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Study Design: Epidemiological retrospective study., Objective: To describe the demographics, timing to surgery, delay, short-term neurological recovery, and complications in surgically treated subaxial cervical trauma in a resource-constrained country., Methods: Thirty consecutive subaxial cervical trauma patients presenting to a trauma hospital in Nepal between December 2015 and August 2017 were analyzed as a retrospective cohort. Patients were segregated into 4 groups based on the timing to surgery: within 2 days, 3 to 7 days, 8 to 30 days, and >31 days., Results: There were 27 male and 3 female patients with mean age 40 years. Twenty-four sustained fall injury, and 27 patients were from outside Kathmandu. No patients were treated within the first 48 hours; only 9 were treated between 3 and 7 days, 16 between 8 and 30 days, and 5 a month later. Major delay was finance and operating room availability. Thirteen patients had a C6C7 involvement followed by C5C6 in 6 patients. Seven patients had complete neurological deficit while 18 patients had incomplete deficit. A total of 46.7% improved their neurology in 6 months. No neurological recovery was observed in complete deficit patients., Conclusion: Seventy percent of our patients were treated longer than 1 week after injury, which would likely be considered unacceptable in most first world countries. As expected, the outcomes for many of these patients were far worse than reported in North American centers with early access to medical care and insurance. Despite this, nearly half of our patients improved neurologically following treatment; hence, surgery holds hope of some restoration of neurologic deficits., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: K. Daniel Riew: Biomet, Medtronic—Royalties. Osprey, Expanding Orthopedics, Spineology, Spinal Kinetics, Nexgen Spine, Amedica, Vertiflex, Benvenue, Paradigm Spine, PSD—Stock. Spine, GSJ, ESJ, Neurosurgery, Clinics in Orthopedics, Spine Surgery Today—Editorial/Board. AO Spine—Board. The remaining authors have no conflicts of interest to disclose.

Aim: The study is mainly concerned about the care and maintenance of peripheral intravenous cannulation: to determine the knowledge and practice of nurses towards care and maintenance of IV cannula and to find out the obstacles encountered in caring and maintaining IV cannula. Intravenous cannulation is a common procedure performed by nurses in every hospital and closely associated with the risk of nosocomial infections if standard care is not provided., Design: A descriptive cross-sectional study design was carried out., Methods: Nurses' knowledge and practice towards care and maintenance of peripheral intravenous cannula were assessed using a validated semi-structured self-administered questionnaire through the census method. Data were analysed through SPSS program. The comparison was done between knowledge and practice., Results: The findings revealed that 84.72% respondents were doing correct practices despite the fact that only 82.47% respondents had proper knowledge. Most nurses have good knowledge of caring and maintaining peripheral intravenous cannulation but there were some without proper knowledge and practice. This could be a potential risk factor for patient safety., Competing Interests: None.

Aims and Objectives: To explore the perspectives of nursing and physiotherapy academics regarding techniques designed to prevent musculoskeletal pain and injury in nurses., Background: High rates of musculoskeletal injuries are evident in nurses, yet there is an absence of research identifying effective interventions to address this problem. Exploring the perspectives of individuals with specialist knowledge in the area could help identify barriers to musculoskeletal injury prevention, and innovative strategies to investigate in future studies., Design: Cross-sectional qualitative descriptive study., Methods: Between October-December 2017, group and individual face-to-face semi-structured interviews were used to collect data. All interviews were audio-recorded. A thematic analysis was performed, with two researchers coding audio files using NVivo software. The Consolidated Criteria for Reporting Qualitative Research Checklist was consulted to ensure complete reporting of all methods and findings., Results: Nursing and physiotherapy academics ( N  = 10) were aware of a range of techniques to prevent musculoskeletal injuries in nurses, including education, equipment, health and safety policy and multi-disciplinary collaboration. However, several barriers to using these techniques were identified, including age, knowledge and availability of equipment, personal and contextual factors, staffing and time pressures. Several strategies were recommended for further investigation and implementation in clinical practice, such as the sharing of personal experiences, orthopaedic assessments and changes to workplaces that foster a culture of safety., Conclusions: Further research is required to reduce musculoskeletal pain and injury among nurses. This research should account for the barriers to current prevention strategies and consider investigating novel interventions., Relevance to Clinical Practice: These findings highlight strategies for preventing musculoskeletal injuries among nurses that are likely to be most effective in clinical practice., Competing Interests: No conflict of interest has been declared by the authors.

Topological antiferromagnetic (AFM) spintronics is an emerging field of research, which exploits the Néel vector to control the topological electronic states and the associated spin-dependent transport properties. A recently discovered Néel spin-orbit torque has been proposed to electrically manipulate Dirac band crossings in antiferromagnets; however, a reliable AFM material to realize these properties in practice is missing. In this Letter, we predict that room-temperature AFM metal MnPd_{2} allows the electrical control of the Dirac nodal line by the Néel spin-orbit torque. Based on first-principles density functional theory calculations, we show that reorientation of the Néel vector leads to switching between the symmetry-protected degenerate state and the gapped state associated with the dispersive Dirac nodal line at the Fermi energy. The calculated spin Hall conductivity strongly depends on the Néel vector orientation and can be used to experimentally detect the predicted effect using a proposed spin-orbit torque device. Our results indicate that AFM Dirac nodal line metal MnPd_{2} represents a promising material for topological AFM spintronics.

Objective: The purpose of this study was to categorize patients into different grades of nonalcoholic fatty liver disease (NAFLD) by ultrasonography and to compare the findings with their serum lipid profile., Materials and Methods: Descriptive, cross-sectional study design was used. One hundred and nine patients without a history of alcohol consumption of age more than 16 years attending general health checkup were selected at Tribhuvan University Teaching Hospital, Maharajganj, Kathmandu, as per the exclusion and inclusion criteria. Ultrasound scanning of the patients was done and their liver size, as well as grading of fatty liver, was done. Data were collected in predesigned pro forma and were analyzed using Statistical Package for the Social Sciences (SPSS) 16.0, IBM (SPSS Inc., Chicago, IL)., Results: In this study, the mean age of fatty liver in males was found to be 44.3 years and in females was found to be 51.9 years. 22.9% of patients with NAFLD had increased liver size. Significant association with increasing grades of fatty liver was found with increasing levels of cholesterol ( P = 0.028), low-density lipoprotein (LDL) ( P = 0.017), liver size ( P = 0.001), and body mass index (BMI) ( P = 0.045) in patients diagnosed with NAFLD. No significant association with increasing grades of fatty liver was found with increasing levels of triglyceride ( P = 0.32) and high-density lipoprotein ( P = 0.25)., Conclusion: Ultrasound is a safe and first-line modality for the evaluation of fatty liver and its grading. Increasing grades of fatty liver had significant association with increasing levels of cholesterol LDL, increasing liver size, and BMI of patients., Competing Interests: There are no conflicts of interest.

