality for patients with failed conservative management of carpal tunnel syndrome.

Introduction: Postpartum depression, a significant global concern yet a neglected domain that could have dire outcomes for both mother and children. This study aimed to find out the prevalence of postpartum depression among mothers in the Paropakar Maternity and Women's Hospital & explore the experiences of undergoing pregnancy and post-partum melancholy. Methods: A cross-sectional descriptive study with a mixed method approach and consecutive enumeration of sampling units were done among 271 participants at a maternity hospital, within the study period from July,2023 to Dec, 2023 after obtaining ethical approval (Reg no: 63/1992). Data collection was done through in-depth interviews for the qualitative part among the six respondents and self-administrative questionnaires were opted for the quantitative part among all the respondents. Results: Among the respondents, 203 (74.87%) fall within the 20-30 age range. Among them, 33 (12.24%) mothers experienced post-partum depression. Pregnancy and postpartum experiences were complex, with physical and mental challenges. Women often endured painful pregnancies, including excessive vomiting and pain. Mothers lacked support from family and spouses, impeding daily life and newborn care. Traditional superstitions often trumped medical advice, leading to confusion and risks. Despite challenges, some developed coping mechanisms, like self-counselling and community support. Conclusions: The study highlights the importance of pre-pregnancy assessment and depression screening for postpartum care. Social support is crucial, necessitating holistic support with education, mental health services, and destigmatization efforts for postpartum struggles.

Introduction: Antimicrobial resistance is global health problem, amongst major causes for mortality. It is one of the hinderance for achievement of Sustainable Goal 3 (Good health and well-being) of WHO. Multidrug resistant gram negative bacteria are major threat to humanity especially patients admitted in intensive care unit. This is associated with to treatment failure and mortality of the patients in intensive care unit. Therefore, this study was conducted to find out the prevalence of Multidrug resistant gram negative bacteria in intensive care unit of tertiary care center. Methods: A descriptive cross-sectional study was conducted in the Department of Microbiology of a tertiary care hospital from February, 2020 till August, 2021 for 18 months after obtaining ethical approval from the Institutional Review Committee (Reference Number: 246). All the samples from Intensive Care Unit were processed following standard methodology. Only Gram-negative bacteria isolated from samples were included in the study. Convenience sampling method was used. The point estimated was calculated at 95% Confidence Interval. Data was entered in Microsoft Excel 2016 and analysis was done using IBM SPSS Statistics version 16.0. Results: Out of 500 samples only 380 showed growth of gram negative bacteria. The prevalence Multi Drug Resistance was 83.15%. The prevalence of multidrug resistant was notably higher among Acinetobacter spp (100%) followed by Non fermenter (95%) and Escherichia coli (87.1%). Multidrug resistant isolates were least resistant towards carbapenem group of antibiotics. Conclusions: The prevalence of Multidrug resistant gram negative bacteria was found to be lower than in the study conducted in similar setting.

Introduction: Pictorial health warning on cigarette packs is one of the strategies undertaken by Nepal Government as per the directive of World Health Organization Framework Convention on Tobacco Control to control smoking. It has been more than a decade since the introduction of pictorial health warnings on cigarette packs in Nepal. The objective of this study was to assess the impact of the pictorial warnings among current smokers of Dharan, Nepal. Methods: A descriptive cross-sectional study was conducted among current smokers visiting local shops located near ward offices of Dharan after obtaining ethical approval from Institutional Review Committee (Reference number: 204/080/01 -IRC). A structured and validated Nepali questionnaire was used to interview the smokers about the impact of the pictorial warnings based on their noticeability, behavioural and cognitive responses. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 20.0. The responses of the participants were tabulated in frequencies and percentages. Results: The pictorial warnings were noticed by 277 (98.93%) participants in past one month out of which 11 (3.93%) smokers had always read or looked closely at them. Smoking less frequently was the behaviour change reported by 70 (25%) participants and smoking less around others was reported by and 56 (20%) participants. In total, 189 (67.50%) smokers had thought about the harms of smoking and 160 (57.14%) had intention to quit smoking due to the pictorial warnings. Conclusions: The pictorial health warnings were not so effective in bringing about changes in smoking behaviour of smokers.

Key Clinical Message Shiitake mushroom‐induced flagellate dermatitis is a rare but important condition to consider in patients presenting with pruritic skin lesions following mushroom ingestion, especially in regions where such cases are uncommon. Early recognition and appropriate management with oral and topical steroids are crucial for effective symptom resolution and preventing complications. Clinicians should be aware of the characteristic rash and the temporal relationship between mushroom consumption and rash onset. Educating patients about the risks associated with consuming raw or undercooked shiitake mushrooms is essential to prevent recurrence.