Objective: To assess whether the implementation of a package of activities through the joint action of three international healthcare professional associations (HCPAs) increased the use of essential interventions (EIs) for delivery and neonatal care., Methods: A noncontrolled pre-intervention versus post-intervention study was conducted from June 13 to December 13, 2016, among women older than 18 years of age, who had delivered at one of two urban tertiary hospitals in Nepal., Results: The study included 9252 women. Minimal change was found after the implementation of EIs that were used frequently at baseline (e.g. social support during delivery in the emergency room, and promotion and support for early initiation of breastfeeding). By contrast, an increase was recorded for some EIs that had not been used regularly at baseline. For example, the rate of timely administration of prophylactic antibiotics before cesarean delivery increased from 0.0% (0/496) to 94.0% (409/435) at one hospital. Nonetheless, some EIs with low use at baseline did not show improvement after implementation (e.g. kangaroo mother care)., Conclusion: The present study strengthened previous findings regarding the uptake of EIs following joint promotion by HCPAs in low-income settings., (© 2018 International Federation of Gynecology and Obstetrics.)

With less than 3200 wild tigers in 2010, the heads of 13 tiger-range countries committed to doubling the global population of wild tigers by 2022. This goal represents the highest level of ambition and commitment required to turn the tide for tigers in the wild. Yet, ensuring efficient and targeted implementation of conservation actions alongside systematic monitoring of progress towards this goal requires that we set site-specific recovery targets and timelines that are ecologically realistic. In this study, we assess the recovery potential of 18 sites identified under WWF's Tigers Alive Initiative. We delineated recovery systems comprising a source, recovery site, and support region, which need to be managed synergistically to meet these targets. By using the best available data on tiger and prey numbers, and adapting existing species recovery frameworks, we show that these sites, which currently support 165 (118-277) tigers, have the potential to harbour 585 (454-739) individuals. This would constitute a 15% increase in the global population and represent over a three-fold increase within these specific sites, on an average. However, it may not be realistic to achieve this target by 2022, since tiger recovery in 15 of these 18 sites is contingent on the initial recovery of prey populations, which is a slow process. We conclude that while sustained conservation efforts can yield significant recoveries, it is critical that we commit our resources to achieving the biologically realistic targets for these sites even if the timelines are extended., Competing Interests: The authors have the following interests: Author KP was affiliated to PT. Royal Lestari Utama during the course of the study. There are no patents, products in development or marketed products to declare. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.

AimTo describe community representation in Nepal's Health Facility Operation and Management Committees (HFMCs) and the degree of influence of community representatives in the HFMC decision-making processes., Background: Community participation has been recognised as one of the key components for the successful implementation of primary health care (PHC) strategies, following the 1978 Declaration of Alma-Ata. In low- and middle-income countries (LMICs), HFMCs are now widely considered as a mechanism to increase community participation in health through community representation. There is some research examining the implementation process, impact and factors affecting the effectiveness of HFMCs. Despite the documented evidence of the importance of factors such as adequate representation, links with wider community, and decision-making power, there is limited evidence about the nature of community representation and degree of decision making within HFMCs in the PHC setting, particularly in LMICs., Methods: Qualitative interviews with 39 key informants were held to explore different aspects of community representation in HFMCs, and the influence of the HFMC on health facility decision-making processes. In addition, a facility audit at 22 facilities and review of HFMC meeting minutes at six health facilities were conducted.FindingsThere were Dalit (a marginalised caste) and Janajati (an ethnic group) representations in 77% and 100% of the committees, respectively. Likewise, there were at least two female members in each committee. However, the HFMC member selection process and decision making within the committees were influenced by powerful elites. The degree of participation through HFMCs appeared to be at the 'Manipulation' and 'Informing' stage of Arnstein's ladder of participation. In conclusion, despite representation of the community on HFMCs, the depth of participation seems low. There is a need to ensure a democratic selection process of committee members; and to expand the depth of participation.

Objective/introduction: It is known that knowledge, awareness, and practice influence diabetic control. We compared factors pertaining to healthy lifestyle (exercising, avoiding smoking), self-help (attending appointments, following treatment regimens), and diabetic awareness in high-risk patients for diabetic complications, specifically, those on insulin versus non-insulin treatment, and also those with a longer diabetic duration (≥5 years) versus a shorter duration., Methods: 200 consecutive patients with type 2 diabetes (52.0±11.6 years) attending diabetic clinic at a referral hospital in Nepal were recruited. A structured questionnaire explored non-clinical parameters including age, gender, diabetic duration, awareness about diabetes control, self-help, and lifestyle. Clinical data were also measured: HbA1c, fasting blood sugar (FBS), blood pressure, and treatment type (insulin, diet/tablet)., Results: A significantly higher proportion of patients on insulin (vs non-insulin) or with diabetic duration ≥5 years (vs <5 years) self-reported not doing regular exercise, forgetting to take medicine, and not knowing whether their diabetes was controlled (p≤0.005). HbA1c/FBS levels were significantly higher for patients on insulin or with a longer diabetic duration (p≤0.001). 92% of those on insulin (vs 31% on non-insulin) and 91% with diabetic duration ≥5 years (vs 28% of <5 years) self-reported to seeking medical help due to episodes of uncontrolled blood sugar in the last year (p<0.001)., Conclusion: Poor self-help/lifestyle and reduced knowledge/awareness about diabetic control was found in patients on insulin or with longer diabetic duration. This is a worrying finding as these patients are already at high risk for developing diabetic complications. The findings highlight need for targeting this more vulnerable group and provide more support/diabetic educational tools., Competing Interests: Competing interests: None declared.

Introduction: Outcome of spine injury treated in resource constrained regions may not be the same as in developed nations. The aim of the present study was to study the epidemiological characteristics, delay, complications, and outcome of surgically treated dorsal and lumbar trauma., Methods: Retrospective study of dorsal and lumbar spine injury patients treated between December 2015 and August 2017. Patients were segregated into four groups based on the timing of surgery: 0-2 days, 3-7 days, 8-30 days, and more than 31 days. Only one operating room twice a week was allotted to spine surgery, and spine had to compete with orthopedic and surgical trauma for admission and surgery., Results: Ninety-one patients (male 61) with mean age 33 years were operated for dorsal and lumbar spine injuries. 84% of the total patients sustained a fall, and 86.8% were from the periphery. Though 69.2% presented within 2 days, only 4.4% were operated within 2 days. Majority of the delay was due to unavailability of the operating room followed by financial constraints. Twenty-seven patients had complete deficit, 32 incomplete deficit, and 32 normal neurology. Four patients operated within 2 days improved their neurology, 7 incomplete deficit patients in 3-7 days group improved, 6 in 8-30 days group improved, whereas no patient in more than 31 days group improved. Overall 53.1% of neurologically incomplete deficit patients improved if operated within 30 days. No neurological improvement was seen in the 27 complete deficit patients. Wound infection, pulmonary contusion, and deep vein thrombosis were seen in 3 patients., Conclusions: As expected 95.6% of our patients were treated more than 3 days after injury and 60% more than a week later, which may not be acceptable in advanced countries. Despite the delay, 53.1% had an improvement in neurology when operated within 30 days. Hence, surgery still holds the hope of neurological recovery and quicker rehabilitation., Competing Interests: Conflicts of Interest: The authors declare that there are no relevant conflicts of interest.

Introduction: Ultrasound (USG) can be a good screening tool to identify high-risk nodule requiring fine-needle aspiration cytology (FNAC). The study aimed to assess the association of USG characteristic of thyroid nodule with malignancy., Methods: A cross-sectional study was performed from August 2011 to July 2012 at Tribhuvan University Teaching Hospital. Patients referred for USG of the neck with thyroid nodule more than 10 mm were offered FNAC and included in the study after taking informed consent. USG characteristics were compared with histopathologic diagnosis of benign or malignant nodule., Results: USG characteristics significantly ( P < 0.05) associated with malignancy were as follows: size of thyroid nodule more than 30 mm, ill-defined margin, solid echotexture, hypoechoic lesion, microcalcification, and any form of increased vascularity. High sensitivity was seen in microcalcification, hypoechoic echogenicity, and ill-defined margin and high specificity was seen in ill-defined margin and solid echotexture. Relatively high sensitivity and specificity was found in ill-defined margin., Conclusions: Texture, size, margin, echogenicity, and vascularity are important factors for discriminating benign from malignant nodule. Hypoechogenicity, vascularity of any type, ill-defined margin, and microcalcification were independent predictors of malignancy. None of the characteristics were sensitive and specific to be used independently as screening tool to identify high risk of malignancy., Competing Interests: There are no conflicts of interest.

Background: Despite some empirical findings on the usefulness of citizen's charters on awareness of rights and services, there is a dearth of literature about charter implementation and impact on health service delivery in low-income settings., Objective: To gauge the level of awareness of the Charter within Nepal's primary health-care (PHC) system, perceived impact and factors affecting Charter implementation., Method: Using a case study design, a quantitative survey was administered to 400 participants from 22 of 39 PHC facilities in the Dang District to gauge awareness of the Charter. Additionally, qualitative interviews with 39 key informants were conducted to explore the perceived impact of the Charter and factors affecting its implementation., Results: Few service users (15%) were aware of the existence of the Charter. Among these, a greater proportion were literate, and there were also differences according to ethnicity and occupational group. The Charter was usually not properly displayed and had been implemented with no prior public consultation. It contained information that provided awareness of health facility services, particularly the more educated public, but had limited potential for increasing transparency and holding service providers accountable to citizens. Proper display, consultation with stakeholders, orientation or training and educational factors, follow-up and monitoring, and provision of sanctions were all lacking, negatively influencing the implementation of the Charter., Conclusion: Poor implementation and low public awareness of the Charter limit its usefulness. Provision of sanctions and consultation with citizens in Charter development are needed to expand the scope of Charters from information brochures to tools for accountability., (© 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.)

Background and Purpose: BIO 300 nanosuspension (Humanetics Corporation) is being developed as a medical countermeasure (MCM) for the mitigation of the delayed effects of acute radiation exposure, specifically pneumonitis and fibrosis of the lung. The objective of this study was to determine the best dose and treatment duration of BIO 300 to mitigate lung injury and improve the likelihood for survival in C57L/J mice exposed to whole thorax lung irradiation (WTLI)., Experimental Approach: Age- and sex-matched C57L/J mice received a single dose of 11.0 or 12.5 Gy WTLI. BIO 300 (200 or 400 mg·kg -1 , oral gavage) was administered daily starting 24 h post-exposure for a duration of 2, 4, 6 or, in some cases, 10 weeks. Non-treated controls were included for comparison in both sexes. Animals were observed daily for signs of major morbidity. Respiratory function was assessed biweekly. Lungs were collected, weighed and paraffin embedded for histological evaluation post mortem., Key Results: BIO 300 administered at an oral dose of 400 mg·kg -1 for 4 to 6 weeks starting 24 h post-WTLI reduced morbidity associated with WTLI. The improvement in survival correlated with reduced respiratory frequency and enhanced pause. The irradiated lungs of mice treated with BIO 300 (400 mg·kg -1 ) for 4 to 6 weeks displayed less morphological damage and airway loss due to oedema, congestion and fibrotic scarring than the untreated, irradiated controls., Conclusions and Implications: BIO 300 is a promising MCM candidate to mitigate pneumonitis/fibrosis when administered daily for 4-6 weeks starting 24 h post-exposure., (© 2017 The British Pharmacological Society.)