Key Clinical Message Amelogenesis imperfecta (AI) is a rare developmental anomaly characterized by poorly developed or absent tooth enamel, which complicates orthodontic treatment due to weak enamel‐bracket bond strength. This case report presents a successful management of AI using fixed orthodontic appliances and prosthodontic rehabilitation. Abstract Amelogenesis imperfecta (AI) causes enamel defects, complicating oral hygiene, reducing masticatory function and lowering self‐esteem. This case report details an 18‐year‐old female with AI who underwent fixed orthodontic treatment followed by prosthodontic rehabilitation. The multidisciplinary approach restored function and aesthetics, significantly improving her quality of life.

Key Clinical Message Antinuclear antibody‐negative full‐house lupus nephritis though previously reported, is fairly uncommon. Some patients go on to develop antibodies later in the disease course. The presence of RO‐52 antibody in this case suggests an underlying immunological cause. Swift management based on strong clinical suspicion can be life‐saving to the patient. Abstract Lupus nephritis (LN) is a serious complication of systemic lupus erythematosus (SLE) and is more likely to progress to end‐stage renal disease (ESRD). With the recent EULAR/ACR criteria mandating antinuclear antibody (ANA) positivity as an entry criterion, clinicians are faced with a diagnostic dilemma in diagnosing cases of seronegative SLE. We present the case of a 25‐year‐old female who presented with photosensitive malar rash, hair loss, oral ulcers, menorrhagia, and kidney dysfunction, suggestive of SLE. Her ANA tests were negative, raising doubts about the diagnosis. Biopsy was delayed owing to anemia and thrombocytopenia, and clinical judgment led to the patient being diagnosed with LN, with prompt treatment resulting in significant improvement. Renal biopsy subsequently confirmed the case as diffuse class IV LN with full‐house nephropathy. This case highlights the limitations of relying solely on ANA positivity in diagnosing LN and underscores the need for a comprehensive diagnostic approach for SLE that incorporates clinical features, immunological markers, and patient demographics. ANA‐negative SLE patients demand heightened clinical suspicion, especially when other diagnostic parameters align with the disease. Swift intervention with immunosuppressive therapy, as seen in this case, can be life‐saving.

Cases of mental illnesses and suicide attempts while pregnant are of grave concern because they negatively affect both the mother and her fetus. Here we report a case of an 18-year-old woman, who was found at 35 weeks into her pregnancy. She was unconscious when her sister-in-law rescued her. Upon arrival, she was agitated and had respiratory distress. She went into spontaneous labor the next day and delivered a premature infant who succumbed within 24 h. She had a history of mental illness in the past and previous suicide attempts. The reason for her suicide stemmed from conflicts within her family and disagreement with her husband. Various psychosocial elements play a role in suicide risk, such as young age, having a history of mental health issues, experiencing trauma facing domestic violence, and dealing with financial stress. This underlines the need for mental health screening in the course of antenatal visits for a complete risk assessment.

Pentalogy of Fallot is a rare form of congenital cyanotic heart disease with a prevalence of 3/10,000 live births characterized by an association of Tetralogy of Fallot with Atrial Septal Defect. Pentalogy of Fallot with anorectal malformation is also a rare combination. Here we describe one of the rare case reports of a full-term, 38 weeks, female baby diagnosed with pentalogy of Fallot with imperforate anus and rectovaginal fistula at a tertiary care hospital. Pentalogy of Fallot combined with an imperforate anus and rectovaginal fistula is an exceptionally rare and complex congenital condition. The co- existence of these anomalies emphasizes the need for thorough prenatal and postnatal evaluation for early detection and management.

Introduction: Laparoscopic cholecystectomy, being minimally invasive, is widely accepted in comparison to open cholecystectomy. The major benefits are small incision, less wound pain, rapid recovery, shorter hospital stay and earlier return to activities. Although, trauma and injury are limited in laparoscopic cholecystectomy; it is not a pain free surgery. Hence, we aimed to find out the prevalence of pain at wound site after laparoscopic cholecystectomy at various time intervals in post-operative period. Methods: The descriptive cross-sectional study was conducted among 125 American Society of Anesthesiologists grade I/II patients, with diagnosis of symptomatic gallstone disease from October 2022 to September 2023 in a tertiary care hospital after ethical approval was obtained from Institutional Research Committee (Reference number: MEMG/483/IRC). Total sampling was done in this study. The post-operative pain at wound site was measured at 12, 24, 36 and 48 hours. Data were analyzed using SPSS 21.0. Results: At 12 hours postoperatively, 2 (1.60%) patients complained of severe pain, 120 (96%) patients reported moderate pain and 3 (2.40%) patients expressed their pain as being mild. Likewise, at 24, 36 and 48 hours postoperatively, none of the patients suffered from severe pain. At 24 hours post-operative, 105 (84%) patients reported moderate pain which gradually declined over 48 hours. At 36 and 48 hours post-operative mild pain was reported by 85 (68%) and 117 (93.60%) patients respectively. The moderate pain was complained by 40 (32%) and 8 (6.40%) patients respectively. Conclusions: The majority of patients suffered from mild to moderate pain after laparoscopic cholecystectomy, the intensity of which decreased over 48 hours.