Chorioangioma of placenta is the commonest benign tumour of the placenta. It consists of a benign angioma arising from chorionic tissue. We report a case of placental chorioangioma which was diagnosed in the post partum period in a patient with polyhydramnios who went into preterm labor and delivered a premature baby.

Molecular mechanisms underlying development of acute pneumonitis and/or late fibrosis following thoracic irradiation remain poorly understood. Here, we hypothesize that heterogeneity in disease progression and phenotypic expression of radiation-induced lung disease (RILD) across murine strains presents an opportunity to better elucidate mechanisms driving tissue response toward pneumonitis and/or fibrosis. Distinct differences in disease progression were observed in age- and sex-matched CBA/J, C57L/J and C57BL/6J mice over 1 year after graded doses of whole-thorax lung irradiation (WTLI). Separately, comparison of gene expression profiles in lung tissue 24 h post-exposure demonstrated >5000 genes to be differentially expressed ( P <0.01; >twofold change) between strains with early versus late onset of disease. An immediate divergence in early tissue response between radiation-sensitive and -resistant strains was observed. In pneumonitis-prone C57L/J mice, differentially expressed genes were enriched in proinflammatory pathways, whereas in fibrosis-prone C57BL/6J mice, genes were enriched in pathways involved in purine and pyrimidine synthesis, DNA replication and cell division. At 24 h post-WTLI, different patterns of cellular damage were observed at the ultrastructural level among strains but microscopic damage was not yet evident under light microscopy. These data point toward a fundamental difference in patterns of early pulmonary tissue response to WTLI, consistent with the macroscopic expression of injury manifesting weeks to months after exposure. Understanding the mechanisms underlying development of RILD might lead to more rational selection of therapeutic interventions to mitigate healthy tissue damage., (© 2017. Published by The Company of Biologists Ltd.)

Detonation of a 10-kiloton nuclear bomb in an urban setting would result in >1 million casualties, the majority of which would present with combined injuries. Combined injuries, such as peripheral tissue trauma and radiation exposure, trigger inflammatory events that lead to multiple organ dysfunction (MOD) and death, with gastrointestinal (GI) and pulmonary involvement playing crucial roles. The objective of this study was to develop an animal model of combined injuries, peripheral tissue trauma (TBX animal model) combined with total body irradiation with 5% bone marrow shielding (TBI/BM5) to investigate if peripheral tissue trauma contributes to reduced survival. Male C57BL/6J mice were exposed to TBX10%, irradiation (TBI/BM5), or combined injuries (TBX10% + TBI/BM5). Experiments were conducted to evaluate mortality at day 7 after TBI/BM5. Serial euthanasia was performed at day 1, 3 and 6 or 7 after TBI/BM5 to evaluate the time course of pathophysiologic processes in combined injuries. Functional tests were performed to assess pulmonary function and GI motility. Postmortem samples of lungs and jejunum were collected to assess tissue damage. Results indicated higher lethality and shorter survival in the TBX10% +T BI/BM5 group than in the TBX10% or TBI/BM5 groups (day 1 vs. day 7 and 6, respectively). TBI/BM5 alone had no effects on the lungs but significantly impaired GI function at day 6. As expected, in the animals that received severe trauma (TBX10%), we observed impairment in lung function and delay in GI transit in the first 3 days, effects that decreased at later time points. Trauma combined with radiation (TBX10% + TBI/BM5) significantly augmented impairment of the lung and GI function in comparison to TBX10% and TBI/BM5 groups at 24 h. Histologic evaluation indicated that combined injuries caused greater tissue damage in the intestines in TBX10% + TBI/BM5 group when compared to other groups. We describe here the first combined tissue trauma/radiation injury model that will allow conduction of mechanistic studies to identify new therapeutic targets and serve as a platform for testing novel therapeutic interventions.

Background: Despite abundant literature on the different aspects of health care complaint management systems in high-income countries, little is known about this area in less developed health care systems and most research to date has been conducted in hospital settings. This article seeks to address this gap by reporting on research into complaint systems in primary health care (PHC) settings in Nepal., Methods: Using a mixed-methods design, qualitative interviews were conducted with key informants (n = 39) and six community focus groups (n = 56), in the Dang District of Nepal. In addition, interviewer-administered structured questionnaire interviews were held with 400 service users, health facility operation and management committee (HFMC) members and service providers from 22 of the 39 public health facilities. Qualitative data were transcribed, organized and then analyzed using the framework method in QSR NVivo 10, while quantitative data were analyzed using IBM SPSS 22., Results: Despite service users having grievances with the health system, they did not complain frequently: 9% (n = 20) reported ever making complaints about the PHC services. Complaints made were about medicines, health facility opening hours, health facility physical environment, and service providers, and were categorized into environment/equipment, accessibility/availability, level of empathy in the care process and care/safety. Generally, complaints were made verbally to health providers or to HFMC members or female community health volunteers. Use of formal channels such as suggestion boxes or written complaints was almost non-existent. Reasons reported for not complaining included: a lack of complaint channels; lack of knowledge of service entitlements; power asymmetry between service providers and service users; lack of opportunity to choose alternative providers, lack of an established culture of complaining, and a perceived lack of responsiveness to complaints., Conclusion: Very few service users made complaints to PHC services in Nepal. Several contextual factors related to the community and the health system were identified as the reasons for not complaining. We recommend continuing efforts to establish proper complaints mechanisms with an increased emphasis on the existing community health system networks. Furthermore, awareness among service users about service entitlements and complaint mechanisms should be increased.

Nepal has seen impressive recent health gains through a successful community-based health program. However, governance challenges remain within the Nepalese primary health care system that include under-staffing and absenteeism, limited health facility opening hours, poor supervision and monitoring, and insufficient financial management. We propose that these be addressed through expanded community engagement and a power shift towards local communities, enhancing skills of community representatives in co-managing health facilities and of service providers to effectively engage the community, increased quality of community participation, and improved documentation of the process and impact of engagement on health outcomes. Copyright © 2015 John Wiley & Sons, Ltd., (Copyright © 2015 John Wiley & Sons, Ltd.)

Purpose: The World Health Organization (WHO) case management algorithm for acute lower respiratory infections has moderate sensitivity and poor specificity for the diagnosis of pneumonia. We sought to determine the feasibility of using point-of-care ultrasound in resource-limited settings to identify pneumonia by general health practitioners and to determine agreement between the WHO algorithm and lung consolidations identified by point-of-care ultrasound., Methods: An expert radiologist taught two general practitioners how to perform point-of-care ultrasound over a seven-day period. We then conducted a prospective study of children aged 2 months to 3 years in Peru and Nepal with and without respiratory symptoms, which were evaluated by point-of-care ultrasound to identify lung consolidation., Results: We enrolled 378 children: 127 were controls without respiratory symptoms, 82 had respiratory symptoms without clinical pneumonia, and 169 had clinical pneumonia by WHO criteria. Point-of-care ultrasound was performed in the community (n = 180), in outpatient offices (n = 95), in hospital wards (n = 19), and in Emergency Departments (n = 84). Average time to perform point-of-care ultrasound was 6.4 ± 2.2 min. Inter-observer agreement for point-of-care ultrasound interpretation between general practitioners was high (κ = 0.79, 95 % CI 0.73-0.81). The diagnosis of pneumonia using the WHO algorithm yielded a sensitivity of 69.6 % (95 % CI 55.7-80.8 %), specificity of 59.6 % (95 % CI 54.0-65.0 %), and positive and negative likelihood ratios of 1.73 (95 % CI 1.39-2.15) and 0.51 (95 % CI 0.30-0.76) when lung consolidation on point-of-care ultrasound was used as the reference., Conclusions: The WHO algorithm disagreed with point-of-care ultrasound findings in more than one-third of children and had an overall low performance when compared with point-of-care ultrasound to identify lung consolidation. A paired approach with point-of-care ultrasound may improve case management in resource-limited settings.

Background: The sequel of disc degeneration is one of the leading causes of functional incapacity that leads to chronic disability. The study aims to evaluate the MRI findings of degenerative changes in symptomatic patients., Methods: The study was a retrospective study for the duration of 3 years. Symptomatic patients undergoing MRI of LS spine were included in the study. Patients undergoing MRI for neurological symptoms alone and acute trauma or suspected infection or tumor were excluded from the study. MRI of patients was evaluated for degenerative changes and their sequel. Data was entered in a predesigned proforma and analysis was done with SPSS version 19.0., Results: A total of 2037 MRIs of LS spine of symptomatic patients were included in the study. Degenerative changes were demonstrated in 1906 (93.8 %) patients, which comprised 1039 (54.5 %) males and 867 (45.4 %) females. Disc bulge along with disc desiccation was the most common degenerative findings noted in 1667 (81.8 %). Disc herniation was seen in 1032(50.6%), neural foraminal stenosis in 1220 (59.8 %), central spinal canal in 1136 (55.8%) and nerve root compression in 650 (31.9%). Disc bulge, neural foraminal stenosis, central spinal canal stenosis was significantly more common in patients older than 40 years. Disc herniation was however significantly more frequent in patients younger than 40 years., Conclusions: Degenerative changes are common in symptomatic patients and increase in frequency with aging. Disc herniation is however more common in younger patients.

Background: Multi-drug resistance (MDR) in Gram-negative organisms is an alarming problem in the world. MDR and extensively-drug resistance (XDR) is in increasing trend due to the production of different types of beta (β)-lactamases. Thus the aim of this study was to document the incidence of MDR and XDR in clinical isolates of Escherichia coli and also to find out the enzymatic mechanisms of β-lactam antibiotics resistance., Methods: Two hundred clinical isolates of Escherichia coli (E. coli) identified by standard laboratory methods were studied. Antibiotic susceptibility profile was performed for all the isolates and the suspected isolates were phenotypically tested for the production of extended spectrum β-lactamase (ESBL), metallo β-lactamase (MBL) and AmpC β-lactamase (AmpC) by recommended methods., Results: Around three-fourth (78%) of the total isolates were multi-drug resistant. ESBL, MBL and AmpC production was found in 24%, 15% and 9% of isolates respectively. Amikacin, chloramphenicol and colistin were found to be the most effective antibiotics., Conclusions: High percentage of MDR was observed. β-lactamase mediated resistance was also high. Thus, regular surveillance of drug resistance due to β-lactamases production and infection control policy are of utmost importance to minimize the spread of resistant strains.

We present the draft genome assembly of an Elizabethkingia meningoseptica strain isolated from a 67-year-old postoperative endophthalmitis patient who suffered loss of vision in the right eye. The draft genome assembly has 167 contigs with a total size of 4,019,665 bp encoding multiple drug-resistant genes., (Copyright © 2014 Pradeep et al.)

Crossed testicular ectopia also known as transverse testicular ectopia is a rare anomaly of the testis which is ectopically located in contralateral hemiscrotum with absent testis in the ipsilateral hemiscrotum. Most case are incidentally discovered intraopeartively during operation of inguinal hernia and few case reports are available which have reported preoperative diagnosis of crossed testicular ectopia. We report a case of crossed testicular ectopia in 12 year old boy who presented with right undescended testis diagnosed preoperative on Ultrasound and Magnetic Resonance Imaging as crossed testicular ectopia.

Background: Abortion was legalized in Nepal in 2002, following advocacy efforts highlighting high maternal mortality from unsafe abortion. We sought to assess whether legalization led to reductions in the most serious maternal health consequences of unsafe abortion., Methods: We conducted retrospective medical chart review of all gynecological cases presenting at four large public referral hospitals in Nepal. For the years 2001-2010, all cases of spontaneous and induced abortion complications were identified, abstracted, and coded to classify cases of serious infection, injury, and systemic complications. We used segmented Poisson and ordinary logistic regression to test for trend and risks of serious complications for three time periods: before implementation (2001-2003), early implementation (2004-2006), and later implementation (2007-2010)., Results: 23,493 cases of abortion complications were identified. A significant downward trend in the proportion of serious infection, injury, and systemic complications was observed for the later implementation period, along with a decline in the risk of serious complications (OR 0.7, 95% CI 0.64, 0.85). Reductions in sepsis occurred sooner, during early implementation (OR 0.6, 95% CI 0.47, 0.75)., Conclusion: Over the study period, health care use and the population of reproductive aged women increased. Total fertility also declined by nearly half, despite relatively low contraceptive prevalence. Greater numbers of women likely obtained abortions and sought hospital care for complications following legalization, yet we observed a significant decline in the rate of serious abortion morbidity. The liberalization of abortion policy in Nepal has benefited women's health, and likely contributes to falling maternal mortality in the country. The steepest decline was observed after expansion of the safe abortion program to include midlevel providers, second trimester training, and medication abortion, highlighting the importance of concerted efforts to improve access. Other countries contemplating changes to abortion policy can draw on the evidence and implementation strategies observed in Nepal.

Background: Inhibitor of growth 1b (ING1b) is considered to be a class II tumor suppressor gene. Although reduced expression of p33(ING1b) has been reported in many human malignancies, including gastric cancers, the effect of p33(ING1b) on gastric cancer cells has yet to be investigated., Methods: Expression of p33(ING1b) in gastric adenocarcinoma tissues and their adjacent non-malignant gastric mucosa, as well as in gastric adenocarcinoma cell lines and normal gastric epithelial cells, was detected by using Western blotting. Recombinant adenoviruses were prepared to mediate the ectopic expression of p33(ING1b) (Ad-ING1b) and green fluorescent protein (GFP)(Ad-GFP) in the gastric adenocarcinoma cell lines, SGC-7901, MKN28, and MKN45 and the normal gastric epithelial cell line GES-1. Alterations in the proliferation and apoptosis of the cells after adenoviral infection were determined by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay and flow cytometry, respectively, and cell cycle distribution was analyzed in a fluorescence-activated cell sorter., Results: Western blotting confirmed the reduced expression of p33(ING1b) in gastric adenocarcinoma tissues and gastric adenocarcinoma cell lines. The ectopic expression of p33(ING1b) mediated by Ad-ING1b resulted in decreased growth, increased apoptosis, and cell cycle arrest at the G1 phase in both benign and malignant gastric epithelial cells regardless of their p53 status. Addition of a p53 inhibitor, pifithrin-α, did not abolish the pro-apoptotic and cell cycle-arresting effects of p33(ING1b) in p53 wild-type cells., Conclusions: Down-regulation of p33(ING1b) might play an important role in the development of gastric adenocarcinoma. Targeted local expression of p33(ING1b) may offer a promising alternative therapeutic measure for gastric cancer.

Tuberculosis (TB) affects mostly economically active population in underdeveloped and developing countries, therefore TB can have far reaching economic and social consequences among infected people and their household members. The objectives of this study were to estimate the household expenditure before and during the course of disease, to explore the direct and indirect cost burden of tuberculosis in terms of annual family income and to compare the total cost burden in a family of case treated with directly observed treatment shortcourse (DOTS) and without DOTS. A total of 160 treatment completed, pulmonary tuberculosis (PTB) cases fulfilling the inclusion criteria were interviewed. The median patients income before and during illness was US$1.95 and US$0.9 respectively. Similarly, household expenditure before illness was US$3.24 and during illness was US$4.28. Direct cost burden in terms of annual family income was higher (15.2%) than indirect cost burden (8.2%). But, free distribution of anti tuberculosis therapy (ATT) through DOTS reduced the total cost burden of patient by more than 8%. In conclusion, overall cost burden of pulmonary tuberculosis is high even though the treatment is free of cost.

Atlantoaxial fixation is a relatively rare cause of torticollis which may be easily missed in practice. Early diagnosis is important as this indicates a compromised atlantoaxial complex with the potential to cause neural damage or even death. Here, we report a case of atlantoaxial rotatory fixation in a 13 yr old male with torticollis for two years and history of defaulting treatment for tubercular lymphadenitis. In this case, the odontoid peg view revealed asymmetric distance between the odontoid and lateral mass of atlas which was confirmed with Fluoroscopy and Computed Tomography (CT) scan. Magnetic Resonance Imaging (MRI) was also done which showed hyperintensity in alar ligaments with posterior inclination of the odontoid peg along with cervical lymphadenopathy.

Nepal's efforts to decentralize its governance date back to over half a century. These efforts remained incomplete due to different reasons including administrative responses and political development affecting its implementation. The Local Self Governance Act (LSGA), 1999 envisaged, for the first time, to decentralize governance in the health sector through devolution of responsibilities, authority and resources to the local bodies. However, the pace of health sector decentralization in Nepal even after the LSGA was enacted has not progressed satisfactorily due to different reasons. The purpose of this paper is to discuss why health sector decentralization in Nepal has not advanced as expected. This paper identifies many issues--policy related, political, functional, and institutional--as stumbling blocks for health sector decentralization of Nepal. More specifically, the major bottlenecks for progress are lack of a clear cut policy, poor coordination among different sectors, improper handover process, lack of elected bodies, poor selection process of management committees, lack of coherence in the capacity building process of local bodies, ongoing debate about state restructuring including federalism and different political ideologies on decentralization.

We describe here an unusual case of thrombosis of left subclavian artery in a patient with cervical rib. The patient presented with features of ischaemia of left upper limb. X-ray chest revealed bilateral cervical ribs, longer on the left side. Color Doppler studies showed echogenic thrombus within the left subclavian artery. Angiography revealed complete occlusion of left subclavian artery. Embolectomy was done. She was planned for excision of rib.

Health Facility Operation and Management Committee are supposed to govern all the affairs of local health facilities under decentralization policy. The capacity building of the committee was deemed necessary and thus different stakeholders involved in the capacity building process. All agreed up on the need of capacity building of the committee but there were different school of thoughts on the contents and process of capacity building. Major capacity building inputs included orientations and training to the committee. However the follow up part was not uniform; some organizations conducted periodic reflection meeting, where as many ended up with the training. There were some tangible changes observed by the capacity building inputs. Their priority however was on infrastructure and drug purchase. The changes observed were very short lived and not sustainable. The capacity building was equated with training and an event with low priority on follow up, monitoring and coaching. It was not thought as a process. A concept of complete package of capacity building should have been developed where training component would be only an element of overall capacity building.

A G3P(1+1) who underwent dilatation and curettage (D and C) for persistent vaginal bleeding after a month of molar evacuation, underwent successful treatment of choriocarcinoma with methotrexate and was able to have normal baby weighing 2800 gms with good Apgar score and normal placenta. This shows that a normal menstruation and uncomplicated term delivery can be expected after complete chemotherapy for gestational trophoblastic neoplasia (GTN).

Hematometrocolpos drained abdominally at laparotomy done, with suspicion of an ovarian torsion in an adolescent with ipsilateral renal agenesis, was eventually rediscovered to have in coexistent uterine didelphys in a 25 year P3+0 at the time repeat caesrean for breech in the event of third parturition, complicated by partum hemorrhage as in all her previous delivery (first vaginal delivery and retained placenta, second caesarean for obstructed labor by non pregnant half of didelphic uterus). This illustrates how simultaneous occurrence of hematometrocolpos can go unnoticed although there was every reason for this condition not to go unrecognized for the simple fact ofhemivaginal obstruction and hematometra with ipsilateral renal agenesis (on the left side) unaffecting the consecutive pregnancy in the other uterus.

Intramedullary interlocking tibial nailing is usually performed using an image intensifier. But being expensive, it is not available in the most of the hospitals of resource-poor countries of the world. The purpose of this study is to analyze the results of interlocking nailing without the use of an image intensifier. This is the retrospective study of 55 diaphyseal tibial fractures treated with minimally open reduction and internal fixation with interlocked intramedullary nail fixation. The proximal locking of the nail with the screws was made using external jig and for the distal locking direct visualization of the hole was carried out. There were 15 females and 40 males. The average age in years was 32 with a range of 18 to 64 years. The surgical approach was medial parapatellar. The average follow up period was 4 months. This period ranged from 3 months to 14 months. The union time in an average was 4 months. The complication mainly was distal screw loosening leading to valgus deformity and shortening in 1 case. It is, therefore, concluded that interlocking intramedullary nailing can be performed with proximal and distal locking accurately without the use of an image intensifier.

A pregnant woman, gravida 3 with two living children, who frequently experienced syncope from 23(+5) weeks of pregnancy onwards and recurring every week for a period of 3 weeks, was repeatedly treated in line for a case of acid peptic disease/appendicitis in various peripheral hospitals of Nepal, until ultrasonogram/magnetic resonance imaging diagnosis of an (undisturbed) live 27(+5) weeks abdominal pregnancy was made at our hospital. On laparotomy, this materialized to be secondary to the rupture of a left rudimentary horn pregnancy (evidenced from its sealed margin) which still retained a complete placenta, from where an umbilical cord was seen, traversing across towards the right side of the abdominal cavity just below the liver, securing its attachment to the surviving fetus and enclosed in an intact amniotic sac. Excision of the rudimentary horn containing the placenta was accomplished, after the delivery of a live baby weighing 650 g who unfortunately died on the third day of life.

Immediate proper care of newborn is vitally important for survival, growth and development of a baby. Despite several studies conducted in Nepal about maternal and child health care practices, little is known about factors that determine behaviors related to immediate care of newborn. Identification of behavioral determinants for immediate care of newborn in Kailali district was objective of the study. This formative research was conducted in 6 purposely selected Village Development Committees (VDCs) of Kailali. Altogether 17 Focused Group Discussions (FGDs) were conducted with 106 parents. To triangulate the findings, 58 in-depth interviews were conducted with various individuals. Most people are unaware of importance of immediate care of newborn and many unsafe behavior do exist such as common use of untrained attendants, unsafe cord care, immediate bathing of baby. Most of the existing practices are based on deep-seated traditional beliefs. Some used Clean Home Delivery Kit (CHDK) and a few had used knife to cut the cord. All had tied stump with thread and applied mustard oil to prevent infection. The use of CHDK was high in the Tharu group with surprisingly low among Brahmin/Chetri. Yet! This research showed willingness on the part of the community to learn and change harmful practices. Almost all had similar opinion that survival of a baby is with in their control. As child is the center of love of all and targeting a child many behaviors and practices could be changed. The next step would be to prioritize the behaviors that need to be targeted for change and spread key messages for behavior change.

We report a case of hematometra and bilateral hematosalphinx in a 15-year-old mentally handicapped adolescent girl, complicated by vaginal agenesis over cervical atresia in the presence of an ovarian adenoma. The case was managed by abdominal hysterectomy and bilateral salphingectomy of the hematosalphinx, which had formed a tubo-ovarian mass. One ovary was preserved. This case also considers the management of the mentally handicapped patient unable to comprehend pain arising from cryptomenorrhea.

Chronic vaginal discharge in children and adolescents is a common gynaecological complaint which is often resistant to antibiotic treatment. We present a 14 years old, premenarcheal girl who presented to us with the complaints of recurrent, foul smelling purulent occasionally blood stained vaginal discharge for eight years, where a foreign body in the upper vagina was found after releasing a dense adhesion of the lower vagina which was unable to detect by pelvic ultrasound.

This article presents the findings of public health status indicators of Morang District as studied by Lot Quality Assurance Sampling (LQAS) methods 2006. The contraceptive prevalence rate (CPR) and women receiving antenatal service from health workers were 42.0% and 46.0%, respectively. A total of 80.0% mothers were receiving iron tablets whereas 55.0% mothers gave history of taking Vita A during their last pregnancy. Nearly three-fifth (57.0%) of deliveries was conducted by health workers. Thirty-one percent of mothers fed their breast milk within 1 hour during last natal period. These figures were higher compared with previous years.

Removing a degenerated myoma located around the uterine cornu by an innovative technique shelling the myoma a little away from the base by choice of a low placed incision, advantageous in terms of no requirement of blood transfusion because of the reduction in the surgical time is described in a 24 years old lady demanding a fertility conserving surgery.

Unlabelled: Assessment of carotid artery lumen diameter and intima-media thickness is becoming as a surrogate marker of early evaluation of cardiovascular disease. Present study aims to describe the normal carotid dimensions in healthy adults of both sexes. A total of 123 healthy volunteers including 65 men and 58 women, aged 21 to 60 years (mean +/- SD; 35.66 +/- 8.84 years) were studied. Ultrasound study of both carotid arteries were performed with a 7.5 MHz linear array transducer. Common carotid artery lumen diameter ranged from 4.3 mm to 7.7 mm. Difference was not noted between left and right common carotid artery lumen diameter (5.78 +/- 0.57 mm and 5.86 +/- 0.66 mm), and internal and external carotid artery lumen diameter as well. Both left and right common carotid artery, internal and external carotid artery lumen diameter tended to be larger (p < 0.05) in men than women. Common carotid artery intima-media thickness ranged from 0.4 mm to 0.8 mm. Difference was not noted between left and right common carotid intima-media thickness when separately analyzed among men, women and the entire population. Difference was also not noted in comparison between men and women., Conclusion: Common carotid artery and internal and external carotid artery lumen diameter tends to be larger in men than women among young adults. There is no difference between left and right carotid artery lumen diameter. Common carotid artery intima-media thickness is similar in comparison between left and right and both sexes.

Extensive torsion of umbilical cord, a rare complication, shown by 2 fetuses with too frequent changes in their lie and presentation with subsequent development of fetal growth restriction (FGR), culminating intrauterine fetal death of one with transverse lie and survival of the other with decreased fetal movement worsened by impending eclampsia both managed by caesarean section is reported.

Objective: To observe the clinicopathological characteristics of gastric stump cancer (GSC) and evaluate the benefits of radical surgery of GSC., Methods: The clinicopathological characteristics and postoperative survival time of 37 GSC patients who underwent surgery were investigated retrospectively. The survival time was compared according to the type of surgical operation (radical resection vs palliative operation). Twenty-one cases that received radical resection were analyzed based on the pTMN stage. Survival curves were traced by using Kaplan-Meier methods., Results: Most GSC (32/37) was detected in patients who had received Billroth II reconstruction after partial gastrectomy for benign gastric disease. The lesser curvature side and the suture line of anastomosis were the most frequent sites where GSC occurred (27/37). Differentiated adenocarcinoma was the dominant histopathological type (24/37). The postoperative 5-year survival rate of early stage GSC patients (n=9) was significantly higher than advanced stage GSC (n=12) (55.6% vs 16.5%, xL2=11.48, P<0.01). Five-year survival rate of 21 GSC patients with radical resection were 75% (3/4) for stage I, 60% (3/5) for stage II, 14.2% (1/7) for stage III, and 0% (0/5) for stage IV respectively. The median survival time of 21 GSC patients who underwent radical resection was longer than those undergoing palliative operation (43.0 m vs 13.0 m, x L2=36.31, P<0.01), the median survival time of stage IV patients with radical resection was 23.8 months., Conclusions: Without remote metastasis, radical resection for GSC is possible, and is an effective way to improve the prognosis of GSC. Even in stage IV GSC, radical resection can still prolong the survival time. It is necessary for the patients with benign gastric diseases who received partial gastrectomy to carry out the endoscopy follow-up, especially in patients with Billroth II reconstruction procedure at 15-20 years.

Background: Septic abortion is an infection of the uterus and its appendages following any abortion especially, illegally performed induced abortions. It is characterized by a rise of temperature to at least 100.4 degrees F, associated offensive or purulent vaginal discharge and lower abdominal pain and tenderness., Aim: To study maternal mortality and morbidity in induced septic abortions., Methods: Induced septic abortions were analyzed between April 1992 and September 1999 in TU Teaching hospital. Morbidity indicators were surgery other than curettage, prolonged hospitalization and permanent damage., Results: In 92 cases of induced septic abortions, comprising 6% of total abortions; nine deaths occurred because of disseminated intravascular coagulation, acute renal failure and adult respiratory distress syndrome. Vaginal, intraperitoneal and gum bleeding; epistaxis and malaena resulted in severe anemia (Hb < 6 gm/L) in 11 cases. Wound debridement and skin graft cured two cases of necrotizing fasciitis. One of four conservatively managed tubo-ovarian masses spontaneously drained rectally. In 15 cases laparotomy for pus drainage, salpingectomy, salpingo-oophorectomy, hysterotomy/uterine rent repair was conducted, along with four bowel surgeries and six hysterectomies were performed. Post-operative complications included burst abdomen (one case) and reopened pyoperitoneum, which resulted fecal fistula in three cases, one of these patients died., Conclusion: : Induced abortion was proven to be a major detrimental factor for maternal mortality. Morbidity was four times higher than mortality to the extent that patients suffered hemiplegia and forced barrenness.

Utero-vaginal prolapse can be caused by traction on to the cervix by heavy myoma. Here we present a unique case of huge, compressed, pedunculated fibromyoma of the cervix, which led to cervical elongation and third-degree utero-vaginal prolapse.

A 17-year-old girl had a large abdominopelvic mass (12 x 8cm) extending from vagina, due to the presence of a complete transverse vaginal septum in its middle third which on resection facilitated the drainage and disappearance of the mass finally diagnosed as a case of mucocolpos.

Sera from randomly selected 345 pregnant Nepalese women aged 16-36 years and 13 women with bad obstetric history (BOH) were tested for the presence of Toxoplasma antibodies using microlatex agglutination (MLA) and ELISA methods. The overall prevalence was 55.4% (191/345). Prevalence was slightly higher (59.0%) in older age-group (27-36 years) compared with younger age-group (16-26 years) (52.2%). No significant difference in antibody prevalence in women belonging to two different ethnic-groups (Tibeto-Burmans 57.8%, Indo-Aryans 52.7%) was observed (p>0.05). MLA antibody titer ranged from 1:16 to 1:2,048. Over three-fourth of the women showed either high (1:510 or over) or low (1:16 or 1:32) antibody titer. Three percent (6/191) of MLA antibody positive subjects had Toxoplasma IgM antibodies by IgM-ELISA. All six IgM antibody positive pregnant women had MLA antibody titer of over 1:510. Of the total 13 women with BOH, 5 (38.5%) had Toxoplasma antibodies of which 2 (40.0%) were positive for Toxoplasma-IgM antibodies.